Misdiagnosed Plantar Fasciitis – How To Figure Out Heel Pain
/in Podcast/by dmiddaughHey there, El Paso! This is Dr. David Middaugh, specialist, physical therapist over at El Paso Manual Physical Therapy, and I'm your host of the Stay Healthy El Paso Podcast. Today we're going to talk about misdiagnose plantar fasciitis, and specifically how to figure out your heel pain. Because if you really don't have plantar fasciitis then what the heck is it? What's going on? And how do we feel?
Get this out so that you can get back to being normal, get back to being active, healthy, and mobile in your foot and ankle without having to rely on pain medications, injections and of course, dreaded surgery.
Let's get into some specifics about how plantar fasciitis is typically diagnosed, what healthcare professionals are looking for, as far as symptoms, signs that that are classified or diagnosed as plantar fasciitis. And then what kind of treatment options are out there. I'm going to get into the controversial stuff, the misdiagnosis, and how we look at it here in the clinic at El Paso Manual Physical Therapy, and how we find misdiagnosed plantar fasciitis.
Almost every time we see a plantar fasciitis patient, somebody that comes in saying they got plantar fasciitis. So let's get into it. First off, the biggest symptoms that people have, whenever they go to see their physician, or their foot doctor, or whoever it is they are seeing as a healthcare professional for their heel pain.
When doctors, physicians, foot specialist diagnose plantar fasciitis, the number one sign they are looking for is when you get up in the morning. Your first few steps, if you have sharp stabbing pain in the heel, that tends to get better as you walk around more, but maybe never goes away or maybe it does if it's not that severe. But the classic telltale sign is that sharp stabbing pain with your first few steps in the morning.
That is often called plantar fasciitis. And there may be some associated limping that goes on. If you can't walk normal. You have to walk very, very carefully, holding on the furniture, holding on to things as you get up. And then some people report swelling as well. They get swelling around the heel area.
They get a different sensation. At the bottom of their foot, on the heel side of their foot, and some people perceive it as swelling. The last patient we had in here with these kinds of symptoms said that she felt like the pad at the bottom of her of her heel was flat. Like it lost its air, like a tire on a car. Like she said, she was like I have a flat tire and I'm stepping on the bone, instead of the cushion, the meat of the foot under the heel. That's kind of the description people have. And it can get better and worse without ever really knowing or understanding how it happens.
As far as treatment, once you tell a physician that you have this, and then they are going to automatically start writing down plantar fasciitis treatment. There are tons of ways to go with this. Of course, physical therapy is one of the treatments. I'll talk more about that later. But let's talk about other treatment options that people go towards if they have plantar fasciitis.
The simplest easiest one that people do is ice, they start icing their heel.
They will just get a bag of ice or some sort of cold thing that you can buy the story to those, those gel packs. The other thing that's commonly done is they will get a water bottle that they freeze. So it's like a cylinder shaped ice block essentially. And they will roll it on their heel and the arch of their foot. And that can be quite beneficial.
Actually, the reason for that is because it numbs the tissues, and everything under the foot and can be relieving, but it doesn't solve the root problem. Which I'll get into more about what the root problem is. But let's just go through these treatment options.
The next one is braces.
People often try all kinds of braces, the ones that you lace up the ones that have struts, metal struts or hard plastic struts on the sides. There are braces that you just wear at night. Those are called night splints. You may not use anything during the day. But there are special plantar fasciitis braces that you wear at night.
The reason why they are special is because they typically have this fabric strap that hangs off the end of the toes that is attached to the shin area of the brace. So it holds your foot and toes up, like you're lifting your toes up, and it puts a stretch on the bottom of the foot into the heel. And some people report they feel a little bit of relief with that.
Another more invasive treatment option is injections. Injections are commonly done for plantar fasciitis symptoms, specifically cortisone or corticosteroid injections because that drug is an anti inflammatory and pain reliever. The thought is that the plantar fascia, which is a tissue, and I'll go more into it in a second. It it's inflamed, and so if we inject anti-inflammatory medication, then it would help with the pain and with the long-term outcome.
The problem is that the plantar fascia is made of connective tissue. And corticosteroids are known to degenerate connective tissue with prolonged use. So, it's very much a short-term solution. And then, in extreme examples, you can have surgery. There are plantar fascia release surgeries where a surgeon will go in there and cut the plantar fascia to relieve pressure.
