WHEN IS HEEL PAIN NOT PLANTAR FASCIITIS?
It’s estimated that 93% of lower heel pain is caused by degeneration of the plantar fascia. However, in a 2003 study in the Journal of Foot and Ankle Surgery, they found that in 84 patients with a chief complaint of plantar heel pain, more than 72 percent had a sensory disturbance of the medial calcaneal nerve and/or tarsal tunnel syndrome.1 What this means is that your heel pain may be nerve pain. Of course, you can have more than one cause of your heel pain. Often, chronic heel pain is a puzzle that needs to be solved in order to be treated effectively.
So, what do we look for when diagnosing your heel pain? Diagnosis always starts out with the history. Here are some factors that make us think that your pain is neurogenic:
1) Your pain is burning in nature.
2) You have pain at night when you are OFF your feet.
3) Your pain worsens after you are up on your feet.
4) Orthotics have either not helped or have made it worse.
Although these criteria haven’t been scientifically validated, it has been proven accurate for multiple independent practitioners including us.
We then use physical examination to rule in/out entrapment of a nerve, plantar fasciitis, and other possible causes. Knowledge of the specific anatomy is integral in proper diagnosis.
Often, neurogenic pain can be elicited by stretching a nerve. Below is an example of a nerve stretch test. A positive test implicates the nerve tested and often includes a reproduction of symptoms or even an asymmetrical sensation compared to the other side.
Watch the first video below for a demonstration of the tibial nerve tension test.
We can then prescribe neurodynamic stretches to provide the nerve with blood flow and movement. Massage techniques can be useful in facilitating blood flow and movement as well.
Watch the second video below for a demonstration of the tibial nerve slider and massage technique.
1. Rose JD, Malay DS, Sorrento DL. Neurosensory testing of the medial calcaneal and medial plantar nerves in patients with plantar heel pain. J Foot Ankle Surg. 2003; 42(4):173-177.
2. Tassone J, Barrett DL. Diagnostic Ultrasound of the Foot and Ankle. Data Trace, Baltimore, 2013.