Plantar Fasciopathy: Tangible Tips from a Real Case

One in ten people experience plantar heel pain within their lifetime, and it contributes to 8% of all running injuries. For clinicians and patients alike, it can be a notoriously stubborn condition to manage.

With insights from a real-life Case Study where world-leading plantar heel pain physiotherapist Dr Henrik Riel shares how he assessed, diagnosed, and treated a middle-aged woman with plantar fasciopathy, this blog focuses on his differential diagnoses and early treatment strategies.

If you want to see exactly how Dr Henrik Riel assessed and managed a real patient with plantar fasciopathy, check out his full Case Study HERE. With Case Studies you can step inside the minds of experts and apply their strategies to get better results with your patients. Learn more here.

Differential diagnosis

The first step in the appropriate management of plantar fasciopathy is ensuring the diagnosis is correct! As Henrik notes, heel pain can arise from several different sources, and not all are related to the plantar fascia.

A common misconception is that a heel spur is the cause of pain. But as Henrik explains, approximately half of people with heel spurs don’t experience pain, and only two thirds of people with plantar heel pain have a heel spur – so, a heel spur is a finding, not a diagnosis. While it may show up on an X-ray, it shouldn’t be the sole reason for diagnosis or treatment direction.

Here are some key differential diagnoses Henrik outlines:

• Fat pad atrophy: More commonly seen in older adults, this condition causes heel pain that worsens with prolonged walking or standing (rather than warming up), due to a thinning of the heel’s natural cushioning.
• Fat pad contusion: Unlike atrophy, this has an acute onset, often due to trauma, and typically worsens with ambulation.
• Spondyloarthritis: A systemic inflammatory condition that can present with bilateral heel pain, often accompanied by low back pain or pain in other joints.
• Tarsal tunnel syndrome: A nerve entrapment issue characterised by tingling, burning, or numbness radiating distally. Tests such as Tinel’s sign or the Tarsal Compression Test (TCT) may be positive.
• Baxter’s neuropathy: This is similar to tarsal tunnel syndrome, but involves the entrapment of the inferior calcaneal nerve, leading to medial heel pain that may radiate laterally. Palpation over the medial heel often reproduces symptoms.
• Plantar fibroma: A benign soft tissue mass on the plantar fascia, often palpable as a lump in the arch of the foot.
• Calcaneal stress fracture: Mimics symptoms of fat pad contusion but is typically confirmed via a positive calcaneal squeeze test and imaging.
• Plantar fascia rupture: Sudden and severe pain, usually more distal than typical plantar fasciopathy, often following a distinct incident. Pain does not improve with ambulation and may be associated with swelling or bruising.

Watch Henrik clinically reason through the differential diagnosis for his patient in the below video from his Case Study:

First steps in management

Once the diagnosis is confirmed, early management becomes the next priority. As with many potentially persistent musculoskeletal conditions, education plays a central role. Helping patients understand the nature of their condition, and what to expect in terms of recovery, is often as valuable as any physical intervention. See Henrik walk through his initial treatment goals and strategies in the below clip from his Case Study:

In addition to education and footwear, pain and load management strategies are integral, especially in a case of recurrent pain. Advising patients on activity modification to manage symptoms and ultimately enable them to progressively reload is a key element in the management of plantar fasciopathy. But this isn’t always easy! That’s why Henrik provides us with the tangible pain management tool he uses with his patients, see this snippet from his Case Study:

After all, if your patient doesn’t understand the 90% they need to do outside the clinic, then the 10% you do inside the clinic won’t make much difference!

Wrapping up

Plantar fasciopathy can be a stubborn and frustrating condition for both patients and clinicians. From ruling out alternative diagnoses to tailoring early interventions based on individual needs and experiences, successful treatment relies on a combination of science and communication. As physios, it’s great to have Case Studies to enable us a peek inside the mind–and the clinic–of real experts, with tangible tips we can apply straight away! And we haven’t even covered the long-term management yet..

To see how this case unfolded, and what happened as the treatment progressed, watch Dr Henrik Riel’s full Case Study HERE.