“Not Plantar Fasciitis”: the differential diagnosis and management of heel pain syndrome

Plantar heel pain (PHP) is a common orthopaedic presentation, but our understanding of this symptom is still limited. Multiple risk factors have been proposed but few substantiated. Obesity and foot pronation are known risk factors, whilst running or standing for long periods probably also contribute. There, however, is no relationship between heel spurs and PHP. As well as plantar fasciopathy, a number of different conditions can also give rise to PHP. It may be helpful to consider the differential diagnoses in terms of the structures that are symptomatic: the plantar aponeurosis, other soft tissues, the calcaneum and the peripheral nerves. The pathophysiology of PHP is still unclear but could be multi-factorial. Histological specimens show evidence of degeneration in the plantar aponeurosis but not inflammation. Seronegative arthritis should be excluded in cases of bilateral PHP. A number of different treatment options have been tried but very few have been rigorously investigated. Indeed, the overwhelming majority of cases will improve on conservative treatment. Shock wave therapy and surgery may be of use in selected subsets of patients who do not respond to other modes of conservative treatment.