Heel Pain Isn’t Always Plantar Fasciitis: Rethinking Strategies

Heel pain is one of the most common complaints in podiatric practice—but are clinicians sometimes oversimplifying the diagnosis? In this episode of the Podiatry Today Podcasts, Dr. Jennifer Spector speaks with Dr. Patrick DeHeer, President of the American Podiatric Medical Association, about the complexities behind heel pain and why plantar fasciitis shouldn’t always be the default diagnosis.

Key Takeaways

• Heel pain/plantar fasciitis (office setting): Heel pain is a symptom, not a diagnosis; clinicians should assess equinus, reported to be present in ~85% of patients with plantar fasciitis, and include equinus treatment as part of a comprehensive management plan.
• Differential diagnosis: Lack of improvement despite appropriate treatment should prompt evaluation for fat pad atrophy, Baxter’s neuritis, calcaneal stress fracture, or radiculopathy. Suggested assessment tools include VAS pain scale, tuning fork testing for stress fracture, nerve palpation, and advanced imaging (MRI or ultrasound) when indicated.
• Treatment monitoring: Reassess response over time; persistent pain after 3–6 weeks of therapy or lack of improvement after a 12-day prednisone taper should trigger reevaluation, repeat examination, and additional diagnostic testing.

Transcript

Please note: This content is a direct transcript, capturing the authentic conversation without edits. Some language may reflect the flow of live discussion rather than polished text. 

Jennifer Spector, DPM, FACFAS: Heel pain walks into nearly every podiatry practice, but are we sometimes walking past the real diagnosis? In this episode, we take a closer look at one of the most common and oversimplified presentations in foot and ankle care. While plantar fasciitis is frequently a default diagnosis, emerging insights suggests that heel pain is far more complex than many of us were trained to believe. 

Welcome to Podiatry Today podcast, where we're bringing you the latest in foot and ankle medicine and surgery from leaders in the field. Today we're thrilled to have with us Dr. Patrick DeHeer, who is the current president of the American Podiatric Medical Association. He's the residency director at St. Vincent's Hospital in Indianapolis and he is double board certified by the American Board of Foot and Ankle Surgeons. We are just thrilled to have him here with us today. Welcome, Dr. DeHeer. 

Patrick A. DeHeer, DPM, FACFAS, FASPS, FFPM, RCPS(Glasg): Thanks for having me. 

Jennifer Spector, DPM, FACFAS: I'm Dr. Jennifer Spector, the associate editorial director for podiatry today. So let's get started. Dr. DeHeer, heel pain we know is one of the most common pathologies that presents to podiatrist offices. And as mentioned, we might default many of us to an automatic presumption of plantar fasciitis. But what have you found and what has the research evidence found on this topic as far as is it really—it's just not that simple, is it? 

Patrick A. DeHeer, DPM, FACFAS, FASPS, FFPM, RCPS(Glasg): No, I think because it is so common, we tend to pattern match quickly and label it as plantar fasciitis, but really heel pain is more of a symptom and plantar fasciitis is just one of the possible diagnoses for it. Now clearly it's the predominant. We talk about horses and when we hear hoof beats, horses and zebras, it's obviously the horse in that picture. But if I think it's plantar fasciitis and I'm treating it with a really comprehensive treatment plan and it's not responding in a reasonable time period and we can talk about what that is, then that's when you need to start looking like, is there something else going on here that's causing the heel pain? 

Jennifer Spector, DPM, FACFAS: So are there any specific components to the pathology of heel pain as a whole that you feel like clinicians might be under evaluating? 

Patrick A. DeHeer, DPM, FACFAS, FASPS, FFPM, RCPS(Glasg): Yes, first and foremost is equinus. Equinus was mentioned in the very first textbook on orthopedics that was written by John Nutt in early 1900s and he talked about shortening or tightening of the posterior muscle group leading to a strain on the plantar supportive tissue. So I think it was in 1912 when that book was written. So it's over 114 years old and there's so much research on it. I think that people kind of halfheartedly check for equinus and then they may or may not treat it as part of it. 

That's what I think is so important with plantar fasciitis and heel pain, first of all is having a solid comprehensive treatment plan and really doing justice to the treatment. And if it's not responding, that's where you need to start looking at other causes. Is it a fat pad atrophy problem? Is it Baxter's neuritis? Is it maybe a calcaneal stress fracture? Is it a referred pain from maybe a radiculopathy or something like that? 

So there's these sort of zebras that we have to consider, but if it is plantar fasciitis and you're treating it, you really need to treat it comprehensively. And we know from the research at least around 85% of the patients who have plantar fasciitis have an associated equinus. And when I'm talking to patients about this, I like to use this little sort of analogy that in chronic refractory plantar fasciitis, so the ones that aren't responding, when I do surgery on them, I do a gastroc recession. I don't do anything to the heel. And there's been 25 or so articles written on gastric recessions to treat chronic refractory plantar fasciitis. So it's very well researched, it's very well published and that shows you the importance of equinus. And I've been doing that for well over a decade and my results are very similar to what I see in the literature on that. And that just sort of drives home the importance of, "Hey, we got to treat your equinus." And we can treat that non-surgically or surgically. It doesn't matter. 

