This putative case report challenges you to make a differential diagnosis and prescribe a treatment plan for a patient presenting with chronic heel pain. Hopefully, you will identify the cause of the heel pain by identifying the painful tissue through the history-taking process and physical examination. Identification of the pain-generating tissue is an essential part of the neuromusculoskeletal evaluation and differential diagnosis process.
History and Examination
This patient is a physician in a full-time practice within a hospital system. He has referred patients with back pain to you over the past five years. One of his colleagues, an orthopedic surgeon, advised that he have a surgical intervention. The patient would like to know if you are able to help him with conservative care. He would like to avoid surgery and return to work without pain in the heel asap.
Subjective: This 51-year-old male presents with severe pain in the left heel. The pain began six months ago. He denies any specific trauma. Initially, the sharp pain in the left heel occurred only upon waking and during the initial few steps in the morning, followed by throbbing pain.
Until three months ago, he was able to jog or walk 10-15 miles per day. On Sundays, he would run a nine-mile mountain trail and then walk down. He denies any previous problems with his heels. He also complains of minor pain in the right heel.
He continues to experience throbbing pain in the left heel at night and severe, stabbing pain in the morning with the first few steps. Recently, he began experiencing burning pain and numbness with prolonged standing and walking, or upon rising from a chair after sitting for more than one hour.
For the past two weeks, he is barely able to walk and limps because of the severe pain in the left heel. Currently, the burning pain with tingling and numbness in the left heel progressively worsens as the day passes. He does stand and walk extensively at the hospital. Rest, ice and NSAIDs do reduce the pain.
The daily pain in the left heel is rated at 10/10 at worst and 5/10 at best. The pain is around the plantar surface of the heels, with the right heel pain being minor and rated at 2-3/10. He points to the medial aspect of the calcaneus in each heel as the location of the pain. The throbbing pain in the left heel is now interfering with his sleep.
Eighteen months ago, he began an executive MBA program, which requires a great deal of study and work at the computer. He has been consuming a.m. and p.m. venti breve latte coffee drinks during his early-morning and evening study sessions. Study time and pain in the heel have reduced his exercise routine. He mentions that he has gained 50 pounds over the past 18 months.
Objective: Middle-aged, mesomorphic male presents with an antalgic limping gait (left lower extremity). He appears mildly obese.
- Posture: inferior and posterior left ilium; anterior and superior right ilium.
- Kemp's maneuver full, without pain.
- Gillet demonstrates fixation of left SIJ.
- Long sit test reveals a functional left leg-length deficiency supine, functional right leg-length deficiency seated.
- Straight-leg raises bilaterally 85 degrees without back or leg pain.
- Palpation of the left medial calcaneal tuberosity and plantar fascia reproduces the chief concern (pain) and produces a grimacing reaction and withdrawal of the foot. Palpation of the right medial calcaneal tuberosity and plantar fascia produces mild pain.
- Palpation 1" medial to the left calcaneus also produces heel pain.
- Passive dorsiflexion of the left foot produces a sharp, stabbing pain at the medial calcaneus.
- Plantar neurodynamic testing with eversion, great-toe extension, SLR and internal rotation of the hip produces tingling and a burning pain in the medial heel.
- Achilles squeeze testing produces moderate pain in the left calf.
- Gastrocnemius squeeze produces moderate pain in the left calf.
- Passive dorsiflexion of the left foot produces severe pain.
- Passive dorsiflexion of the right foot produces mild to moderate discomfort.
Assessment and Treatment Plan
Assessment: Post-traumatic, repetitive strain of the plantar fascia with resultant chronic plantar fasciosis complicated by neural compression of Baxter's nerve, a branch of the lateral plantar nerve.
Treatment Plan: Rest, weight loss, NSAIDs, and daily stretching of the plantar fascia and nerve flossing to reduce the pain and promote function. Night splint to be worn on the left foot while sleeping for two weeks. Spinal manipulation to reduce the pelvic obliquity; 1-3 visits over the next three weeks. Discuss referral to a podiatrist for injections= therapies, including PRP, prolotherapy or corticosteroids. He elects to see the podiatrist.
| 1. Have you diagnosed a patient with plantar fasciosis, rather than fasciitis? | |
| a. Yes b. No |
|
| 2. Have you ever performed plantar neurodynamic testing? | |
| a. Yes b. No |
|
| 3. Have you ever diagnosed a neural cause of heel pain? | |
| a. Yes b. No |
|
| 4. Have you ever performed nerve flossing or neural gliding for a patient with heel pain? | |
| a. Yes b. No |
|
5. What is your diagnosis and treatment plan? I would appreciate hearing from you. Do you agree with me or do you have a different opinion? Contact me at  |
|
Discussion / Clinical Pearls
Plantar fasciitis is a quite common cause of heel pain, often caused by repetitive strain. More than 1 million Americans per annum visit health care providers for heel pain. Plantar fasciitis may be the correct diagnosis during the acute, inflammatory stage, but once it becomes chronic and non-inflammatory, the diagnosis should change to plantar fasciosis.
Some believe neural entrapment of the lateral plantar nerve plays a significant role in the cause of plantar fasciitis.1 Others suggest chronic plantar fasciosis and neural entrapment may occur in combination and complicate the diagnosis and treatment of heel pain.2
Dr. Brandon Steele demonstrates the performance of neurodynamic testing for heel pain in his video, "Chiropractic Evaluation of Neurologic Heel Pain," available here.
It has been my experience that injection of cortisone, performed by a primary care physician with injection therapy training or a podiatrist, provides the quickest relief of plantar fasciosis pain and return to normal walking and standing activities. I suggest the literature supports my opinion.3 Of course, rehabilitation procedures should be recommended to provide long-term benefits.
References
- Thakar HD, Samson A, Palekar TJ. Prevalence for plantar fasciitis of neural origin in community-dwelling adults. Med J DY Patil Vidyapeeth, 2022;15:393-7.
- Moroni S, Zwierzina M, Starke V, et al. Clinical-anatomic mapping of the tarsal tunnel with regard to Baxter's neuropathy in recalcitrant heel pain syndrome: part I. Surg Radiol Anat, 2019 Jan;41(1):29-41.
- Ang TW. The effectiveness of corticosteroid injection in the treatment of plantar fasciitis. Singapore Med J, 2015 Aug;56(8):423-32.
Click here for more information about James Lehman, DC, MBA, DIANM.