Heel Pain

Clinical Pearls of Wisdom Q&A Case

Heel pain is defined as physical discomfort on the back or the underside of the heel that may make walking uncomfortable or difficult. Heel pain can have causes that aren't due to underlying disease. Examples include poorly fitting shoes, wearing high heeled shoes, prolonged period on feet, overuse such as long walks or marathons, sprains, strains, or trauma.

Try this heel pain board review question-based case and pick up another "pearl of wisdom" from Med-Challenger.

Clinical Scenario:

A 48-year-old woman presents with right heel pain. She describes sharp heel pain that is bad in the morning, abates somewhat in the course of the day, and then returns by the end of the workday. It started insidiously and has progressed over the past three months. She does not recall any specific inciting injury.

She works as a picker in a warehouse and is on her feet during the workday. Her prior medical history includes hypertension, for which she takes amlodipine. Her prior surgical history is significant only for cesarean section. There is no family history of rheumatologic disorders.

On examination, her heel pain can be reproduced by firm palpation of the anteromedial heel. There is no edema, erythema or warmth.

Question:

What are the most appropriate next diagnostic / therapeutic steps for this patient with heel pain?

Answer Options:

Obtain a lateral foot x-ray, looking for calcaneal spur, and, if present, consider extracorporeal shock wave treatment.

Inject calcaneal tuberosity with dexamethasone and lidocaine, and use supportive taping.

Recommend rest, cushioned shoe inserts, home stretching exercises, and simple analgesics.

Order erythrocyte sedimentation rate (ESR), c-reactive protein (CRP), and an ultrasound.

See the Answer:

The correct answer is:

Recommend rest, cushioned shoe inserts, home stretching exercises, and simple analgesics

Key Point:

Plantar Fasciitis is a clinical and not a lab or imaging diagnosis, and its first-line treatment is rest and stretching, not medication or surgery.

Explanation:

This patient with heel pain has a history and physical examination consistent with plantar fasciitis.

The plantar fascia connects the metatarsals to the calcaneus and forms the arch of the foot. Plantar fasciitis is an overuse condition characterized by pain the insertion of the fascia into the calcaneus at the calcaneal tuberosity. Fasciitis is a misleading characterization of the disorder, as it is not characterized by inflammation so much as degenerative changes from overuse. It is the most common cause of foot pain and the impetus for a million visits to providers yearly, often in primary care.

Risk factors for plantar fasciitis include limited ability dorsiflex at the ankle, increased BMI, running, jumping and impact of working on concrete surfaces, particularly in flat or poorly cushioned shoes.

The patient will often present with a complaint of heel pain, often worst with the first few steps of the day. On physical exam, the patient will often have pain with palpation of the anteromedial calcaneus, at the tuberosity where the plantar fascia inserts. The heel pain can often be provoked, as well, by forcibly dorsiflexing the toes and forefoot, stretching the plantar fascia.

Labs and imaging are NOT required to diagnose plantar fasciitis. Since plantar fasciitis is not an inflammatory disorder, inflammatory markers in the blood will not be elevated. While many patients will have a calcaneal spur (‘heel spur’) on plain X-ray, the presence of heel spur is neither sensitive nor specific for plantar fasciitis and will not alter treatment decisions. Similarly, while ultrasound and MRI may show edema or tissue thickening, but they will not change the management. Plantar fasciitis is a clinical diagnosis.

Treatment of plantar fasciitis consists of rest, stretching both the plantar fascia and the Achilles tendon as well as the use of cushioned shoe inserts. Analgesics can be used. Other therapies include steroid and local anesthetic injection, night splint use, extracorporeal shock wave therapy, casting, and surgery.

The prognosis of plantar fasciitis is good, and 80% or more patients will have a favorable outcome at one year with conservative therapy, so that remains first-line. Injection carries the risk of fascia rupture and fat pad atrophy and is thus reserved for those not responding to first-line conservative therapy.

Night splints and shock wave therapy for plantar fasciitis, while often used, are not supported by high quality evidence for high efficacy.

Surgery is reserved for a small minority of patients who do not improve with prolonged (one year plus) attempts at conservative therapy.

Figures:

Heel Pain: Plantar Fasciitis vs. Heel Spur

References:

Schneider HP, Baca JM, Carpenter BB, Dayton PD, Fleischer AE, Sachs BD. American College of Foot and Ankle Surgeons clinical consensus statement: diagnosis and treatment of adult acquired infracalcaneal heel pain. J Foot Ankle Surg. 2018;57(2):370-381

Becker BA, Childress MA. Common foot problems: over-the-counter treatments and home care. Am Fam Physician. 2018;98(5):298-303

Trojian T, Tucker A. Plantar Fasciitis. Am Fam Physician. 2019; 99(12):744-750

About the Author:

Gerard Kiernan, MD, FAAFP, FHM is a Dartmouth-Hitchcock Clinic hospitalist in Keene, NH. He attended the University of Rochester School of Medicine and Dentistry, followed by a Family Medicine residency at the University of Wisconsin, Madison, where he was a chief resident. Dr. Kiernan is a Lean Six Sigma Greenbelt and has led hospital medicine quality improvement efforts. He is a fellow of both the American Academy of Family Physicians and the Society of Hospital Medicine. He has achieved the Recognition of Focused Practice in Hospital Medicine offered through the AAFP and ABIM via their joint examination pathway.

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