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If a patient presents with plantar heel pain that surges when they step out of bed in the morning or start to walk, most evidence-based chiropractors think plantar fasciitis. But what if that’s not the diagnosis. There are several frequently overlooked possibilities in the differential diagnosis.

Watch this quick and valuable tutorial: Differential diagnosis of plantar heel pain.

Diving Into #2 🤔

Following plantar fasciitis, heel pad syndrome is the second most common cause of plantar heel pain, claiming approximately 15% of all presentations. (3,4) Up to one in ten people will suffer from heel pad syndrome at some point in their lifetime. (5)

Your ChiroUp team recently took a deep dive into Heel Pad Syndrome. With the help of a few experts like Tom Michaud, our advisory board has authored and released ChiroUp protocol #104- Heel Pad Syndrome.  What did we learn? – A lot. Here’s our 2-minute, Top 10 Summary:

1. Anatomy

The heel fat pad is a specialized shock absorber that overlies the inferior and posterior calcaneus to impart cushioning and help dampen ground reaction forces. (7-10) The heel pad is composed of closely packed honeycombed fat globules held together by a collagenous septum. (6,11,12)

2. Etiology

Time and stress promote atrophy of the fat cells and degeneration of the fibrous septae. This leads to decreased elasticity and shock absorption, resulting in increased calcaneal pressure. (18-24) While atrophy and degeneration seem to be the most likely sources of trouble, fat pads can also become inflamed, thick, stiff, and inelastic with a painfully similar outcome. (26,27)

3. Symptoms

Heel pad syndrome complaints are typically described as a deep, diffuse, nonspecific bruise-like pain localized at the center of the heel. (42) Patients may report tenderness to touch. Symptoms are typically exacerbated by walking on hard surfaces or barefoot, particularly for prolonged periods. (42,43)

4. Clinical Signs

The hallmark clinical feature of heel pad syndrome is tenderness to palpation at the center of the heel. (43) Springing palpation of a healthy heel pad should demonstrate significant elasticity. Loss of this springing elasticity suggests dysfunction.

Differentiating Heel Pad Syndrome from Plantar Fasciitis

Patients presenting with heel pad syndrome typically demonstrate centralized heel pain after prolonged activity, whereas plantar fasciitis patients experience medial calcaneal pain that is provoked upon initiation of activity. (18,52) 

Clinicians should also inquire if symptoms improve when walking on their toes. Heel pad complaints typically improve with toe walking, whereas plantar fasciitis symptoms do not (aka Heel Pain Differentiation Maneuver). (88,89)

Heel Pain Differentiation Maneuver

5. Heel Cups

Conservative management consists of offloading with relative rest and cushioning via padding or shoe modifications. (24,37) Cushioned heel cups are a mainstay of treatment (e.g., Tuli heel cup). (24,56-58) Heel cups can help dissipate pressure via weight redistribution. Heel cups can also help maintain proper positioning of the fat pad. (24,56,57)

6. Myofascial Release

Significant data shows that myofascial release techniques applied to the gastroc, soleus, and plantar fascia may reduce pain and improve function in plantar heel pain patients. (61-67)

7. Manipulation & Mobilization

Foot and ankle joint restrictions routinely contribute to heel pain. (48) Manipulation and mobilization of the foot and ankle joints may improve outcomes, although high-quality research support is lacking. (4,68)

8. Rehab

Stretching exercises should focus on restoring flexibility to the gastroc, soleus, and plantar fascia. (3,48,94) Proprioceptive exercises may help improve dynamic control of the foot and ankle.  

Strengthening exercises should promote foot and ankle stability. Strengthening the toe flexors is an essential component of heel pain management. (91) Toe muscle rehab performed from a stretched position has been shown to improve strength by as much as 40%.  (95) Peroneal muscle strengthening must not be overlooked. (91)  

Check out one of our favorite exercises that incorporates several of these components:

9. Taping

Various taping techniques seek to dissipate force at the heel and limit foot hyperpronation. Therapeutic low-dye taping has shown merit in the management of heel pad syndrome. (69-71)

10. Medical Management

Medical management commonly includes anti-inflammatory medications. However, the value of steroid injections is questionable for plantar heel pain. (77) Repeated steroid injections can promote fat pad atrophy, thus are contraindicated. (57)

Summary

Manual therapists like you and me can easily be lulled into complacency by assuming that every heel pain presentation is plantar fasciitis. Recognizing the potential imposters for common diagnoses is essential for establishing our reputation as proficient providers. There’s a vast difference between merely treating someone and consistently applying best practices for the correct diagnosis. And in the future of healthcare, only the latter will be valued and reimbursed.

Did you know there’s also a difference between receiving this weekly blog and being part of the ChiroUp provider network? It’s like the difference between receiving the Mayo Clinic Newsletter and being a Mayo clinic provider. One’s a nice resource…but the other comes with countless additional benefits and privileges.

  • Access to 104 up-to-date best practice condition protocols with straightforward video tutorials of every associated test, treatment, exercise, and ADL – to help you nail down clinical excellence.
  • The ability to nearly instantly relay this information to patients via condition reports, like this one for Heel Pad Syndrome, that answers your patient’s essential questions plus video demonstrations of exercises and ADL’s -meaning better compliance with fewer questions. 
  • Automated patient satisfaction and clinical outcome collection so you can see real-time feedback and know where and how to improve continually.
  • Automated Google and Healthgrades reviews from your most satisfied patients so you can market your most credible endorsements – high patient satisfaction and outcomes.
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