Why your plantar fasciitis treatment isn't working: the misdiagnosis factor

You're listening to the Restoring Human Movement podcast, where movement experts discuss the latest evidence-based practices to help you and your clients move with mastery. Hey everyone, this is Mandy for the Restoring Human Movement podcast. I'm your handy-dandy running expert here, so thank you for joining the Movement Movement. Today we're going to be going over conditions that masquerade as plantar fasciitis, but in reality are not plantar fasciitis. I get a lot of people coming in and they say they've had plantar fasciitis for two years, they've tried PT or other chiro or rehab, and they've failed traditional plantar fasciitis treatment in the past, so they come to me for something different.

So I'm going to go over the top three conditions that I see that are commonly feeling like plantar fasciitis, but in reality are different diagnoses altogether. I am going to save the most common diagnosis for last. This is not like a viewer retention trick or anything, it's just that these first two diagnoses are higher risk and they require medical intervention ASAP, so I want you guys to listen to that first and then we'll move to the most common one. And hopefully you're in that last boat, but if you're in one of those first two, you need to go see a doctor immediately. So quickly, before we move into things that are not plantar fasciitis but feel like plantar fasciitis, if you have been diagnosed with plantar fasciitis, it's been confirmed with imaging, several doctors have told you it, and you are seeing results from traditional plantar fasciitis treatment, but you want some more information, check out the link in the description below.

Sebastian and I just released an e-book, it's on this podcast and it's on our website at p2sportscare.com, and it's all about plantar fasciitis. You get information, you get risk factors and self-assessment for risk factors, you get things that commonly turn off in plantar fasciitis that need to be addressed to be healthy, and a whole lot more, so go check that out. Okay, now on to the good stuff. Number one misdiagnosed condition is a heel stress fracture or a calcaneal stress fracture. This hurts like hell, and there's a few risk factors that go into it. The most common one that I see is a history of REDS, or relative energy deficiency in sport.

There's another podcast earlier on, you can scroll down on what that is. But the short and narrow of it is you are expending a lot of calories by doing your sport. It's really common in runners and triathletes. Spending a ton of calories doing your sport, and you're not taking in enough calories, whether that's intentionally or not. And your body starts shutting down, turns down some metabolic factors and some endocrine factors, and one of the biggest fallouts that I see early on is that your bone density may decrease, or even shorter term, you get stress reactions or stress fractures. So heel stress fractures or calcaneal stress fractures can feel like plantar fasciitis, where you stand up and it hurts, and it doesn't seem to respond to anything.

And it may be a really sharp pain, but more commonly, it's this dull ache that hurts more with pressure, but you can't really, you know, it doesn't zing at all, so to speak. This is really common in runners, especially those who do barefoot running, especially, especially those who do barefoot running on hard surfaces like concrete. Respect to y'all, I could never, but it is more common. And folks who use minimalist shoes, this can also happen for folks who use minimalist shoes when in the past they've used maximalist shoes, like, you know, like Clifton's or Hoka's or really cushy, marshmallow-y shoes that we all know and love.

If you switch into minimalist shoes without a transition period or into barefoot shoes, especially like those five-finger shoes that seem to be popular, that can be a higher risk for a heel stress fracture, but the stress comes from the load on the ground, not a metabolic side of it. So the two most common sides of a heel stress fracture is either you're in reds, you're not getting enough calories, and your body is not replenishing bone density as quickly as it's breaking down, or you have changed your running or your surface that aggressively so that you're putting way more pressure on the heel that you weren't experiencing before.

So it'd be like an exposure spike. I do also see this in some people who say step up and race distance and they don't have the training to back it up. So for example, I had somebody a few weeks ago who did a hundred miler like a month prior to me seeing them, and I asked about their training beforehand, and their maximum mileage beforehand had been like 40 miles a week. They only had six months of running under their belt ever, but they really wanted to do a hundred miler. They were really motivated to do it, and they got through it. It sounded like it was a tough race. They got all the way through it, finished, and then they'd had this heel pain all the way after until they saw me.

