How can a runner tell a heel bone stress fracture from plantar fasciitis? Well, that’s what we’re talking about today on the Doc On The Run Podcast.
I just did a consultation call with an injured runner who had a really interesting history with his heel pain, and there was some concern that he might actually have a calcaneal stress fracture. And in case you don’t know, calcaneal stress fracture is just the medical term for a stress fracture in the heel bone.
Now, the heel bone’s the largest bone in your foot, and you can actually get a stress fracture in the heel bone. There are a couple of ways that you can get them. They’re relatively rare. The good news is they heal pretty quickly. But if you have one, you really need to know because you don’t want to run on it. If you have plantar fasciitis, you can actually get away with running on it for quite a long time without any really serious risks, but not true with stress fractures of the heel bone.
So the thing is, when you’re trying to figure out, do I just have run-of-the-mill heel pain, is it plantar fasciitis, or is it something worse like a stress fracture, there are really about six ways that I think of that can help you tell the difference. And some of them you can do yourself, some of you can’t. But we’re going to talk about those.
Now, the first one is your story. This is what doctors call your past medical history or the history of the present illness. What it really is is your story. And so when I think about this, does your story fit with plantar fasciitis or something else?
The first thing in your story is, is the pain constant, or is it different? So if you have a stress fracture in the heel bone, you really can’t walk or stand or run or put any kind of pressure on it without actually making it more inflamed. So typically with a stress fracture in the heel bone, if you’re standing on it all day, working, it generally hurts more throughout the day. If you run on it, if you’re doing more activity, if you’re walking more, the pain generally increases pretty steadily throughout the day.
But if you have plantar fasciitis, the story’s totally different. There’s a very specific thing with your pattern of your story of pain that doctors think of that actually directly correlates with plantar fasciitis. And that is what we call post-static dyskinesia. Now, that’s just a fancy word for it hurts when you get up after you’ve been sitting still. So if you say, “Doc, my heel doesn’t really hurt that much throughout the day. But every morning when I wake up and first step out of bed, it really hurts,” alarm bells start going off that say, “Plantar fasciitis.” If you say, “When I drive a car for two hours and then I get out of the car to get gas, it really hurts those first couple of steps, but then it doesn’t hurt for a while,” that sounds like plantar fasciitis. Stress fractures in the heel bone don’t do that. They just act completely differently.
The second thing is the look of it and so what I mean by that is the appearance of your actual foot that indicates it could be one thing versus another. The planner fascia is a big ligament on the bottom of your foot. Although it gets inflamed and itis means an irritation or inflammation, there’s very little swelling associated with plantar fasciitis. But that’s not true of stress fractures in the heel bone. So if you look at your foot really closely, and it looks like you actually have some swelling, more indicative of a stress fracture in the heel bone than it is of plantar fasciitis. At the same time, you could have something else that causes that. But we’re just talking about these two conditions right now.
But bruising is one of the worst things. Plantar fasciitis never, ever causes bruising in the foot or around the heel. But if you have a stress fracture in the heel bone and you actually crack that bone, you have to remember the heel bone is one of the most vascular bones in your foot. So when you crack it, it bleeds a lot, and you get a lot of bruising around the inside of your foot, outside of your foot, the bottom of the foot, all over the place around the heel. Plantar fasciitis never does that.
The third thing is when we ask you, “Well, what have you done? Did your running buddies tell you to do anything? Did you try anything?” How you respond to these self-treatments really can clue you in on whether or not it might be a stress fracture versus plantar fasciitis. For example, all the stuff to treat these conditions is in the Runner’s Heel Pain course and you don’t necessarily need that because I think most of the time you can figure this out on your own. If you want all the details, go check it out. But here’s the simple thing. If you try something super simple that we know almost always helps plantar fasciitis, like you try to ice it a little bit, you try to stretch the Achilles tendon doing some very specific stretches that we know will help the plantar fascia, and you have no improvement at all, then it’s probably not plantar fasciitis.
If you’re doing the things that you know work for that condition, but it doesn’t work for that condition, either you’re doing those treatments wrong, or you’ve got a different condition. Maybe you have a calcaneal stress fracture. So if you’re stretching the Achilles tendon and you know you’re doing the stretches right, you’re doing them way your doctor told you, you’re doing them the way that I show you how to do in the Runner’s Heel Pain course, but you’re not getting better, you might want to think about a stress fracture or one of these other conditions that can cause runner’s heel pain.
The next thing is a self-diagnosis test. It’s pretty simple. Plantar fasciitis hurts when you push on the fascia. A calcaneal stress fracture hurts when you squeeze the heel bone where you have the fracture. They’re in different places. Now, there are a couple little nuances that you know have to make sure you’re not overlapping, and this is part of what I teach to runners at medical conferences.
