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Unresolved Chronic Pain of the Heel

There are thousands of patients that are treated the plantar fasciitis every year. Many of these patients satisfactorily resolve their heel pain with standard treatments that include taping, oral medication, physical therapy, orthotics and sometimes surgery.

However, there are large group of patients that are diagnosed with plantar fascia that do not have plantar fascia. What they have is a sharp stabbing pain in the morning getting out of bed , pain in the bottom of the heel that grows as the day progresses, that is completely unresolved by a traditional treatment associated with plantar fasciitis. The patient’s may have a spur on the bottom of the heel on x-ray, or they may not have a spur. The diagnosis of a spur on x-ray does not always correlate with outcome of treatment. Ultrasound examination demonstrates clearly that the plantar fascia is normal. And oftentimes these patients have been to several doctors with chronic, severe heel pain, unresolved by traditional treatment.

These patients clearly do not have plantar fasciitis, although they have severe pain in the bottom of their heel. Oftentimes a thorough examination, which includes examination of the neurologic system elicits pain in other areas beyond the bottom of the heel. Often this reflects nerve entrapment on the medial heel and treatment is very different for this type of problem. Nerve compression can be effectively treated with both conservative and sometimes surgical care. But the appropriate treatment direction needs to be taken.

Case Study

WG is a cook was on his feet all day long. He complains of severe pain that feels like a knife penetrating the bottom of this heel. The patient presented with the classic diagnosis of plantar fasciitis. However Nonsteroidal anti-inflammatory medication, orthotics, cortisone injections, and extensive stretching and physical therapy, as well as shoe modifications were not effective in relieving the patient’s pain and discomfort. An ultrasound is performed and showed normal plantar fascia. Why is the plantar fascia normal when the patient has severe plantar heel pain? Careful examination demonstrated positive Tinel’s sign over the posterior tibial nerve. Nerve block to the same area demonstrated three days of relief. Although the anesthetic only lasted a couple hours. This is a classic presentation of nerve compression in medial heel. The patient completed extensive conservative care. He ultimately underwent a tarsal tunnel decompression and was able to resolve his pain.