So it is common, and that may be put in like an acute reds sort of boat there, or it could be an exposure spike. To me, it's kind of sounded like both. This is also quite common in jumpers. So triple jump, long jump, high jump. It's usually a technique fallout. So if you're working with a coach, any jumper really should be working with a coach one-on-one or as close to one-on-one as you possibly can get. But if there is a technique issue, or if there's reds, again, in conjunction with it, you're slamming on the heel, trying to produce as much force as you can. So either the bone can't handle the stress of that through reds, again, that bone density has decreased and it can't handle the load you're putting through it, or the technique is wrong and you're slamming on your heel more than you really should and not pushing off your foot in a more ergonomic fashion.

And both of those cause a heel stress fracture, kind of in the same boat as all the stuff we've been talking about. If you think you have a heel stress fracture, stop doing whatever you're doing. This is one of the few times, stress reactions, stress fractures, where I sit my patients and they have to take rest. For folks who have a history of reds or under fueling, whether intentional or not, folks who have had a history of iron deficiency or they're currently or recently breastfeeding, any of those things all kind of lump into reds. But if you have any of those, it needs to be absolute rest for at least four weeks until you can get the image and then probably another four to eight after that as well.

But absolute rest means you don't do anything weight bearing on that foot, apart from eventually walking when your doctor clears you for it. Versus if you don't have a history of any of those things, you may be able to get away with relative rest. Although I would be careful about this. Relative rest is you're still doing something that doesn't aggravate the area of complaint. So in this case, the heel and in this case does not put pressure on the heel, but it's still an activity that's it's like cross training. So for runners, the classic example is hopping on a stationary bike or in the pool like aqua jogging or swimming.

Aqua jogging can work great here for runners and triathletes. It sucks to do, but it does do wonders for cardio while you can't put pressure on anything. But again, make sure you don't have any of those REDS markers, because if you do and you're doing relative rest, you're still putting your body through metabolic stress and it may prolong the stress fracture healing timeline if you're not recovering from REDS and able to put down that bone again. Okay, on to the second. And again, these first two are our higher risk categories. So again, if you think you have either of these first two, get to a doctor ASAP.

But number two, we're talking about an actual plantar fascia tear. So this is not like the micro tears that you may have heard about where, say, you do an ultrasound and you're like, oh, there's micro tears in this fascial plane or in this tendon. This is like a tear tear. This is a grade two or three tear. And this hurts. You will probably know if you have a true actual plantar fascia tear. For some people, it can be a little bit more moderate pain rather than true severe pain. But we're talking about the severe case here. Severe often, there's a little bit of pain before it happens, like kind of like a warning signal.

And then there's sudden onset. You may feel a pop. You may like have a tearing sensation in the bottom of your heel kind of towards your arch. And all of a sudden, you can barely walk on it if you can walk on it at all. The case that I've seen for this, this was a collegiate runner. He was running a race and he had had some foot pain, I think, for a month or two beforehand in the heel. Pretty mild through all of that. Still was running high mileage. I think he was something like 90 miles a week while he was training. And he was mid-race, mid-8K, and took a step down and felt his plantar fascia tear, which has to be every runner's nightmare.

I can't think of much worse than that. But felt it tear. And it was obvious tearing sensation. Fell to the ground. They had to get the little golf cart that they have swinging around the cross-country course to pick him up. And I think he went to the hospital right after, got imaging, and confirmed it was actually a full plantar fascia rupture. I believe he had surgery on it because he was back running by the time I saw him. I saw him about a year later for more just chronic fallout from that. But when it actually happened, it was very obvious. And he did have those warning signs a couple months before of heel pain.

But it never really got worse until it ruptured, which, again, worst nightmare. But in that moment when it ruptured in the same day or two, it got really, really swollen. It bruised. And all the bruising pooled at the bottom of the foot. Remember, gravity sucks. So if you have something that tears in the lower leg or even up towards the hamstring, the bruising will go down towards your foot or towards the lower leg. And commonly, even like in ankle sprains, the bruising you can see on one or both sides of the heel. Same case here. And, you know, surgical intervention, all that good stuff. So obviously, that's higher risk.

