Many runners experience heel pain and in most cases, they think that the diagnosis is plantar fasciitis. Many times they’re right. However, about half of the runners that I treat come to my office thinking they have plantar fasciitis, but in fact, have something else.
The plantar fascia is a thick ligamentous structure that connects the heel to the forefoot. There are three bands of the plantar fascia: medial (inside of foot), middle, and lateral (outside of the foot). Anyone or all three can become problematic. If the plantar fascia is inflamed, then plantar fasciitis is present (itis = inflammation). However, there is a lot of variability of how thick the plantar fascia can be. A routine X-ray is questionably diagnostic. An MRI may be more definitive, but much more expensive.
Here are some common diagnoses that mimic plantar fascial pain:
Plantar fasciosis. If the plantar fascia becomes painful for more than one month, it is probably starting to degenerate, a diagnosis called plantar fasciosis. This is similar to a tendon that starts to degenerate (a.k.a tendinosis). A rubber band is a good analogy: As it ages, it starts to lose its elasticity and small tears start to form. That is essentially occurring with fasciosis.
Calcaneal stress fractures. A fracture of the calcaneus (heel bone), that commonly occurs when the heel is crushed under the weight of the body. The key diagnostic clue here is to squeeze the sides of the heel. If that produces pain, a stress fracture may be present. X-rays are rarely helpful in diagnosing this issue. MRIs or bone scans can also be used to rule out a stress fracture, but a positive test doesn’t always mean that a stress fracture is present.
Nerve entrapments. A nerve can be entrapped as it exits the spinal cord, in the gluteal region (usually sciatica), around the outside of the knee, the inside of the ankle (tarsal tunnel syndrome) or within the muscle layers in the foot (Baxters neuritis). Physical exam, history and specific diagnostic studies are used to evaluate for these conditions.
Muscle cramps. There are three small intrinsic muscles that also start at the heel and connect to various parts of the forefoot (abductor digiti minini, flexor digitorum brevis and abductor digiti quinti). Since they are in fact muscles, they can spasm or cramp just like the hamstring or calf muscle, creating the feeling of plantar facial pain.
Several other possibilities exist that may cause heel pain/plantar fascia-type symptoms, including heel bone tumors (benign or malignant), systemic diseases such as diabetes, or several types of arthritis. Over 100 years ago, the most common cause of heel pain was syphilis.
If your symptoms are not responding to treatment, the diagnosis may need to be reevaluated. Once that is done, the correct treatment can be initiated.
Dr. Ira Meyers is board certified in podiatric surgery and specializes in treating running injuries. Dr. Meyers is part of the Montogmery Podiatry Associates. For more infomration, visit montgomerypodiatryassociates.com.
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