About a week ago, I was lecturing at a conference in Iowa, doing a lecture on runners heel pain, teaching doctors the differences between athletes and non-athletes. And I have a very specific animation in there that is one of the things in the Runner’s Heel Pain course where I show them exactly how doctors even make this mistake. When you squeeze the heel bone, and you’re checking for a stress fracture, but you actually push on this nerve on the inside of the heel and it causes pain, so we think you have a stress fracture, but actually you have neuritis.
But the bottom line is that if you’re squeezing the heel and you have pain, well, you know it’s not plantar fasciitis if you’re not irritating the fascia. If you push on the fascia and it causes heel pain, it’s probably because of the fascia, not because of the bone, because you’re not pushing on the bone, as long as you don’t push on those two things at the same time.
Another thing is the way that your condition either gets better or worse when you try certain things. What do I mean by that? Well, let’s say that you have plantar fasciitis on your right foot. If you run in the road, facing traffic, the slope of the road will actually pronate your right foot. It increases the stress and strain on the plantar fascia, and then it gets worse. Whereas if you switch to the other side of the road and you run with the road supinating your right foot, so it decreases the stress and strain on the planter fascia, well, in that case, your pain should actually theoretically decrease.
If you have a stress fracture, it’s going to hurt no matter where you run. But plantar fasciitis will hurt more or less depending upon the amount of stress placed on the fascia, which can change a lot, just based on the surface you’re running on, the side of the road you’re running on, the side of the sidewalk you’re running on; all those different surfaces that slope you in different ways.
A last thing is what to do in terms of imaging. Can you get an X-ray or an MRI or something to see this? Well, in general, yes is the short answer. But S-rays, although most doctors will do an S-ray of your foot when you have a suspected calcaneal stress fracture or a suspected case of plantar fasciitis, they’ll check for other things that might be contributing with X-rays. But we almost never see those things directly on an S-ray. A calcaneal stress fracture almost never shows up. Calcaneal stress reaction definitely won’t show up. A case of plantar fasciitis does not show up on your X-ray.
Now, an MRI can definitely help you rule out those things. In fact, this guy that I was doing in this webcam consultation with, going over his MRI, well, he had inflammation in the bone. And inflammation in the bone on an MRI suggests that you have a stress fracture.
However, his inflammation was all near where the plantar fascia attached. It was not anywhere near where we would expect to see the inflammation if you have a stress fracture. So just because you have inflammation in the bone, that does not mean you have a stress fracture, particularly if it’s right next to another structure like the plantar fascia that is really, really inflamed on your MRI.
Sometimes ultrasound can also help you tell because if you do ultrasound, which sometimes can be a lot faster than getting MRI, the inflammation in and around the planter fascia can actually show up on ultrasound really easily. The stress fracture, you can’t really visualize the bone as well with ultrasound, but it can help you rule out this and figure out which is most likely for you and with each of these little pieces we’re talking about right here, they can all help you.
If you take all of these things, and you really think about each one of these individually and your own foot and your own case of heel pain, what it’s looked like, what it feels like, whether or not it’s responded to the treatment you’ve tried, whether or not it changes when you run on one side of the road versus another, it can go a long way to helping you pin down the diagnosis for yourself. Now, I know this because I wrote the book Self-Diagnosis and Self-Treatment of Runner’s Heel Pain and you can get it on Amazon if you want to get it. But the bottom line is you’ve just got to think about the nuances between these different conditions and figure out which one is going to help you the most, so you can get back to running as quickly as possible.
If you want more detail on this, I’m planning on doing something. If you get this, and you’re listening to it soon enough after it comes out, within a couple of days, I’m going to be doing a live masterclass called Running with Heel Pain: Dos and Don’ts and what I’m going to do is I’m really going to talk about all those principles I teach to doctors when I go lecture at medical conferences on running injuries.
The idea is that every runner needs to really think about in order to fast track their recovery is also something we’re going to talk about during this live master class and I’m also going to share with you the approach that I use whenever I see a runner in person who has a case of plantar fasciitis, a case of calcaneal stress fracture, any of these conditions that we think of as runners heal pain.
As a bonus also, if you have specific questions about your case of runner’s heel pain, you can send those to me, and I’ll be answering all of those live. This is free. You don’t have to pay for it. But it’s only there if you’re there. It’s live. Don’t send me an email saying, “I really want the replay. Record it and send it to me.” I’m not going to do that. I just don’t have time for it. Don’t have the bandwidth. But I am going to do the live masterclass, and you can come join me for free. Just go to docontherun.com/runningwithheelpain, and I’ll see you in the training.