That's usually pretty clear if you have it. And again, worse, worse, worse nightmare. So if you're scared of that like I am and you feel something that feels like plantar fasciitis, I would recommend jumping on that treatment. We need to avoid that boat as much as possible. And last but not least, our very much most common condition that masquerades as plantar fasciitis but isn't plantar fasciitis is nerve-mediated pain, which sounds very scary. But actually, it's much easier to deal with 98% of the time than true plantar fasciitis. So the specifics here, most commonly, I see a radiculopathy or radiculitis, which means that the nerve root at the spine is irritated.

I usually call it just pissed off because I don't have MRI or ultrasound vision. I wish I did. That'd be great. But the nerve is irritated for some reason. It can be chemical where there's inflammation in the area and the nerve is swollen. Much more commonly, it's mechanical, which means that there's something, say, slamming onto the nerve root. The nerve root comes out of a hole in the spine called the intravertebral foramen. And if, for some reason, that foramen, that hole is slamming over and over and over on the nerve root, again, the nerve root can get swollen. And then it actually takes up more space in the hole, which makes it easier for the hole to slam onto it, which causes more swelling at the nerve root and so on and so forth.

This is really common with people who have had plantar fasciitis for a long, long time, and they haven't been able to deal with it. And other kind of category that can result in nerve-mediated plantar fasciitis is a disc irritation or a disc herniation, disc bulge. Any of those can cause it, and it's not always seen on MRI. So this is confusing for folks, especially that have had a history of back pain and they maybe have gotten an MRI before. The disc bulge does not always correlate to how much pain you're in. And even more confusingly, it may not tell you where the pain is. So we know there's things called dermatomes where there's patterns of where the nerve pain may go in accordance to what level of your spine the problem's at.

But that being said, we don't know a ton about why it goes higher or lower on the dermatome itself. Like, for example, in the mid-lumbar spine, so middle of your low back, those dermatomes tend to go from kind of the thigh area down into your lower leg. And then some of it in certain patterns in your feet. And some people only have foot pain. They don't necessarily have, you know, like side of the knee pain or thigh pain or anything like that, even though the problem is in their back. So this is mega confusing. I have personally had this, and I've gone to Sebastian and said, hey, I have plantar fasciitis.

Can you treat it? I try not to treat myself. That's very difficult. So I go to Sebastian. I say, I have plantar fasciitis. Can you treat it? And he puts me in a position that essentially opens up the hole where that nerve root is. And I get up and I retest my foot. I'm like, it's gone. He's like, cool, I didn't do anything to your foot. I did something to your back. So this nerve pain, this nerve-mediated pain is incredibly common. I would say the vast, vast, vast majority of the patients that I see with plantar fasciitis that have failed traditional plantar fasciitis treatment or not. Honestly, the folks who I just see with plantar fasciitis symptoms are nerve-mediated.

Thankfully for this, it's most of the time way easier to treat, and it goes away much faster. My kind of anecdotal theory on that is because nerves have higher kind of rates of response. So I think when you hit your funny bone, immediately you get those little tingles, and then they go away real quick. So I think that nerves go away quicker, but they also come back quicker. They're a little bit more volatile if you piss them off or not. But that can mean that if you un-piss them off or anti-piss them off, they calm down a lot quicker. So I've seen people who come in with plantar fasciitis, they've had it for years and years, and within two visits or two weeks, they are having a hard time trying to reproduce the pain.

And usually their morning pain, when they step out of bed and they feel like you've got a sharp rock in your heel, is almost gone. And then within like another two weeks, they can't reproduce it at all. They don't feel it when they get out of bed. The good thing about this is it's usually okay to train through. You're going to risk more irritation to the area, not necessarily injury, like you're not going to tear anything. But it is more volatile. So if you do train through it and you don't have the right treatment in place, it may just like stay around for a long time or get way more irritated super fast and you don't know what happened.

So for me, since thankfully I've had the education and the workshops and all that to know what the signs are for that. And again, it's very similar to plantar fasciitis, bottom of the heel pain, worse in the morning and then nearly or completely goes away quickly. Often that's a nerve-mediated plantar fasciitis. History of back pain, even back stiffness, especially if it's concurrently at the same time. And if you have tingling at any time in that area, it is not the plantar fascia. Tingling does not come from fascia. It comes from nerve. And most commonly, again, failed traditional plantar fasciitis treatment.