Now I'm not 100% sure on exactly how this is done, as far as if they cut the entire plantar fascia or a portion of it. This isn't a common surgery. So it's not something that I know a lot about because we just rarely see it. I've seen it in two people before and where they cut it on the scar, it looks like it's only a partial cut not a complete cut of the plantar fascia. I think that's how they are doing it is he just cutting an edge of it to lengthen it a bit. Just to relieve some pressure. But they will cut it the whole way is my is my hunch.
Anyway, as far as the way I think about the body mechanically, I doubt that a surgeon would completely cut the plantar fascia. In most cases when they are going where they are looking to do surgery on the plantar fascia.
Okay, so we're going to get into the PT treatment discussion about what is done in physical therapy for plantar fasciitis. But real quick, let's visit what plantar fasciitis is, physiologically, what's going on in the body so that listeners can understand how this all works.
Let's start off with the plantar fascia itself. The plantar fascia is connective tissue that attaches from the heel of the foot. And if you want a visual of this, it's easy to just go plantar fascia, Google will probably autocorrect if you have trouble spelling it. Because it is a little difficult to spell and click on the images tab, and you'll see tons of pictures of plantar fascia. It's all over the internet.
Anyways, it's a white tissue, a connective tissue. It's white because it has a low blood supply. And its job is to help maintain the arches of the foot. There are actually three arches in the foot. The main one that everybody talks about is a medial longitudinal arch, but there are a lateral longitudinal arch and a transverse arch. But its job is to primarily help hold up the medial lateral longitudinal arch.
The theory, and I say theory because this is this is not proven. This is how most healthcare professionals are operating. The theory is that plantar fasciitis develops because it's getting overly stretched out. So if you have flat arches, it's tensioning the plantar fascia. And if you do that too much, then it begins to irritate the plantar fascia at the insertion point at the heel. And that's why it's tender at the heel. And that's why people get these symptoms when they first stand up, it hurts a lot right in the heel.
That's why the treatment options are such that's why they do the surgical, the plantar fasciitis releases, that's why the braces The idea is that it's too short and needs to get stretched out as well at the heel. That's the thought process with normal plantar fasciitis. But what most healthcare professionals don't think about, that I need you to be aware of, is that the plantar fascia is not the only structure in the heel, which means it's not the only thing that can cause pain or discomfort or some problem.
You also have a pretty substantial fat pad, under the heel. There are bones there, the calcaneus in the heel bone. And there are tendons that pass in the area. Tendons are what connects the muscles to bones. They help to transfer forces to pull on things and make them move. And then the biggest culprit of heel pain in my opinion is nerves.
Nerves cover our entire body. And specifically, in the heel. There are several nerve branches that cover the heel and there is one that runs right over the insertion point of the plantar fascia. So when I do my testing, when I have a plantar fasciitis patient here in the clinic, one of the first things I do is, I do something called a wineglass test and I do a modified version of it. I'm looking to put some tension on the plantar fascia. And then I have to poke on it. And now what we'll do is we'll poke on it without tension and poking it with tension.
The idea here is that if it is truly plantar fasciitis, if it is the plantar fascia that is affected when we put tension on it because it's connective tissue, it's designed to maintain some tension to hold certain body parts together, in this case, the arches of the foot. It stresses the tissue a bit, and then if we apply pressure on it, that stresses the tissue a bit more. It should theoretically hurt most at the plantar fascia. If we apply tension to it and put pressure on it with it with the finger versus if we take tension off, we put it on slack and then apply pressure it should hurt less consistently.
When I get a patient with plantar fasciitis, I do this one last test and it is negative. In other words, it shows that the plantar fascia is not the culprits. And then I'll cross references tests with the nerve tests, where we feel and tension and affect the nerves that run into the heel. And those tests become positive. I have to make the call the diagnosis with the patient that the heel pain is not plantar fascia driven. Its nerve driven.
Now this changes everything because if its truly plantar fascia driven, then the treatment is going to look different. Now we have to ask the question of if it's a nerve problem, do we need to be stretching? Do we need to be splinting it? Do we need to be bracing it? Is injections going to help? Is doing a plantar fascia release surgery going to be effective for a nerve problem in the heel?
