We have discussed the importance of obtaining an accurate diagnosis as the critical first step in effectively treating heel pain on this blog. Also, the blog contains lists of common causes of heel pain. It is certainly possible for heel pain to have more than one cause in a patient.
I just completed a fascinating course taught by Stephen L. Barrett, DPM called the Heel Pain Boot Camp in Scottsdale, Arizona: http://www.heelpain.guru. Dr. Barrett is an internationally acclaimed expert on the subject of heel pain and has authored a number of publications on the subject.
Dr. Barrett discussed the concept of the multifactorial causes of heel pain in 2006 in this article: http://www.podiatrytoday.com/article/6294 Importantly, he advised practitioners, in the article, to broaden their approach to the diagnosis and treatment of heel pain. Old paradigms take time to change but hopefully his Heel Pain Boot Camps will accelerate the understanding and application of these concepts.
We are taught, in our training, the motto: "If you hear hoofbeats, don't think of zebras." That advice means that if a patient has a symptom, always start with the most common cause, not the more "obscure" or exotic causes. It is true that plantar fasciitis represents about 93% of heel pain. Nevertheless, true plantar fasciitis, which is an inflammation of the plantar fascia is often self limiting and relatively easy to treat. It is for that reason, that podiatrists may not see that much plantar fasciitis....we see patients with heel pain that has persisted and is not self limited. In other words, the patients we see with heel pain probably represent a population whose heel pain causes go beyond simple plantar fasciitis.
Traditionally, patients who present with heel pain may have an x-ray performed. What does an x-ray show? Bone and joint but not ligaments, tendons and nerves. The plantar fascia is a ligament. A ligament can be seen via diagnostic ultrasound or MRI. MRI may be needed under some circumstances but not used routinely. Office based diagnostic ultrasound (sonography) is thus the gold standard in the diagnosis of heel pain and should be the first test performed as opposed to x-ray.
High resolution ultrasound can also allow visualization of nerves with attention to the type of nerve problems that can cause heel pain such as tarsal tunnel syndrome, medial calcaneal neuritis and Baxter's neuritis.
It is not uncommon for us to encounter patients in our offices who have had heel pain for many months or even years and are convinced that they have the toughest cases of plantar fasciitis only to discover, upon sonographic exam, that their heel pain is not caused by plantar fasciitis.