Plantar heel pain case study – the importance of correct diagnosis

In my experience I have seen various heel pain related injuries (e.g. plantar fasciitis) cured with a variety of treatment options and plans. Common treatments include:

• Strapping
• Strengthening exercises
• Stretching
• Orthotics
• Footwear changes
• Heat ultrasound
• CAM walker (moonboot)

There are multiple factors which contribute to determining the most appropriate treatment option for patients. Most importantly, the proper diagnosis should be determined in the first instance, so that a suitable course of action may be tailored to the patient. In the absence of a correct diagnosis, the patient may not respond to chronic heel pain treatment.

Accurate diagnosis is key for plantar heel pain treatment

My colleagues and I at Melbourne Podiatrists & Orthotics have encountered many cases of heel pain that have been misdiagnosed in the past and therefore patients have not been given the most suitable treatment and advice – resulting in a lack of improvement. In many cases, patients have been told that plantar fasciitis (excessive strain of the ligament on the bottom of the foot) is the cause of their heel pain, however when properly examined it is often determined that the cause of the pain is in fact, nerve entrapments at the heel of the foot (similar to a ‘pinched’ nerve), medial ankle nerve entrapments, fat pad impingement and even bone bruising in rarer cases. Other times we have picked up substantial tears within the plantar fascia – an injury that requires a significantly different approach to fully recover from than a plantar fascia injury without a tear.

Whilst all these pathologies cause pain at the heel, our treatment advice and options can vastly differ depending on the injury. Accurate diagnosis is key for and accurate and effective treatment plan.

Plantar Heel Pain Case Study

The following briefly discusses a case study relating to a patient who has suffered with long term heel pain. These cases highlight the importance of diagnosis of the exact cause of the heel pain.

A 60 year old female presented to me with left heel pain for over 12 months. It was impacting her ability to be able to walk day to day as she was dealing with severe pain with most steps. It also made it very difficult for her to play golf – she would push through the pain but the hours after golf and the day after were absolute agony for her. She was unable to walk the course like she had in the past. She told me that she had found 1 pair of shoes (a casual sneaker) that reduced her pain somewhat. The sneakers were the only shoes she could wear to manage with her pain.

“I have plantar fasciitis”

This patient was told by another health professional she had plantar fasciitis affecting both her feet, and therefore that is what she told me she had when she came to me. Her treatment with that health professional was not progressing. When she started telling me about her pain many of her symptoms were not adding up. She was getting pain on the base of the heel – which is often plantar fasciitis as this is where it connects to the heel bone. But upon further assessment the majority of her pain was actually located on the inside of her heel about 1cm up from the base of the heel. The pain in this area was excruciating.

Diagnostic ultrasound can aid diagnosis of plantar heel pain

I decided to do an ultrasound scan of her plantar fascia ligament (we have an on-site diagnostic ultrasound system). Mild plantar fascia injury thicknesses are of about 4mm. Moderate is 5-6mm and anything more is a severely inflamed plantar fascia ligament. This patient’s plantar fascia measured less than 3mm. This told me her plantar fascia ligament wasn’t causing the pain like she had been told previously – it was a nerve entrapment causing localised and referred pain to the plantar fascia.

Heel pain improved following the correct diagnosis

With this important information I was able to prescribe soft supportive orthotics (hard ones can make nerve entrapment pain worse during early stages of treatment), the correct exercises and refer her for the correct runners to help improve the pain. After the soft orthotics settled the day to day pain, we prescribed her customised foot orthoses. After 5 months of treatment after the correct diagnosis (remembering her pain had been debilitating for over 12 months) she has been able to walk 80% of the golf course and has minimal to no day to day pain. She is now able to wear 3-4 different types of shoes.

Had someone like her received a steroid injection – this would have gone straight into the base of the heel and likely have had no effect. A case like this highlights the importance if getting the initial diagnosis correct – something we pride ourselves on at Melbourne Podiatrists & Orthotics.

Let us help your plantar heel pain

So if you or someone you know is suffering from any kind of heel pain and past treatment has not worked – chances are the initial diagnosis was not correct or investigated thoroughly enough, in which case making an appointment with one of our Melbourne podiatrists is a fantastic first step to an accurate diagnosis and treatment of your heel pain.