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Study: Heel Pain, Very Common and Debilitating, Often Misdiagnosed as Plantar Fasciitis Use of Diagnostic Ultrasound Leads to More Accurate Diagnosis

New York, NY—April 15, 2015

A new study by Rock G. Positano, DPM, MSc, MPH, director of the Non-Surgical Foot and Ankle Service at Hospital for Special Surgery (HSS), and colleagues finds that a safe and painless ultrasound test can pinpoint the exact cause of heel pain, a common ailment that can be severely debilitating if not properly diagnosed and treated.

The study, published in this month’s Journal of the American Podiatric Medical Association, finds that many times, a diagnosis based on a medical examination alone is inaccurate.

Heel pain affects an estimated two million Americans annually. Stabbing pain in the heel can literally stop patients in their tracks. Unable to perform activities they enjoy, stand on their feet for extended periods or, at times, even walk, quality of life can suffer tremendously.

The cause is often diagnosed as plantar fasciitis based on a clinical exam. Plantar fasciitis is an inflammation of a thick band of tissue called the plantar fascia that runs across the bottom of the foot, connecting the heel bone to the toes. Although plantar fasciitis is the most common reason for heel pain, there can be other causes, and that is why ultrasound is an important diagnostic tool, according to Dr. Positano, director of the Joe DiMaggio Sports Medicine Foot and Ankle Center at HSS.

"Physicians often diagnose plantar fasciitis based on the clinical exam alone, without performing ultrasound to rule out other possible causes. The wrong diagnosis can not only prolong a patient’s suffering, but can do more harm than good if the incorrect treatment is prescribed. It can also lead to unnecessary surgery," said Dr. Positano.  

Tears of the plantar fascia and plantar fibroma, a benign cyst, are commonly found in patients with heel pain, but often their diagnosis is overlooked, he noted.

"Our study demonstrates the usefulness of diagnosing heel problems using ultrasound and therefore verifying the presence or absence of plantar fasciitis, plantar fibroma or a plantar fascia tear, so the physician can develop the most effective and safe treatment plan," Dr. Positano said.  

A misdiagnosis caused one of Dr. Positano’s patients, a ballerina, to give up dance and suffer constant foot pain. For an entire year, Alexandra Ansanelli says she saw multiple doctors,  receiving "a new diagnosis every month." She had CT scans, X-rays and an M.R.I.  Several physicians told her she would probably never dance again.

Dr. Positano finally was able to make the correct diagnosis. It turns out that she had almost severed the plantar fascia in her foot. She began treatment and improved enough to dance again as a principal ballerina in the New York City Ballet and subsequently the Royal Ballet of London. 

Although Ms. Ansanelli’s odyssey to find the correct diagnosis and treatment was years ago, Dr. Positano says people continue to suffer the consequences of misdiagnosis. What has changed, though, are advances in ultrasound imaging. “Technical advances and higher-frequency transducers have made ultrasound technology more desirable than MRI in the diagnosis of foot pain, and it’s much less costly,” Dr. Positano said.  

For the study, investigators reviewed the medical records and diagnostic ultrasound reports of 143 patients seen at the Joe DiMaggio Sports Medicine Foot and Ankle Center over a 13-month period. Patients ranged in age from 16 to 79. All had a clinical presentation of plantar fasciitis or a previous diagnosis of plantar fasciitis. Ultrasound evaluation was then performed to confirm the diagnosis.

Thirty-two of the patients had an ultrasound evaluation of both feet due to pain, resulting in a total of 175 feet scanned for plantar fasciitis. Based on ultrasound results, plantar fasciitis was diagnosed in 73 percent of the feet scanned (128 feet). Thirty-four percent (43 feet) with plantar fasciitis also revealed concomitant plantar fascia tears on ultrasound.

Despite the initial diagnosis of plantar fasciitis, the ultrasound failed to confirm the diagnosis in 27 percent (47) of the feet tested. The ultrasound revealed the presence of at least one fibroma in 27 of those feet.  

“"Our findings led us to conclude that diagnostic ultrasound can effectively and safely identify the true cause of heel pain. The high prevalence of plantar fibromas and plantar fascial tears cannot be determined by clinical examination alone, and, therefore, ultrasound evaluation should be performed to confirm the diagnosis," Dr. Positano said. "The test could spare many people an incorrect diagnosis, potentially harmful treatment and needless suffering.


About HSS | Hospital for Special Surgery
HSS is the world’s leading academic medical center focused on musculoskeletal health. At its core is Hospital for Special Surgery, nationally ranked No. 1 in orthopedics (for the ninth consecutive year) and No. 3 in rheumatology by U.S.News & World Report (2018-2019). Founded in 1863, the Hospital has one of the lowest infection rates in the country and was the first in New York State to receive Magnet Recognition for Excellence in Nursing Service from the American Nurses Credentialing Center four consecutive times. The global standard total knee replacement was developed at HSS in 1969. An affiliate of Weill Cornell Medical College, HSS has a main campus in New York City and facilities in New Jersey, Connecticut and in the Long Island and Westchester County regions of New York State. In 2017 HSS provided care to 135,000 patients and performed more than 32,000 surgical procedures. People from all 50 U.S. states and 80 countries travelled to receive care at HSS. In addition to patient care, HSS leads the field in research, innovation and education. The HSS Research Institute comprises 20 laboratories and 300 staff members focused on leading the advancement of musculoskeletal health through prevention of degeneration, tissue repair and tissue regeneration. The HSS Global Innovation Institute was formed in 2016 to realize the potential of new drugs, therapeutics and devices. The culture of innovation is accelerating at HSS as 130 new idea submissions were made to the Global Innovation Institute in 2017 (almost 3x the submissions in 2015). The HSS Education Institute is the world’s leading provider of education on the topic on musculoskeletal health, with its online learning platform offering more than 600 courses to more than 21,000 medical professional members worldwide. Through HSS Global Ventures, the institution is collaborating with medical centers and other organizations to advance the quality and value of musculoskeletal care and to make world-class HSS care more widely accessible nationally and internationally.


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