Diagnosing heel pain

author : AMSSM
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Calcaneal bursitis vs plantar fasciitis, or "osis"

Member Question from Jami:

"I have dealt with plantar fasciitis for about two years in my left foot.  I had it in my right for about a year. I've noticed the left foot has been so different, and I have tried just about everything. I had the shot and it left me with a calcaneal stress fracture.  I've done PT twice, currently a third time.  This time I'm having ASTYM done. I have done the splint, bought custom orthotics, stretched, and stretched some more, iced, heat, etc.  I've been doing a little research and I really think that I have a bursitis. I have pain just on the bottom of the heel.  It feels like a marble stuck to my heel bone.  Like I have something in my foot. My current PT is doing an aggressive form of ASTYM and he noticed that my fascia is not tender at all.  It's just the pain on the bottom of my heel and now where I have favored it so much, my ankle is very weak as well. I am calling my Ortho in the morning to try and get back in, but I guess my question is how different are the treatments for bursitis vs. PF? I noticed when I do heel raises individually I am so much stronger with my right foot. I am not running much at all. And I have ordered a pair of Hoka shoes that should be here Tuesday. I have also tried so many shoes.  Mostly stability/motion over the years, but the last 2 years those shoes haven't helped.  I tried Newton’s and I don't think those helped or hurt."

Answer from Aaron D Campbell MD, MHS
Member, AMSSM

Jami, first let’s review some of the differences in the issues you have mentioned. A bursa is a thin, jellylike sack that allows the smooth transition of tendons over joints and bony prominences in your body. When irritated, they can become thickened, often due to an overuse or stress in that body area. The calcaneal bursa is located at the base of the Achilles tendon, not the bottom of your foot. Calcaneal bursitis may present as swelling, pain, and sometimes redness, at that location, (but not the midsubstance of the Achilles tendon), where the pain is worsened with direct pressure or repetitive ankle flexion and extension. Plantar fasciitis is an issue at the bottom of your foot or heel, otherwise known as the calcaneus bone. It is typically at the medial aspect of the calcaneus. The tissue is fascia, a lot like a ligament structure, which is thin, and acts to connect that single attachment point on the medial aspect of the calcaneus to all of the bases of your toe joints. Irritation at this area is considered a friction and overuse issue. It too can become thickened at the attachment point of the calcaneus leading to pain, and the sensation of stepping on a marble or pebble. An “-osis” is a suffix used to describe pathology in a structure that is not inflammatory. For example, Achilles tendinitis, is a misnomer because this is not an inflammatory process, and should be called Achilles tendinosis describing the injury as a possible tearing, or degenerative changes, all based on overuse or improper mechanics.

The differential diagnosis (list of things that could be wrong) in heel pain, involves a good physical exam after obtaining a history of the problem. Location of pain is a very important piece in the diagnosis because it can tell the provider what structures are involved vs not involved. Imaging such as x-ray’s can evaluate for fractures, and musculoskeletal ultrasound is now widely used to evaluate soft tissues such as bursae, fascial planes, tendons and ligaments for thickening, tearing, fluid and other abnormal changes. Based on what you’ve described, I think you have plantar fasciitis.

Treatment for any of these things depends on the issue. Injections or a “shot” as you mention are available, but the preferred injectable substance depends on the affected structure. Steroid injections are for inflammatory processes, not overuse and degenerative changes, and they can increase one’s risk of rupture if used at a tendon attachment. While commonly used, probably because they can improve pain, steroids target inflammatory processes, however, none of these issues are inflammatory. Steroid injections are reasonable as a first treatment in prolonged plantar fasciitis after other interventions have failed. However, it is important to pair any injection with an appropriate course of physical therapy (PT), which involves strengthening the structures involved as well as related structures, such as core musculature, and improving upon body mechanics to avoid improper loads on the affected areas.

Foot fractures should always be managed with non-weight bearing until pain completely resolves, then activity as tolerated, assuming approximately 6 weeks to heal a fracture. Large bursitis issues can sometimes be drained with needles, but again warrant a good course of PT. Other injections have also been demonstrated as useful, many of which are biologics such as whole blood or blood products such as platelet rich plasma (PRP), or even dry needling or dextrose. Shoes like “hoka” style shoes have not been found to be effective, but arch supports have been found effective, especially in individuals who have flat feet. Modifying your training is also essential to improve mechanics and the transfer of forces across weight bearing joints. Strengthening is a mainstay in treatment, likely why your right leg felt stronger and less affected after performing heel raises. ASTYM is a type of regenerative therapy where local destruction of tissue stimulates your body’s immune system to scar down and heal an injury. Dry needling or percutaneous (below the skin) needle tenotomy (using a needle to perform local tissue destruction) followed by an injection of a healthy biologic substance, but probably not steroids, in addition to arch supports, proper body mechanics, and body restoration through physical therapy are probably of the more effective approaches to plantar fasciitis.

Aaron D Campbell MD, MHS
Sports medicine and Urgent Care
Park City, UT

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date: January 30, 2016

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The American Medical Society for Sports Medicine (AMSSM) was formed in 1991 to fill a void that has existed in sports medicine from its earliest beginnings. The founders most recognized and expert sports medicine specialists realized that while there are several physician organizations which support sports medicine, there has not been a forum specific for primary care non-surgical sports medicine physicians.

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