From the Clinic; "I thought I had plantar fasciitis... but the scan told a different story."

Heel pain is one of the most common reasons people seek my help. In fact, almost every week I meet patients who have already been told they have plantar fasciitis before they've even walked into my clinic.

Sometimes that diagnosis is correct.

Sometimes it isn't.

This case highlights why making assumptions can delay recovery, and why establishing the correct diagnosis should always come before deciding upon treatment.

Patient presentation

A patient attended my clinic with persistent pain beneath the heel that had gradually worsened over several months.

They described the pain as being worst when getting out of bed in the morning and after sitting for prolonged periods. Walking longer distances had become increasingly uncomfortable, and previous self-treatment, including stretching exercises and changing footwear, had provided very little relief.

Having read online about plantar fasciitis, they understandably assumed this was the cause of their symptoms.

From the history alone, that seemed entirely reasonable.

Assessment

Although the history was suggestive of plantar fasciopathy, one of the first things I explain to patients is that heel pain is a symptom, not a diagnosis.

Several conditions can produce remarkably similar symptoms, including plantar fasciopathy, Baxter's nerve entrapment, fat pad syndrome, calcaneal stress injury, inflammatory arthritis and even referred pain from elsewhere in the lower limb.

Clinical examination demonstrated tenderness around the heel, but some of the findings were less typical than I would normally expect with classic plantar fasciopathy.

Rather than making assumptions, diagnostic ultrasound was performed during the consultation.

The result was unexpected.

The plantar fascia appeared completely normal.

Its thickness was well within normal limits, the collagen fibres were well organised, there was no evidence of tearing, inflammation, calcification or increased blood flow, and the attachment to the heel bone looked entirely healthy.

In other words, there was no ultrasound evidence of plantar fasciopathy.

That immediately changed my thinking.

The diagnosis explained

One of the biggest misconceptions surrounding heel pain is that every painful heel must be plantar fasciitis.

In reality, the heel contains numerous structures capable of producing pain.

A healthy plantar fascia on ultrasound doesn't mean the patient's symptoms aren't genuine—it simply means we need to continue searching for the true source of the problem.

This is where combining clinical assessment with imaging becomes so valuable.

Rather than confirming what we expected to find, the scan ruled out one of the most common diagnoses and prevented treatment being directed at the wrong tissue.

What we did

The ultrasound findings immediately changed the direction of the consultation.

Rather than confirming plantar fasciopathy, the scan confidently excluded it. This meant that treatments commonly used for plantar fasciopathy, such as corticosteroid injection or shockwave therapy directed at the plantar fascia, would have been inappropriate at this stage.

Instead, we discussed the fact that heel pain is a symptom rather than a diagnosis. With the plantar fascia appearing entirely normal, the focus shifted towards identifying less common causes of the patient's symptoms, including nerve entrapment, stress injury, inflammatory pathology and other soft tissue conditions that cannot always be fully assessed with ultrasound alone.

The treatment plan

At this stage, I felt further imaging was warranted.

Whilst diagnostic ultrasound provides excellent assessment of many superficial soft tissue structures, it has recognised limitations. Bone marrow oedema, stress reactions, deep soft tissue pathology and certain neurological conditions are often better evaluated with magnetic resonance imaging (MRI).

Given the persistence of the patient's symptoms, the absence of ultrasound evidence of plantar fasciopathy, and the need to establish a definitive diagnosis before commencing further treatment, an MRI scan was arranged.

I explained to the patient that the purpose of the MRI was not simply to perform "another scan", but to answer the next clinical question.

Every investigation should either confirm or exclude a diagnosis and directly influence management. Having confidently ruled out plantar fasciopathy, MRI represented the most appropriate next step in establishing the underlying cause of the patient's heel pain and ensuring treatment was directed appropriately.

What can we learn from this?

One of the most important lessons from this case is that normal investigations are not failed investigations.

In fact, a normal ultrasound can be one of the most valuable findings of all.

Rather than confirming what we expected to see, it prevented an incorrect diagnosis and avoided treatments that were unlikely to help.

Sometimes the correct answer is not immediately obvious.

Knowing when to progress to the next investigation is just as important as knowing when further imaging is unnecessary.

My specialist thoughts

One of the phrases I use most often in clinic is:

"Heel pain is not a diagnosis."

It's simply the location of the symptoms.

My job is to identify which structure is responsible.

Sometimes ultrasound provides that answer immediately.

Occasionally, as in this case, ultrasound provides the equally important answer of what isn't causing the problem. That information allows the investigation to progress logically, with MRI often becoming the next step in reaching a definitive diagnosis.

For me, that's what specialist assessment is really about—not simply performing scans, but knowing which investigation is most appropriate, how to interpret the findings, and when it's time to move on to the next stage of the diagnostic pathway.

About the author

Mr Liam Stapleton MSc, PGCert, PGDip, FFPM RCPS(Glas), FRCPodM

Mr Liam Stapleton is a Consulting Podiatrist, Independent Prescriber and Specialist in Podiatric Sports Medicine. He has completed postgraduate qualifications in Independent Prescribing, Musculoskeletal Ultrasound, Advanced Clinical Practice, the Theory of Podiatric Surgery, and Podiatric Sports Medicine. His clinical practice focuses on the diagnosis and management of complex foot and ankle conditions, combining detailed clinical assessment with diagnostic ultrasound to provide accurate diagnosis and evidence-based treatment.

If you're struggling with persistent foot or ankle pain and would like a specialist assessment, including diagnostic ultrasound where appropriate, appointments can be booked with Kent Sports Podiatry at clinics across Kent.