Think quick …
An athlete comes to you complaining of right foot pain along the inferior and medial portion of the heel. With just that information alone, what are you thinking?
… and you can’t look at the title ….
that’s cheating … cheater!
Since you already had that thought, let’s find out together what else could be manifesting around that area shall we?! It’s time to plug your nose and take a dive into the wonderful world of feet!
For an area that can get pungently sour while working on it, I’ll make every effort to make this information short and sweet. I know that the mechanism of injury can be a major player in categorizing your differential diagnoses, so let’s just omit that fact right now. Here’s the breakdown of common conditions seen at the inferior and medial portion of the heel. I’ve playfully broken them down into: Soft Tissue Scoundrels, Bony Bad Guys, and Neural Naggers.
Soft Tissue Scoundrels:
Plantar fasciosis (a degenerative process)
Strained intrinsic foot muscle(s)
Flexor digitorum brevis
Flexor hallicus brevis (although it doesn't attach at the calcaneus, some say it’s a player)
Abductor hallicus longus
Quadratus plantae
Abductor digiti minimi
Enthesopathies (the tendinous attachment sites to bone)
Fat pad syndrome
Bony Bad Guys:
Calcaneal contusion
Calcaneal stress fracture
Inflammatory arthropathies (rheumatoid arthritis, psoriatic arthritis, gout, etc)
Neural Naggers:
Medial plantar nerve entrapment
Lateral plantar nerve entrapment
You may be thinking to yourself, “Self, with so many players that could be causing heel pain, how the heck will i figure out exactly what it is?”
You can be a mediocre clinician with non-specific diagnostic outcomes and subpar treating methods, crossing your fingers the whole way through therapy, praying that it’ll help … or you can go the extra mile and investigate further to isolated the exact culprit(s) causing all the grief in your athlete’s foot. There’s only one thing that we can assume will be stinky … and that’s the foot, not you, so take the extra time so your stuff “don’t stank!”
So in an attempt to help you find your way like Yoda guiding Luke Skywalker, here’s some tips you can use to rule in/out these suspected conditions.
Ask questions!
What’s the mechanism of injury?
Was there trauma, or one incident that triggered the complaint?
Was it progressive over time?
These questions will help determine if it’s acute, chronic, or a chronic re-injury. If “yes” is the answer, you can plug in the Soft Tissue Scoundrels and Bony Bad Guys here. Think of these other suggestions to get more specific:
Any recent fevers or infections?
Any other joints bother (contralateral foot, hands, spine, etc)?
Plug in any other inflammatory questions you can think of (swelling, redness, etc.)
Asking these specific questions will help determine whether or not they are inflammatory in nature. Addressing these questions will also provide insight as to whether or not an underlying condition is adding insult to an already agitated area; however, if these answers came up negative, drop the suspicion of inflammatory arthropathies.
Palpate the exact location.
Find the calcaneus and isolate the exact location of pain, then ask yourself:
Is it right on the calcaneus?
Is it right off the calcaneus and abutting it?
Is it more in the muscle belly proper?
If it’s right on the calcaneus - it could be one of the Bony Bad Guys. Depending on the mechanism of injury, you can hypothesize whether it’s a contusion or stress fracture (since you already ruled out an inflammatory arthropathy). If you don’t think it’s bony in nature, squeeze and provoke the heel pad. If this lights up the person, then suspect that the fat pad is the player.
If it’s right off the calcaneus - it could be one of the Soft Tissue Scoundrels. Think more plantar fasciosis or enthesopathy. At times, if you can recreate the chief complaint by contracting the tissue, then think more enthesopathy versus plantar fasciosis because the former is challenging contractile tissue such as the tendinous attachment to the heel. Determining between these two conditions can be somewhat challenging, but as you differentiate between each muscles (which is discussed later), then a more precise understanding of what structure is involved can be developed.
If the source is further away from the calcaneus and more into the soft tissue itself - think muscle belly strain, or even actual plantar fasciopathy (fasciitis if it’s acute with active inflammation, or fasciosis if it’s chronic in nature). Again, differentiating amongst the tissues will help you determine which structure is compromised.
Differentiate muscles.
