Misdiagnosed? When Heel Pain Isn’t Plantar Fasciitis

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Here at UFAI, we field a lot of questions about heel pain! Heel pain is one of the most common complaints among podiatric patients. But, the cause of the pain isn’t always easy to identify.

About 7 times in 10, the prime culprit is plantar fasciitis. Plantar fasciitis is the inflammation of the plantar fascia – the tissue which connects the heel to the ball of the foot.

When the plantar fascia becomes overstretched, dozens of tiny tears develop and irritate the tissue. While at rest, the tissue heals and tightens. The result? That characteristic pain and stiffness in the heel first thing in the morning. The pain usually subsides within a few minutes of bearing weight, as the fascia has a chance to stretch out.

But what about those times when it’s NOT plantar fasciitis? If your pain isn’t responding to treatment, our doctors can provide a second opinion! Check out what our experts had to say about some of the more obscure sources of heel pain.

“Every possibility must be considered.”

With such a high diagnosis rate, it’s easy to slap the plantar fasciitis label on every case of heel pain that hobbles into the clinic. However, misdiagnosing heel pain can delay healing and can even cause more problems.

When you visit your foot and ankle specialist, he or she will rule out possible conditions through testing and examination. But if their list of working diagnoses is incomplete, it will be that much more difficult to zero in on the true cause.

Dr. Bob Baravarian explained, “Heel pain could stem from many causes: nerve pain, bursitis, stress fracture, bone bruise, bone cyst. When you’re dealing with a mechanism as complex as the human foot, every possibility must be considered.”

Nerve Pain

Nerve pain can often feel much like plantar fasciitis, except the pain often gets worse with extended periods of walking or standing. Nerve pain can also feel more like tingling or burning and can migrate to the lower back.

Nerve conditions that cause pain in the heel come in two main flavors: Baxter’s neuritis and tarsal tunnel syndrome.

heel pain
  • Baxter’s Neuritis: Associated with a small nerve branch that runs from the inside of the heel to the bottom of the heel.
  • Tarsal Tunnel Syndrome: Associated with nerve compression on the side of the ankle. Comparable to carpal tunnel syndrome in the wrist.

“To distinguish between the two, we would apply pressure or tap on certain points of the foot, and note any pain or tingling sensations that result,” said Dr. Baravarian. “Another thing we can do is administer a numbing agent to pinpoint the particular nerve that’s causing the problem.” If the pain dissipates, you’ve got your answer.

Bursitis

A bursa is a thin, fluid-filled sac that cushions soft tissue from friction against a bone. Heel bursitis develops when one of these bursae, located on the bottom of the heel, becomes inflamed. Unlike plantar fasciitis, bursitis pain gets worse with increased walking, as extended pressure irritates the tissue.

Your foot and ankle specialist can diagnose bursitis using an ultrasound. The imaging will show an inflamed bursa alongside a normal plantar fascia.

Getting the right diagnosis is crucial to healing because while many treatments for heel pain involve sturdy custom orthotics, bursitis actually requires soft cushioning to reduce pressure.

Heel Stress Fractures

Heel stress fractures are born from trauma and are usually associated with at least one other injury. Stress fractures can develop gradually – say, while spending too much time in a bad pair of shoes – or they can result from an acute injury – such as a long fall with a hard landing.

Your foot and ankle specialist can usually identify a stress fracture with a squeeze of the sides of the heel (psst – it will hurt!) and an advanced imaging test, such as an X-ray or MRI.

To treat a stress fracture, your foot will be placed in a boot or a cast to allow it 4-6 weeks of rest.

Heel Bone Bruise

A bone bruise on the heel bone also results from trauma, but there’s no fracture: just inflammation of the bone and bruising. An X-ray can’t pick up on a bone bruise, but an MRI can offer clues. Bone bruises hurt and can hinder your daily activities, but there isn’t much to be done except to rest and let it heal itself.

In rare cases, the inflammation goes deep into the internal bone structure, making it difficult for the bruise to resolve on its own. Your foot and ankle specialist can inject the bone with donor material to reduce inflammation and promote healing.

Heel Bone Cyst

Heel bone cysts are the rarest cause of heel pain, but they can and do occur. An internal tumor or bone cyst can weaken the heel bone, causing swelling and pain, especially when in motion and bearing weight. Furthermore, the weakened bone is more susceptible to stress fracture, which can greatly increase the pain.

Your foot and ankle specialist can diagnose a bone cyst using an X-ray. A follow-up CT scan or MRI may be needed for confirmation. Typically, a surgeon would perform an excision to remove the cyst, or at least administer a biopsy to rule out any possibility of malignancy (cancer).

