Rock G. Positano, DPM, MSc, MPH, DSc

Heel Pain, Very Common and Debilitating, Often Misdiagnosed as Plantar Fasciitis Has Become a Rampant Musculoskeletal Public Health Issue During the Post-Pandemic

Heel pain is one of the most common ailments that is found in the active population. Unfortunately a painful heel can be severely debilitating if not properly diagnosed and treated. It may not be life threatening but it is certainly quality of life threatening and affects a person’s ability to walk, stand, exercise and participate in social activities.

Heel pain is the great impersonator and can signify a wide range of medical problems from a common musculoskeletal problem known as plantar fascia to a cancer metastasis in the heel bone from breast, prostate, lung and other areas. There is no such thing as simple heel pain and this complaint should never be trivialized and relegated to an internet search. All too often we will evaluate a patient who has had heel pain for over a year only to find that there is a more serious underlying problem such as a tear in the plantar fascia.

Interestingly, heel pain is one of the most misdiagnosed musculoskeletal conditions.  Physicians often misdiagnose heel pain as plantar fasciitis based on the clinical exam alone or in conjunction with an MRI, without performing a diagnostic ultrasound to rule out other possible causes. The wrong diagnosis can not only prolong a patient’s suffering and decrease quality of life, but can do more harm than good if the incorrect treatment is prescribed. For example, it can lead to unnecessary surgery. Even worse, it can trigger serious systemic health issues such as cardiovascular disease, Type 2 diabetes, obesity, osteoporosis, and depression, due to inactivity and lifestyle changes caused by pain.

Many clinicians as well as the public often conclude that MRI should be the diagnostic test of choice when looking at a heel injury, however, technical advances and higher-frequency transducers have made diagnostic ultrasound technology more desirable than MRI in the diagnosis of foot pain, and it’s much less costly and does not require an often claustrophobic environment associated with the MRI tube.

We published a 2015 study conducted by our Non-surgical Foot and Ankle Service and Heel Pain Center at Hospital for Special Surgery (HSS) and found that a safe and painless diagnostic ultrasound test can pinpoint the exact cause of heel pain and ensure the most effective and safe treatment.

Our findings led us to conclude that diagnostic ultrasound can effectively and safely identify the true cause of heel pain. The high prevalence of plantar fibromas and plantar fascial tears cannot be determined by clinical examination alone, and, therefore, ultrasound evaluation should be performed to confirm the diagnosis. This specialized diagnostic test could spare many people an incorrect diagnosis, potentially harmful treatment and needless suffering.

The pandemic has produced an unprecedented increase in foot problems, particularly in the heel.

Foot pain isn’t just a unidimensional issue. Our experience both anecdotally as well as scientific research has revealed that a painful foot will quite often cause pain and dysfunction elsewhere in the body especially the knee, hip and lower back. What starts in the foot most likely will travel up the motion chain to these other body parts.

Due to the tremendous forces sustained by the foot and ankle on a daily basis this non-surgical service developed specific therapeutic and preventive protocols that help to retard and prevent the rapid development of osteoarthritis as well as degeneration and damage to the numerous muscles, tendons and ligaments in the foot and ankle. 

Treatments that include therapeutic ultrasound, phonophoresis, and EPAT combined with a well- designed and prescribed foot orthoses used to stabilize and protect the foot has proven to be both beneficial, therapeutic and preventive in nature. 

This benefit also extends to the knee, hip and lower back as improved foot and ankle function and shock absorbing ability is directly connected to decreased force and malalignment of these other parts of the lower extremity.

It has been well established that in addition to soft tissue and hormonal changes, the lower extremity and especially the foot and ankle, undergoes various structural and functional changes throughout the course of pregnancy. These lower extremity and foot changes can continue into, or even advance beyond, the postpartum period. Each trimester of pregnancy carries certain challenges that the lower extremity, and especially the foot and ankle, have to overcome for the patient to maximize their quality of life. 

As the fetus grows in both size and weight, there is a gradual shift in the expectant patient’s center of gravity due to increased volume within the gravid uterus. This shift, along with increased gravitational pull of increased BMI, in turn creates a stronger fulcrum, or bending/pivot force, on the lower extremity which increases demand on the lower extremity and foot, forcing it to compensate in order to maintain the proper musculoskeletal balance needed for metabolically efficient walking to occur. 

Increased ‘turning in’ (or pronation) of the foot with consequent turning in (or internal rotation) of the lower leg, due in part to both the dimensional and volumetric changes of the growing fetus, increases stresses throughout the entire length of the foot and in particular the arch and heel of the foot, especially during walking or weight bearing activities.

To add, whatever foot and ankle pathology or morphology that may have existed before the onset of pregnancy (whether properly addressed or not) risks being further exacerbated, or even uncovered, by the various anatomic and physiologic changes brought on by pregnancy. 

Conditions such as heel pain, ankle pain, bunion pain, lower leg pain, knee, hip and lower back discomfort are very common during and after the pregnancy. These conditions left untreated can cause major discomfort in the expectant mother. 
 

Diabetes Mellitus is the most common metabolic disease in the world with a global prevalence reported up to ~451 million people and rising and a major source of our global disease burden. Type 2 Diabetes (DM2) accounts for >90% of all cases of diabetes types and typically affects active adults of all ages. 

One of the heralding, and perhaps underdiagnosed, features of DM2 is its effect on the musculoskeletal system such as the foot, ankle, knee, shoulder, hip and spine (lower back/upper spine) in particular.

The excess glucose circulating around the body over an extended period of time will start to negatively affect the soft tissue structures supporting our joints contributing, but not exclusive, to common pathologies such as: 1) tendonitis 2) osteoporosis 3) osteoarthritis 4) muscle and foot cramping 5) limited joint mobility syndrome 6) peripheral neuropathy 7) circulatory compromise affecting arteries, veins and nerves.

If left untreated or mismanaged, these issues singularly, or in concert, will disrupt a person’s quality of life because it will affect their ability to move as they please and participate in exercise and walking activity.

This can prove troubling especially if the person leads a motivated and active lifestyle, and can further precipitate the negative cascade of increasing the risk of developing more serious chronic systemic diseases especially involving the cardiovascular system and maintenance of weight control and DM2 related monitoring levels of insulin/glucose indicators such HbA1c, insulin resistance, Body Mass Index (BMI) and other metabolic factors.

Musculoskeletal issues affect the DM-2 patient’s ability to exercise which is imperative to improve cardiovascular function, maintain blood pressure and bone density, anxiety and stress reduction just to name a few.

DM2 patients have specific needs and prevention strategies when dealing with musculoskeletal issues especially if the patient would wish to begin an exercise program or maintain a current one to best avoid injury.

This is the first practice of this kind that directly addresses the musculoskeletal needs of DM2 patients and has the participation of multiple health care practitioners, a specially trained NP (Nurse Practitioner), MD (Medical Doctor), DPM (Doctor of Podiatric Medicine), DC (Doctor of Chiropractic) and a Motion Gait Analysis facility that provides the patient with the ultimate comprehensive musculoskeletal care team approach.