Differential Diagnosis
Plantar fasciitis (PF) is defined as a painful heel with inflammation of the plantar fascia (Lemont, Ammirati & Usen, 2003). Bill has reported pain under the left heel. Bill is a 42-year-old with subcalcaneal pain which is a common orthopedic problem occurring in people between the age group of 30 to 70 years (Meyer et al., 2002). Diagnosis of PF can be reasonably made by Bill’s clinical assessment, history, and physical examination (Alvarez-Nemegyei & Canoso, 2006; McPoil et al., 2008). Patients of PF report severe pain especially during the first-morning activity involving walking usually after a period of inactivity (McPoil et al., 2008). PF patients experience morning pain along with inflammation and commonly present local calcaneal tenderness (Young et al., 2004). The pain usually reduces with activities such as walking or running but may tend to worsen towards the end of the day (Alvarez-Nemegyei & Canoso, 2006). Research indicates that patients generally report a recent change in the level of activity such as walking or running for increased distances or longer periods (McPoil et al., 2008).
Differential diagnosis of heel pain can be overwhelming in the absence of a systematic approach (Alvarez-Nemegyei & Canoso, 2006). The first point of interrogation is the actual place of pain which could be at the back or bottom of the heel or around the ankle (Alvarez-Nemegyei & Canoso, 2006). The next step is to consider any structural faults by examining motion and palpations. The final question should be aimed at finding any inflammatory and metabolic diseases in the patient (Alvarez-Nemegyei & Canoso, 2006). Some of the differential diagnoses which must be considered in patients with PF are calcaneal stress, bone bruise, fat pad atrophy, soft tissue primary or metastatic bone tumors, and severe disease (Alshami et al., 2008; Nuhmani, 2012). The differential diagnosis for Bill will include the following aspects.
Fat pad atrophy
Patients of PF having soft and thin heel pads could experience aggravated pain by wearing hard heeled shoes or walking on hard surfaces. Pain does not radiate and medial calcaneal tuberosity and PF are not tender (Alshami et al., 2008).
Tumors
PF pain has been uncommonly related to the presence of benign tumors in patients who occasionally complain of a local loss of sensation (Alshami et al., 2008).
Proximal nerve lesions
Proximal nerve disorders among patients of PF should be ruled out with neurological tests to confirm that the tibia nerve has not been compressed which could be a cause of pain being radiated to the heel (Alshami et al., 2008).
Biomechanical Assessment of PF
The diagnosis of PF is mostly clinically indicated by the pain location (Alvarez-Nemegyei & Canoso, 2006). An alternate diagnosis such as calcaneal stress fractures and soft tissue tumors may be ruled out with imaging studies such as ultrasound of the hind foot are preferred due to the low costs and high-resolution images (Alvarez-Nemegyei & Canoso, 2006).
Comprehension of the biomechanical factors affecting the development of tension in PF is crucial for enhanced management of the problem. A biomechanical assessment of Bill is necessary to rule out the prevalence of biomechanical risk factors such as pests planus, valgus heel alignment, and discrepancies in the length of the legs (Young et al., 2001). The biomechanical function of the plantar fascia is to provide support for the longitudinal arch of the foot and absorb any occurrence of shock during standing, sitting, or motion (Hunt et al., 2004). Since the plantar fascia is the primary means of stabilization for the arch of the foot, the anatomical position of the foot and the mechanical strength play a crucial role in the development of PF and pain associated with it (Nuhmani, 2012). Increased tension of the plantar fascia has been shown to deform it by 9% to 12% (Nuhmani, 2012). The plantar fascia’s breaking strength has been calculated approximately 1.7 to 3.4 times the body weight (Hunt et al., 2004). As such, it will be important to check whether Bill’s body weight is in excess and is a cause for PF. It has also been estimated that the tensile strength of the plantar fascia peaks at about 800N to 1000N during walking (Hunt et al., 2004). Bill needs to be investigated to confirm whether he engages in work or exercise which necessitates him to bear the strain of weight for long periods. Research indicates that pain in the heels can occur due to chronic damage of the tissues which have not completely been repaired (Hunt et al., 2004). The impact of cellular and tissue degenerations and loss of fiber has been noted to hurt PF with increased pain. Some patients with a long and chronic pain history of PF have shown evidence of inflammation of cells present within the involved tissues (Hunt et al., 2004). Bill needs to be assessed biomechanically to confirm the nature of his activities and whether these are responsible for PF and severe pain.
References
Alshami, A. M., Souvlis, T. & Coppieters, M. W. (2008). A review of plantar heel pain of neural origin: Differential diagnosis and management. Manual Therapy, 13, 103-111.
Alvarez-Nemegyei, J. & Canoso, J. J. (2006). Heel pain: diagnosis and treatment, step by step. Cleve Clin J Med, 73, 465-471.
Hunt, G., Sneed, T., Hamann, H. & Chisam, S. (2004). Biomechanical and histiological considerations for development of plantar fasciitis and evaluation of arch taping as a treatment option to control associated plantar heel pain: a single-subject design. The Foot, 14, 147–153.
Lemont, H., Ammirati, K. & Usen, N. (2003). Plantar Fasciitis: A Degenerative Process (Fasciosis) Without Inflammation. J Am Podiatr Med Assoc, 93(3), 234-237.
Meyer, J., Kulig, K. & Landel, R. (2002). Differential Diagnosis and Treatment of Subcalcaneal Heel Pain: A Case Report. J Orthop Sports Phys Ther, 32(3), 114-124.
McPoil, T. G., Martin, R. L., Cornwall, M. W., Wukich, D. K., Irrgang, J. J. & Godges, J. J. (2008). Heel pain–plantar fasciitis: clinical practice guidelines linked to the International Classification of Function, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther, 38(4), 1-18.
Nuhmani, S. (2012). Plantar Fasciitis: A Review of Current Concepts. Indian Journal of Basic and Applied Medical Research, 5(2), 414-418.
Young, C., Rutherford, D. & Niedfeldt, M. (2001). Treatment of Plantar Fasciitis. American Family Physician, 63(3), 467-474.