I always ask the question of, did the doctor that diagnosed you with this plantar fasciitis do these tests? And it's always no because they just aren't aware. It's just not something that they are trained to do or have figured out to do. And I don't expect it of other healthcare professionals. This is our profession as a manual physical therapist. So it's our specialty.
But we can figure out if it's truly more nerve or more plantar fascia or something else, there are issues in the joints of the foot that can also contribute to heel pain. And we looked at that and then there are also a situation where you can have a combination of things. So we have to judge that scenario as well and then make the proper treatment recommendations for the patient moving forward.
But what we'll settle on here is about nine times out of ten, when we get a plantar fasciitis diagnosis here in the clinic, patients coming in saying I saw a doctor, they told me about plantar fasciitis. I googled the symptoms and all over the internet, it says heel pain, limping and swelling or symptoms. So I'm Dr. Google's confirm for me and a real doctors confirm for me and I have the paper here from the doctor saying that I have a plantar fasciitis syndrome, then I'm thinking to myself, I'm not going to I'm going to take this with a grain of salt. I'm going to check it for sure, but let's check the nerves too and other things so that we can know exactly how to treat this.
Now, if it's plantar fasciitis, if it’s true plantar fasciitis, physical therapy treatment is usually focused on improving the arch. Which makes sense, because you want to take pressure off of the plantar fascia using muscles and other structures in the foot to alleviate the pressure on the plantar fascia.
But if it's not plantar fasciitis, and if it's a nerve problem, and we're doing a treatment that's treating plantar fasciitis to better support the arch, we're going to miss the boats and people can experience a situation where they go through physical therapy. Do all the foot and ankle and toe exercises, they typically will do heel raises, calf raises is another name for it, whether tippy toeing, they might do it in different ways, maybe seated to do a live version of it standing to do a harder version of it, with weights to do an even harder version of it, on a foam pad to add a balance aspect to it single legged.
They will do ankle stretches where they stand against a wall and push their heel back and put a stretch to the achilleas in the foot and the heel. They will do toe exercises as well. A common one is where they have to scratch up a towel with their toes, or pick up marbles with the toes, or I've seen some people have to pick up pins or other objects with their toes and it always makes people feel like a monkey because you're having to use your toes like fingers.
It can help to alleviate some of the symptoms, even if it's a nerve driven problem. Simply because we're just getting more motion to the foot and the heel. Motions that haven't been done before. But to truly fix the problem for the long term, so that it's not coming back in three months, or six months or a year, we've got to look at the entire length of the nerves that end up in the heel, and typically it's the sciatica nerve.
One of the questions here is the misdiagnosis that I'm talking about. One of the questions that I have to ask every patient, whenever they come in with heel pain, is do you believe you have, or do you have minor amounts of sciatica or low back pain? Because the nerve that ends up in the heel that is commonly affected, it's a branch of the plantar nerve, which is a branch off the tibial nerve, which is a branch off this sciatic nerve which starts up in the back.
So, do you have pain in your butt area, your thigh, your calf? Do you have any cramping that occurs in the calf and the thigh up in the hip? Do you have any shakiness? Have you had any back problems? Or maybe it's not really painful now but in the past have you had issues?
I'm also looking at the way their back moves, any other muscle imbalances that might be further up the chain. And I'm putting all this together to formulate the best diagnosis which will then lead us to the best treatments. And time and time again, it happens where we find an issue we, find a some sort of back pain, and usually the heel pain is so intense and so limiting that our patients often forget that they have back pain. It's not something that they are worried about.
And if they are on pain medication for the heel, that lower level sciatica pain, or back pain kind of diminishes, and they just don't even think about it. They are completely focused on getting rid of the heel pain. That they just don't pay attention to the back or thigh pain that they've been having. But have to dig there. And then I'll do some nerve tests. And once we do those nerve tests that are biased and tensioning nerves into the heel, if those tests are positive, if they create some sort of symptoms, then it's absolutely a nerve driven problem.
Then the treatment for that is completely different. We're doing some foot exercises, some foot, hands on treatments, that I have to look at the knee, we have to look at the hip, the thigh and the lower back. And oftentimes, we're doing treatment on the low back, hips, and knees in addition to the foot and that's what truly clears up the heel pain. I wouldn't even call it plantar fasciitis at that point.
