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Are we speaking the same language?
During the last 300 years, a range of terms have been used to describe pain under the plantar aspect of the heel including gonorrhoeal heel, Policeman’s heel, heel spur syndrome, subcalcaneal pain, jogger’s heel, plantar fasciitis, plantar fasciopathy, plantar fasciosis and plantar heel pain. To facilitate effective communication between clinicians, improve patients’ understanding of their condition and allow for shared decision making, consistent and unambiguous terminology is required. Similar challenges with terminology have been recognised for other conditions, including groin pain experienced by athletes.1 The aim of this article is to provide a stimulus for discussion about the terminology used to describe pain under the heel and propose an appropriate term based on current knowledge. By doing so, we hope that we will set the scene for a future consensus on appropriate nomenclature for the condition of pain under the heel and its associated diagnostic criteria.
The typical presentation
Pain under the heel is typically characterised by pain located at the anteromedial aspect of the plantar heel during weight-bearing. It is usually exacerbated by prolonged periods of standing and walking and may also be particularly acute on first stepping on the heel after periods of rest (eg, when first stepping out of bed in the morning). There is a range of possible presenting patient types, ranging from the athletic person with a high training volume (eg, distance running) to the middle-aged to older-aged sedentary person who typically has a high body mass index. Whether these patient types have the same underlying pathology remains unknown.
Findings associated with pain under the heel
A number of findings have been found to be associated with pain under the heel, although most investigators have focused on the plantar fascia. These include both histological and medical imaging findings that, along with the clinical signs and symptoms, might provide some insight into the condition. Histological findings include fragmentation and degeneration of the plantar fascia,2 although most histological studies are derived from long-standing cases that progressed to surgical removal of the proximal fascia and plantar heel spur. Medical imaging findings include plantar calcaneal spurs observed on X-ray, the presence of hypoechogenicity on ultrasound assessment and thickening of the plantar fascia quantified using ultrasound and MRI.3 Individuals with plantar heel pain are 105 times more likely to have a fascial thickness >4.0 mm compared with those without plantar heel pain. In addition, perifascial oedema4 and bone marrow oedema5 have been reported on MRI. It is unclear if these imaging findings are incidental or truly part of the pain process because many of the studies have substantial methodological weaknesses. There is a clear need for more high-quality cross-sectional and longitudinal observational studies in individuals with and without pain under the heel. There is also a need to relate these findings with symptoms, although it should be noted that there is an unpredictable association that exists between pain and tissue integrity, as pain is an output of the brain and is not just simply caused by a noxious stimulus at a local level.6 Accordingly, it is unlikely that histological examination and medical imaging provide all of the answers and until more evidence is available, caution should be exercised before routine medical imaging of all patients with pain under the heel is recommended.
What do we call it?
In individuals with pain under the heel, histological examination and medical imaging have illustrated that multiple tissues might be involved. There is now sufficient evidence that the plantar fascia may not be the only culprit. With this in mind, we suggest the term ‘plantar heel pain’ to describe the condition of pain under the heel. If first-line treatment fails, there may be a need for further investigations such as medical imaging. If these indicate specific tissue involvement, then more precise terms can be used to help inform the clinical picture. Examples of these more precise terms include: a fractured plantar calcaneal spur diagnosed via X-ray, plantar fasciopathy diagnosed via ultrasound (indicated by thickening and hypoechogenicity/heterogeneity of the fascia), a tear of the plantar fascia diagnosed via MRI (indicated by a high signal disruption of the proximal plantar fascia) or a stress reaction of the calcaneus diagnosed via MRI (indicated by bone marrow oedema). While imaging may be of use in understanding plantar heel pain, we do not know if it leads to better patient outcomes. There is a need for further outcome-focused research that provides a basis on which to make a precise diagnosis. Any imaging-based subclassification should be studied further before widespread implementation can be advised.
We propose the term ‘plantar heel pain’ to describe the condition of pain under the heel when no differential diagnoses are indicated and until further research is undertaken to arrive at a clear understanding of the appropriate terminology and associated diagnostic criteria. Clear, consistent and unambiguous terminology to describe plantar heel pain can improve communication between clinicians, an individual’s understanding of their condition and ultimately enhance treatment outcomes. While imaging may result in more appropriate subclassifications of plantar heel pain, there is still no clear evidence that this will improve patient outcomes and further discussion and research is needed.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.