Plantar heel pathologies

Red flag screening

• Sinister pathology
• Emergency conditions such as acute tendon rupture or fracture
• Osteomyeltis/infection/charcot.

Consider

• Mechanism of injury
• Duration and severity in symptoms
• Change in symptoms.

Limitation of function
Swelling pattern and severity
Structural changes in foot.

• Assess passive and active range of motion, bony tenderness, muscle power.
• Digital drawer test to assess integrity of plantar plate and joint capsule.
• Pattern of pain e.g. pain on rising.
• Function test restrictions.
• Assessment of the triceps surae flexibility.
• Calcaneal compression.

• X-ray to exclude fracture/osteomyelitis. X-rays for plantar heel spurs not appropriate.
• Ultrasound scan to assess tarsal tunnel, baxters nerve entrapment. Ultrasound scan for plantar fasciitis generally not indicated unless strong suspicion of rupture.

• Calcaneal stress fractures
• Tarsal tunnel syndrome
• Baxters nerve entrapment
• Inflammation of the fat pad
• Bursitis
• Infection
• Stress fracture
• Calcaneal apophysitis
• Enthesitis.

Patient education and self management advice, with supporting literature including:

• Weight management advice if appropriate
• Activity modification and management advice
• Analgesia & non-steroidal anti inflammatory drugs as appropriate
• Exercise prescription
  • Intrinsic foot exercises
  • Calf/achilles stretches
  • Balance and proprioception
  • Heel raises
• Footwear advice
• Avoidance completely flat footwear, up to 1.5 inch heel height acceptable
• Advice on lacing techniques
• Rigid rocker.

• Failure of first line treatment
• Ambiguous diagnosis
• Worsening symptoms.