And then however you want to treat the plantar fasciitis, whether you do oral, I'm an oral steroid person versus an injection person and then support and stretch I think are really important. Physical therapy can be a part of it. I do think the steroid thing that I've learned recently over the last couple years, I was a big Medrol dose pack fan and honestly, the Medrol dose pack is kind of a lower dose of steroids and it doesn't last quite long enough for most people to fully get the inflammatory component up. 

Now you can argue, is this inflammatory or is it more degenerative type of a process? And I think maybe it starts out as inflammatory and then it goes into more of a degenerative process. So it goes from plantar fasciitis to plantar fasciosis and that's more of a deeper dive in things. 

But what I've gone to is a 12-day steroid pack where I do a 10 milligram of prednisone and I do 60 times two days, 50, 40, 30, 20, and 10. So it's a 12-day pack and it's a much higher dose of steroids and I find it to be really, really effective to get the area calmed down. 

Jennifer Spector, DPM, FACFAS: Are there any diagnostic or therapeutic steps that you feel podiatrists could be incorporating into their workflows to improve outcomes? You talked about how long do you let them go before you investigate deeper as far as response to treatment? And are there any milestones there that you think we need to call out? 

Patrick A. DeHeer, DPM, FACFAS, FASPS, FFPM, RCPS(Glasg): Well, I think it depends on progression or progress of the patient through the treatment. If you've done 3 or 4 or 6 weeks of treatment and they came in with a pain level of 8 and they're still at an eight, that's a red flag to me, that's going to get my attention and I need to investigate this further. As long as that they're going down the pain scale in a reasonable time period, then I'm going to stay on track with what I'm doing. But if I'm not seeing them progress along the pain scale, that's where I'm going to step back and I'm going to reevaluate. 

I also will say part of my initial exam for heel pain patients is pain on palpation, obviously I'm looking for edema, but I also use—I check with a tuning fork. That's a quick way to rule out a stress fracture the calcaneus. And then also I will palpate Baxter's nerve. Now that's a little more of a difficult thing to really do clinically, but it'll give you some idea if you're palpating between the medial malleolus and the back corner of the heel that's kind of in the mid part of that line, that's about where the nerve is and they get some radiating pain down. And that could be a sign that's more of a nerve type, a neurogenic type pain as opposed to structural plantar fasciitis type pain. But those are part of my initial exam anyway. I was one of the first people writing about Baxter's neuritis and podiatry and was doing that surgery a lot. 

I've kind of stepped back from the surgery part of it. Even if I note they have Baxter's neuritis, I'm still going to treat them as plantar fasciitis, but I know that there's a percentage of those patients who are less responsive to conservative care and that's just part of the discussion with the patient that you have a little more of a complicated diagnosis with this nerve involvement that might require something else, but I still treat them with the same conservative pathway. 

Jennifer Spector, DPM, FACFAS: So as we start to wrap up this episode today, what one thing do you really hope that podiatrists will take away from this conversation as far as shining a new light on their approaches to heel pain? 

Patrick A. DeHeer, DPM, FACFAS, FASPS, FFPM, RCPS(Glasg): Well, first, make sure you're checking for equinus. And when you want to supinate the foot and dorsiflex the ankle joint with the knee extended and -5 or less is really the definition that's been established by Gad et al in their article. And if they do have equinus, which most of the time they are, treat that aggressively, whether you do manual stretching or use a brace, it doesn't matter, but treat it in conjunction to however you treat plantar fasciitis normally and then really monitor your patient's response to therapy. And I use the VAS pain scale, I think that's the best sort of method to monitor it. And if they're not moving down the pain scale and what would be an expected sort of timeline, if I give somebody a 12-day steroid pack, when they come back in two weeks, that's usually when I see them, they should be significantly better. 

If they're not, then I'm probably going to bring in a steroid shot. And then if they're still not, then I'm going to have to say, "Hey, I need to get more information." Whenever you're not seeing progress or improvement, you need to get more information. And for me, that's going to be an MRI often. So I'll get an MRI to see if there's something else going on. Also, or if you want to get an ultrasound, whatever, but when things are not progressing like they should, that's where you need to take a step back, reevaluate, redo your physical exam, double check your biomechanical exam, and then order any additional testing to give you more information. 

I kind of think of myself as a detective sometimes where I'm trying to gather as much information as I can to make an informed decision, then I can make a treatment recommendation on that. Because if you have the wrong diagnosis, the treatment recommendation's not going to be applicable. So correcting the diagnosis and getting the right diagnosis oftentimes requires more information. 

Jennifer Spector, DPM, FACFAS: Well, we really do need to be diagnostic detectives as you've mentioned. And thank you so much for sharing your experience with us on this topic today. 

Patrick A. DeHeer, DPM, FACFAS, FASPS, FFPM, RCPS(Glasg): You're welcome. It's my pleasure. 

Jennifer Spector, DPM, FACFAS: Well, as we've been reminded, heel pain is not always as straightforward as plantar fasciitis and expanding how we evaluate these patients may be one of the most impactful shifts that we can make. If you found this conversation valuable, be sure to follow our podcast on SoundCloud, Apple or Spotify so you don't miss upcoming episodes. And if there's a colleague who would benefit from a broader perspective on this, consider sharing the episode with them. Thanks for listening and we'll see you next time.

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