Any of those warning signs. Thankfully, again, like I've had the education to know how to deal with nerve-mediated plantar fasciitis type pain. But if you're not with somebody who does, well, shameless plug, reach out to us, obviously. But if you're not with somebody who does know how to mediate that and you're training through it, it's going to feel confusing because it's going to get better and worse randomly or just worse and worse and worse and you don't know why. Commonly with this too, rest does not help. A lot of people actually say that rest feels worse once they get back into it. I just had a patient like that who elected to take three weeks off of running.

And I actually didn't see him for a while. I think he was on vacation or something. He came back like two months later. He's like, it's worse. What happened? I asked. And he's like, oh, I took three weeks off. I just felt like taking three weeks off. And yeah, he came back worse. He wasn't doing his homework, but he came back worse. So rest doesn't seem to help, at least long term. So like two or three days might help. And it might kind of band-aid it for the following two or three days. But after that, it seems to either stay the same or get worse when you get back into usually running. You can feel it the most.

So just as kind of a wrap-up here are three conditions. One, if you have a heel stress fracture that commonly comes with a history of reds or underfueling, commonly with jumping sports, commonly with minimalist or barefoot running, that usually feels like kind of dull pain, not very zingy, like doesn't go up or down your leg at all. And that's a go to the doctor immediately. They'll probably order imaging. And that's an absolute rest. Unless you have absolutely no history of reds, then you can maybe get away with some relative rest instead. Our second condition was an actual plantar fasciitis tear or rupture, which is awful.

It's sudden onset of severity, although you may have warning signs before, like a couple months of mild kind of heel pain that has been simmering. But the actual tear is sudden onset. You might feel a pop. You might feel that tearing sensation. And immediately, you'll barely be able to walk on it if you're able at all. And you'll see, you know, constant pain afterwards, bruising, swelling, the whole nine yards. And that's an immediate doctor, like go the same day if you're not already just going to the ER. And last but not least, our most common by far misdiagnosis is it's actually nerve-mediated pain.

That's usually coming from the spine, and it usually has to do with a nerve irritation at the nerve root itself, where it exits the spine. Often that's because the hole that the nerve comes out of is like slamming back and forth on the nerve root, and then the nerve root swells. The hole gets smaller because the nerve root is taking up more of the space. It's easier to pinch, and then you get in this terrible cycle. This is really common with people who feel that it's worse in the morning, and then nearly or completely it gets better. And especially in like that first 10 minutes in the morning, if you don't feel it after that, it's probably nerve-mediated.

And especially for folks who have had a history of back pain or concurrent back pain or stiffness. And if there's any tingling at any time in that area, it's probably nerve. And most importantly with that, if you failed traditional plantar fasciitis treatment, especially if you had it for a long time, you need somebody to assess if it's possibly nerve-mediated here. Those first two diagnoses are higher risk. Those are go to the doctor right now. The last one, the nerve stuff, is more volatile, so it may get better or worse randomly. And that's more common for it to stick around for a long time, like several months or years after the first instance that you feel for it.

So important to get treatment for all of these for different reasons. First two, because the fallout from it is higher. Last one, because it's trickier and more volatile and can stick around way longer. But in reality, it's pretty easy to treat if you have somebody who knows what to look for. If you guys need help with this or you haven't been evaluated for any of these three diagnoses and you think you might be in one of these categories, we are real people that exist and are taking new clients right now as of the time of recording this podcast. So reach out to us. The information is in the description again and go back in the podcast and check out the other stuff on plantar fasciitis.

We go over, we touch on some of these other diagnoses in our other plantar fasciitis podcasts. And we go over true plantar fasciitis as well in the podcast and in our e-book, which again is in the description. But there's a lot of information out there on true plantar fasciitis. There is very, very little on nerve-mediated plantar fasciitis. So if you guys get stuck, send us an email or reach out directly.