DIFFERENTIAL DIAGNOSIS OF HEEL PAIN
may also be lessened by shoe gear, such
as Skechers or MBT, because the built-
in rocker bottom present in these shoes
limits the range and speed of digital
dorsiflexion.
In addition to strengthening the digital
flexors, chronic plantar fasciitis often
responds well to low-dye taping and to
custom and prefabricated orthotics
Fig. 2. Plantar fascia
(which are equally effective for
home stretch. This
the short-term treatment of plantar
stretch is held for 10
fasciitis [3]). As demonstrated by
seconds and repeated
Kogler et al. (4,5), buttressing
30 times per day. The the
plantar fascia should
medial longitudinal arch and
be lightly massaged
incorporating rearfoot varus and/or
while performing this
forefoot valgus posts may significantly
stretch.
lessen tensile strains present in the
plantar fascia. Other conservative
treatment interventions include
frequent stretching of the posterior calf musculature and the
use of night braces. DiGiovanni et al. (6) demonstrate improved
clinical outcomes occur with the simple addition of the
home stretch illustrated in figure 2. This stretch is held for 10
seconds and repeated 30 times per day. Although deep tissue
massage may be helpful because it improves resiliency of the
plantar fascia and may stimulate repair, care must be taken to
avoid irritating the medial and lateral plantar nerves, which
may be contused by overly aggressive cross-friction massage.
When performed properly, deep tissue massage coupled with
stretches to restore first metatarsophalangeal joint dorsiflexion
almost always results in a 10° increase in the range of hallux
dorsiflexion. This is significant, since surgical release of the
medial band of the plantar fascia has been shown to increase
Fig. 3. Baxter’s neuropathy test. When the nerve to abductor digiti
quinti is compressed, the patient is unable to abduct the fifth toe (A).
MPN=medial plantar nerve; LPN=lateral plantar nerve; BN=Baxter’s
nerve.
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Pedorthic Footcare Association www.pedorthics.org
the range of first metatarsophalangeal joint dorsiflexion by
10° (7). Because of this, surgical release of the plantar fascia
(which may result in a gradual destruction of the medial arch)
should not be considered unless manual therapy fails to improve
the range of first metatarsophalangeal joint dorsiflexion. The
response to manual therapy can be evaluated with careful pre-
and post-treatment measurements of hallux dorsiflexion. The
efficacy of manual therapies for lessening plantar heel pain was
proven in a randomized controlled trial in which the addition of
trigger point massage to a conventional self-stretching protocol
produced superior short-term outcomes compared to stretching
alone (8).
Alternate causes of heel pain include enthesopathy from
various autoimmune disorders, Baxter’s neuropathy, calcaneal
stress fracture, and/or heel spur syndrome. The autoimmune
disorders, such as rheumatoid and psoriatic arthritis, frequently
produce pain and swelling at the plantar fascia origin, and are
often misdiagnosed because the early signs are similar to those
associated with mechanical plantar fasciitis. Clinical clues
suggesting autoimmune causes for heel pain are that these
disorders tend to produce discomfort bilaterally, and the swelling
tends to be more extreme. If psoriatic arthritis is the cause, skin
plaques can often be seen on the hands or behind the ears.
Suspected cases should be referred to a rheumatologist.
Another cause of heel pain is Baxter’s neuropathy. This
condition represents a nerve entrapment syndrome in which
the nerve to abductor digiti quinti (also known as Baxter’s
nerve) becomes inflamed beneath the proximal portion of the
plantar fascia. Clinical signs of Baxter’s neuropathy include
the reproduction of pain by abducting and dorsiflexing the
forefoot for 30-60 seconds, a positive tourniquet test (i.e., pain is
reproduced by inflating a blood pressure cuff placed around the
lower leg to slightly above systolic pressure for 30 seconds) and/
Fig. 4. Nerve glide technique. To mobilize Baxter’s nerve, the patient
places the heel on an elevated platform and then alternately extends
the neck while dorsiflexing the ankle and toes (A), and then flexes the
neck while plantarflexing the involved ankle and toes (B). Each cycle
is performed for approximately 5 seconds and there should be minimal
discomfort while performing this procedure.