WHY CHOOSE UNIVERSITY FOOT AND ANKLE INSTITUTE FOR YOUR FOOT CARE?

If you’re experiencing heel pain and your symptoms aren’t getting better with treatment, schedule an appointment with the physicians at UFAI. Incorrect treatment can only exacerbate your injury and prolong your pain. An accurate diagnosis is key to a speedy and complete recovery. Our nationally recognized foot and ankle doctors offer the most advanced foot care and the highest success rates in the nation. We are leaders in the research and treatment of all foot and ankle conditions.

At University Foot and Ankle Institute we take our patients’ safety seriously. Our facility’s Covid-19 patient safety procedures exceed all CDC recommendations. Masks are required in our institutes at all times.

For more information or to schedule a consultation, please call (877) 736-6001 or make an appointment now.

We are conveniently located through the Los Angeles area with locations in or near Santa Monica (on Wilshire Blvd.), Beverly Hills, West Los Angeles, Manhattan Beach, Northridge, Downtown Los Angeles, Westlake Village, Granada Hills, and Valencia, California.

16 comments

  1. I’ve been training for a half marathon (which is Sunday) and I started feeling arch discomfort two weeks ago.

    In the last two weeks though I’ve done a couple short runs with no soreness, maybe just some pulling feeling in the bottom of my foot. I am going to do the run Sunday, but if I feel pain throughout my race Sunday, what is the point where I absolutely have to stop, assuming the pain is not crippling? If I feel moderate but not horrible pain while running the race, will the pain subside in a day or two or might I be making things worse running through moderate, or even mild pain?

    • As a general rule, if you’re feeling pain then you should not be running, but instead walking to your doctor to be checked out. You should see your doctor even though the pain may not seem “all that not bad” because it’s virtually impossible to know how bad it is unless you get it evaluated.

      Pain is an indicator of a problem and should not be ignored. We have seen more patient than we could ever count who said the pain “we not too bad” until it was and it turned out to be something serious. And then it’s too late.

      In closing, there are three things to remember:

      1) Better safe than sorry
      2) Almost anything can be “fixed”
      3) In regards to treatment, earlier is always better thank later.

      Hope this helps!

  2. This article was really helpful to me. My dad has been having a lot of pain in his heel recently and I’ve been worried about him. Thank you for mentioning that the doctor will typically take an x-ray to make sure it is not a tumor or cyst. I honestly think it might be a bruised heel or a stress fracture.

  3. Orthotics For Heel Pain

    Really very useful article. Thanks for sharing.

  4. I was diagnosed with planter fasciitis an it’s been 4 months now. I’m doing everything they say to cure it. From rest stretching an icing. Haven’t ran on it in 4 months. But still nothing me. So what is the next steps for me. I’m getting very discouraged.

    • Hi Glenn,

      I am sure this answer will not surprise you, but at this point, it is time to see a very good foot expert. For me personally, my doctor plus physical therapy (strengthening my foot) has given me great relief (thank goodness).

  5. For the past 2 months I had symptoms of plantar fasciitis and was not going away even after cutting back on my long runs. Yesterday I went for a slow 6 mile run got home and went through usual frozen bottle roll and stretch. I took a nap and when I got up on my feet my ankle popped now the heel pain is gone. Should I get my foot checked for a fracture?

    • Greetings,

      I think the old adage, “when in doubt, check it out” could apply here. It really is better to be safe than sorry. Please consult with your doctor and ask them if you should go in and see them.

  6. I have been suffering with planters fachitis for almost 2 years. I have seen a foot doctor which wrapped it many times. I have had steroid injections and pills I stretch every day I’ve been using foot splints every night.

  7. I stepped on a rock and hurt the right side of my right heel and have had pain while sitting and standing. I went to a specialists and he said I had plantar fachilitis. I think was wrong.
    I’ve had that before. X-ray was done.
    Heel hurts a lot

  8. I have got a knot coming up on the side of my font back around my heel could you please tell me what it might be it is very sore thanks

  9. Thanks for the insightful post! Didn’t know there were so many causes behind heel pain.

  10. Hello,
    For 2-3 months now I have been having really bad pain in my heel. I have tried googling this but I have never found anything on it. When I’m laying down or resting I have an intense pain in my left heel. It seems to be around this little spot which kinda looks like a sore. I can touch around my heel gently and it hurts a little but if I touch the sore (I think it is) it gives me extreme pain. Any ideas what this could be thanks.

    • You really need to see a doctor near you as everyone is literally different, so you need to get examined so you can learn what your situation is.

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