Here’s a quick run down of how you can differentiate between muscles. You can either lengthen the tissue, or fire it if it’s contractile tissue. Let’s get our feet wet on how to differentiate the most likely scoundrels.
Flexor digitorum brevis
Have the relaxed ankle in a slightly plantar flexed position
Palpate inferiomedial calcaneus
Passively extend the 2nd to 4th digits
Palpable movement of this tissue will be prevalent
Confirm suspicion by having athlete isometrically flex their 2nd to 4th toes against your resistance
Abductor hallicus longus
Have the relaxed ankle in a slightly plantar flexed position
Palpate inferiomedial calcaneus
Passively extend the great toe, THEN passively adduct (towards 3rd ray)
Palpable movement of this tissue will be prevalent
Confirm by having athlete hold their great toe in extension and abductor as you apply resistance into adduction
Quadratus plantae
Have the ankle preset in a dorsiflexed position while the toes are in full flexion
Palpate inferiomedial calcaneus
Passively plantar flex the ankle and extend the 2nd-4th toes (ensure the distal phalanges are extended to further differentiate between the FDB)
Palpable movement of this deeper tissue will be prevalent
Confirm by having athlete isometrically flex their 2nd-4th toes against your resistance while the foot is in plantar flex position
Abductor digiti minimi
Have the ankle relaxed in a slightly plantar flexed position
Palpate inferiomedial calcaneus
Passively extend the 5th toe, THEN passively adduct (towards 3rd ray)
Palpable movement of this tissue will be prevalent
Confirm by having athlete isometrically abductor their 5th toe against your resistance
Flexor hallicus brevis (Some credible sources say it’s a player, but notice that it doesn't attach to the calcaneus. It’s been associated with causing the heel spur traction enthesopathy, which most suggest is a result of too much pronation occurring in the foot)
Have the ankle relaxed in a slightly plantar flexed position
Palpating inferiomedial calcaneus
Passively extend the great toe
Palpable movement of this tissue will be prevalent
Confirm suspicion by having athlete isometrically flex their great toe against your resistance
Taking the time to finger out the exact tissue will be a ton of help. Not only do you get to take the “Piggies” to the market, bank, and mall, but this will also make managing the condition much quicker and more efficient.
Look out for nerves.
If the previous questions have been asked, and the palpatory findings do not collectively add up, then it’s time to get on the athlete’s nerves a bit more … literally. Specifically, as the tibial nerve descends medially on the ankle and dives underneath the flexor retinaculum, it forks out to innervate the medial plantar aspect (wittingly named the medial plantar nerve) and the lateral plantar aspect of the foot (known just as wittingly as the lateral plantar nerve). Here’s how you can check for plantar nerve pathology:
Nerve Tension Test
Passively EVERT the ankle to end range. Note recreation of complaints
Then, passively add end range DORSIFLEXION to the already positioned everted ankle. Note recreation of complaints.
Finally, perform passive STRAIGHT LEG RAISE to the pre-postitioned everted and dorsiflexed ankle. Note recreation of complaints.
If any of these positions recreate the chief complaint, then suspect a Neural Nagger playing a role.
Tinel’s Sign
Passively evert the ankle to end range. Note recreation of complaints
Identify the flexor retinaculum and tap on top of the structure with two fingertips
Note any recreation of chief complaint specifically upon the medial plantar aspect
Note: Medial and lateral plantar nerves illustrated under highlighted flexor retinaculum
Since most “plantar fasciitis” complaints generate around the medial aspect of the heel, let’s focus attention on the medial plantar nerve more. Recreation of chief complaint when tensioning or provoking this nerve is a diagnostic indicator that is easily available at your disposal.
After implementing these 4 assessment suggestions (asking questions, palpating the exact location, differentiating muscles, and looking out for nerves), it’ll paint a much better picture of what the athlete is complaining about, and give you more data on what you’re working with and what you need to do to reverse engineer what often is a tricky condition to manage. Hope this extra information helps you uncover and “de-feet” your athlete’s foot issues!
Thanks for being curious and taking the time to read this! Hope it added value to your life and equips you to become better than you were yesterday!
Dr. Joe Jaime, DC, DACBSP®, ATC, CSCS®, FRC®ms, CES
Credit: anatomy pictures extracted from the Visible Body - Muscle App