"How I Approach Problems": Plantar Fasciitis with Heel Pain with Swelling

    This is a new series of blog posts on various injuries entitled "How I Approach Problems". I will be going through common injuries to start and then the areas that proven more complex challenges. I hope my thought process will help you if you are treating this injury or have this injury or injured area.

     Heel Pain with Swelling: This is Not Plantar Fasciitis

The “itis” from plantar fasciitis is deep swelling and inflammation that is really hard to feel. The patient does not appreciate any swelling or fullness to the tissues. So, when a patient presents with heel pain, with or without the previous diagnosis being plantar fasciitis, and there is obvious swelling in the tissues, the injury is not plantar fasciitis. From my last post, here is how I summarized Acute heel pain (pain that comes on quickly). 

With an acute (sudden) onset of pain, and swelling in the heel, the 2 common diagnoses are:

1. Plantar Fascial Tears
2. Heel (Calcaneal) Stress Fractures

With the acute (sudden) onset of pain, without noticeable swelling in the heel, the 2 common diagnoses are:

1. Heel Bursitis (only deep palpation away from the plantar fascia finds a painful bursal sac)
2. Heel Neuritis (this can cause heel rim pain or radiating pain or other neuropathic symptoms

Therefore, an acute onset of heel pain, with the presence of swelling is either a Stage 2-3 plantar fascial injury or a boney injury to the heel (commonly a stress fracture). MRI is the image of choice, and even though the treatment is 3 months of immobilization for both, it is different thought process in treatment when the injury is fascial or bone. 

With fascial injuries, you made need to use plantar fascial treatments of taping, orthotic devices, and physical therapy after the period of immobilization.

With calcaneal heel bone injuries, you have to think about bone stimulators, overall bone health, bone density testing, Vit D, and the extent of the fracture up into the vulnerable subtalar joint. 

My next post I will discuss the protocol of plantar fascial stage 2 or 3 injuries, also known as partial or complete tears. 

“How I Approach Problems”: Plantar Fasciitis Not Responding to Treatment

    This is a new series of blog posts on various injuries entitled "How I Approach Problems". I will be going through common injuries to start and then the areas that prove to be more complex challenges. I hope my thought process will help you if you are treating this injury or have this injury or injured area.

                    Plantar Fasciitis Not Responding to Treatment 

Many heel and foot problems are called plantar fasciitis when they are not. Plantar fasciitis is a Grade or Stage I Ligament Sprain. It is inflammation from being pulled on too much in some manner typically in an overuse fashion. In the last blog post we talked about what is and what is not plantar fasciitis. And even though there are always exceptions to every rule, most of these are true. Plantar Fasciitis has the hallmarks of:

• Gradual onset of pain
• Worse in the morning
• Pain after prolonged sitting
• Minimal to no swelling
• Typically at the heel 
• Responds well to treatments of stretching, icing, and taping 
• Responds well to some forms of arch support where the weight is transferred forward off the sore heel

Therefore, it is good if the patient or yourself has this pattern of symptoms, and you are probably correct at calling it Plantar Fasciitis. But what happens if your initial treatment of stretching, icing, and taping does not help. And one or two forms of arch support are not helpful or even seem to make it feel worse. I personally like to follow my patients monthly and I expect if I have made the correct diagnosis, the patient begins to improve. Each visit I have with the patient after the first will show steady and gradual improvement. It is hard to measure time to complete success, as some patients want to pin me down. But, progress is key month by month if your treatment and diagnosis are in sync.

Each diagnosis has very different treatments so it is important to make an exact diagnosis when you are not improving. What are some of the typical signs from the patient that the problem may be something other than plantar fascia?

• The Onset of Pain Happened on one day
• The worse may is not when you first get out of bed in the morning
• The involved heel is more swollen than the other side
• The pain radiates into the arch or toes
• It hurts more when you walk on your heel then when you lift your heel

With an acute (sudden) onset of pain, and swelling in the heel, the 2 common diagnoses are:

1. Plantar Fascial Tears
2. Heel (Calcaneal) Stress Fractures

With the acute (sudden) onset of pain, without noticeable swelling in the heel, the 2 common diagnoses are:

1. Heel Bursitis (only deep palpation away from the plantar fascia finds a painful bursal sac)
2. Heel Neuritis (this can cause heel rim pain or radiating pain or other neuropathic symptoms

So, I have tried to show the myriad of patients who are not improving in their treatment of plantar fasciitis, typically because their heel pain was called  plantar fasciitis and it was something else. That something else, needing totally different treatments, was either:

• Plantar Fascial Tearing or Fasciosis
• Calcaneal Stress Fractures
• Plantar Calcaneal Bursitis
• Infra Calcaneal Neuritis

Each of these problems will be discussed separately in posts later.