The last client that we had with this, she came in and she's been having heel pain for a while. She is an active individual. She's in her 60s, late 60s I believe. She loves to do housework, gardening work. She takes care of her elderly mom, who's gone through some health conditions. She is active and wants to vote. She's a grandmother and is trying to spend time with her family. She's not really a couch potato. And she's been doing that for a long time. She helps out her husband with a business and is on her feet quite a bit for that.
So this active individual all of a sudden was put down by this heel pain and she just kind of muscles through it, but it has to grit through pain and discomfort all the time. And the biggest problem she had was when her mother was at her sickest, she's gotten better. Thankfully. Her mother was waking up at night often and our patient would have to get up to go check on her at night often, and it was just killed her, it would hurt her heels so much to have to take those first few steps at 1am and then at 3am, again at 5am again. And so it was just so painful and aggravating.
When you're in that much pain and that much discomfort, you just don't want to get up, you lose focus, you aren't thinking clearly, you want to take medications, you're grumpy. It's just a bad situation. What she found is that wearing shoes helped. It didn't completely take away the pain. Wearing shoes, it had a little bit of a heel helped.
It also didn't take away the pain though. And she tried doing normal physical therapies, she tried doing ice. She hadn't done injections or surgery and thankfully. She tried braces and splints. And it all kind of helped but didn't really solve the problem. So that's why she ended up visiting us. And once she saw us, she was convinced it was plantar fasciitis. A doctor told her it was plantar fasciitis and she's googled it, and it was plantar fasciitis.
She has all the symptoms and when I look at everything on her, I found that she had a significant back condition that is going to put pressure on nerves and can mask a plantar fasciitis symptom, but it really is a nerve symptom. So as we've gone through treatment for a nerve symptom, not plantar fasciitis. She's done phenomenal. Her getting up in the in the middle of the night is less of a problem and getting up in the morning isn't a big deal.
Now where she's at, we're about a little over a month in. She is really only getting pain or discomfort after she's been on her feet after a long day. Which is a great place to be because now it's just a matter of getting stronger in certain muscles. In her specifically, the biggest weakness that she's got wasn't in the foot. It wasn't in the lower leg anywhere near the heel. It was her abdominals. By strengthening her abdominals, what I determined is that we can take pressure off her back, because that's where she's getting the most pressure on the nerve.
So, by strengthening her dominance properly and having her use them throughout the day properly, that alleviates pressure in her back, which unintentionally, the nerves beginning at the roots in her back, which then will allow more nerve freedom all the way down into the heel. So far we've been successful and I know she's going to be fantastic as she continues to strengthen, and then doing her busy, active lifestyle, gardening, taking care of the house, taking care of family members won't be a thing for her. It won't stop her this heel pain.
That's how plantar fasciitis is often misdiagnosed. It's just taken for words from the healthcare professionals that have its heel pain, if it hurts in the mornings, especially if there are some limping or swelling going on. Then it is plantar fasciitis. But it's not dug into more than that simply because most doctors or physicians, foot specialists just are not specialists looking at the nerve aspect of this.
And if you're out there, you have heel pain and you tried the braces, the splints, you've tried taking over the counter pain medication, maybe even prescription strength pain medication, or worse yet, you've had injections or maybe even a plantar fasciitis release surgery, and you still have the problem. I'm willing to bet that you've probably got a nerve problem that hasn't been addressed. And you've been misdiagnosed, unfortunately, with plantar fasciitis when really you have what I call radiating nerve pain. That's what that means.
And no amount of orthotics or insoles will fix this problem either. It'll help, don't get me wrong. I'm not against orthotics or braces or splints. It will help but I'm talking about long term resolution of this problem. We've got to address a number of symptoms and we've got to look all the way up the chain of joints and muscles, and oftentimes it ends up being in the back and the hips.
So that's our podcast episode for today. I hope you learned a lot if you have plantar fasciitis symptoms, heel pain, and you suspect that this problem might need a deeper look into it. You can definitely reach out to us here at El Paso Manual Physical Therapy, and we're happy to talk to you about it to see what can be done about it, if it can be helped, if we're the right people to help you for that.
We can we can begin that conversation. You give us a call at 915-503-1314 and we're happy to hear about your heel pain story and want to learn more about it and see if we can help out. I hope you have the best day ever today. Bye.
The show is available on Anchor | Spotify | iTunes | Google Podcast | and others...
Would You Like To Talk With A Specialist?
Choose which one works best for you…
