The most important tool in the clinical toolbox for an evaluating Physical Therapist is the ability to accurately assess your symptoms and accurately perform a differential diagnosis.
This differential diagnosis is the backbone of fellowship-trained, Osteopractic Physical Therapy. This is on display (sometimes secretly) at every initial assessment, as your PT is listening to every unique detail of your story and evaluating your movement patterns/strength.
For example, when you present with the ever common “heel pain,” we must first rule out or rule in the many potential causes of non-specific heel pain. We must carefully differentiate between lower back involvement, Achilles Tendonitis, or Plantar fasciitis (among many, many other potential causes).
How does Differential Diagnosis affect a treatment plan? Why does it matter?
This is the most important question you should be asking at this moment. Because there are many practitioners using the cliche’ phrase “root cause treatment approach” without any credibility or explanation.
Additionally, the current model of healthcare not only allows, but promotes, non-specific and generalized treatment programs for pain and injuries. The current status quo in the accepted, fast-paced, in-network healthcare system patterns symptoms and places them in vague diagnostic buckets. So you either have “lower back pain” or “neck pain” or “heel pain” or a few other vague/incomplete “diagnoses.”
This is why 5 different patients can walk into a busy healthcare provider’s office with “lower back pain” and they receive the same treatment protocol as everyone else. This generic treatment protocol may look like: Imaging Studies - X-rays -> Pain Medication/Muscle Relaxers -> MRI is pain is persists -> Injections offered -> Physical Therapy to “try” and improve your symptoms -> Surgical(!) consideration if pain persist.
Sound familiar?
Meanwhile, weeks and even months pass at each phase of the above scenario - which means your condition is worsening and turning chronic before either Physical Therapy has begun (See Blog on Direct Access Physical Therapy) or an actual diagnosis is made.
But let’s take “heel pain” for example, did your initial healthcare provider rule out/in S1 nerve dysfunction, Insertional Achilles Tendonitis, Calcaneal Enthesopathy, Tarsal Tunnel Syndrome, Plantar Fasciitis, Calcaneal Fat Pad injury, and so many more? Or did you just get a handout on basic calf stretches, medicine, and an imaging order?
And you guessed it, each of the above conditions (plus many more that can arise at the heel) are all treated with different nuances.
And if you are lumped into a category of “heel pain,” then odds are you will get extremely generalized “heel pain” treatment which will likely be unsuccessful in the long term. Don’t even get me started on why calf stretching likely isn’t going to help you.
But going to a fellowship-trained Osteopractor at the earliest onset of pain - even the same day in many cases - allows you to get the actual injury and structures involved.
Achilles Tendonitis versus Plantar Fasciitis - What are the similarities? What’s the Difference?
Below we will take a glance at some fundamental differences between Achilles Tendonitis and Plantar Fasciitis. The below list is not a complete list, but rather highlights easy to spot - yet often overlooked - similarities and differences.
Similarities:
They both are an “-itis” meaning they are inflammatory in nature. Achilles tendonitis is an inflammatory condition of the Achilles tendon and Plantar Fasciitis is an inflammatory injury to the Plantar Fascia.
Both the Achilles tendon and the plantar fascia have attachment sites at the heel, causing an overlap in reported symptoms of “heel pain.”
They can both be the result of overuse or sudden increase in walking/running activities.
They both can present with tightness in the calf muscle belly after a long day of activity.
In mild cases, both diagnoses respond favorably to calf stretching and changes in shoe wear.
Key Differences:
Plantar Fasciitis is characterized by a painful FIRST STEP in the morning. The first step of the day will easily be the worst step of the day, and will be focused on the inside portion of the heel.
Plantar Fasciitis is directly affected by 1st toe (big toe) mobility and flexibility.
Plantar Fasciitis commonly presents after beach trips (sand walking) or sudden overuse of flip flops (sandals). This is due improper mechanics of the big toe while walking in flip flops or on sand.
With plantar fasciitis, pain may be reported in the arch of the foot.
Conversely,
Achilles Tendonitis will almost always have point tenderness/painful “poking” at the actual Achilles tendon. And in some forms of Achilles Tendonitis (that’s correct, there are even many different types of Achilles tendonitis!), this painful poking will be less painful while the ankle is moved into dorsiflexion (dorsiflexion is the ankle motion of pulling your toes towards your nose).
Depending on the severity of Achilles tendonitis, there is typically weakness and pain when standing on your tippy toes.
Many times, the calf will present with muscle tightness and the pain will fluctuate throughout the day based on your activity levels.
Achilles tendonitis commonly occurs when weekend warriors suddenly increase recreational activities, such as Pickleball or a community 5k race.
The front of the ankle joint is routinely involved in Achilles tendonitis, and you may experience pain in this region.
Due to one of the calf muscles crossing the knee joint, pain at the knee may be related to Achilles Tendonitis.
Do these differences truly affect the treatment strategy and approach?
Absolutely!
The argument from many people is that there is crossover between the treatment strategies, so if you simply treat the “heel,” then you’ll treat everything at the same time.
This may be correct in very mild cases when the diagnosis is correctly identified and calf stretching is relevant for this diagnosis.
But in many, many cases, if you have tunnel vision on treatment for the heel, then you are going to be left with suboptimal results and potentially incomplete recovery.
The alternative to this generalized heel pain treatment is a targeted treatment approach by your Physical Therapist. This approach, utilizing a thorough differential diagnosis, treats the source and cause of the “heel pain.”
An accurate differential diagnosis in the above scenario of heel pain would drastically change the placement of needles if the patient were receiving dry needling.
To be clear, the needle placement for Achilles tendonitis and plantar fasciitis is extremely different, and when you factor in additional potential diagnoses such as S1 nerve dysfunction, then the needle points are drastically different.
Do you already have stubborn heel pain that won’t go away, now what do you do?
Trying out calf stretches day after day without resounding benefit is a sign that you may need a second opinion with an Osteopractic differential diagnosis.
At your initial evaluation with an Osteopractor, you can be assured that, not only will your heel be evaluated, but all potential causes to your heel pain will be assessed.
This ensures that when treatment commences, the correct treatment target has been identified - leading to quicker and long lasting outcomes.
At Flow Physical Therapy and Wellness in The Woodlands, TX, this is the primary reason we spend 60 minutes with you at every session - including the initial assessment. Despite your diagnosis being seemingly straightforward, we will take the time to ensure the diagnosis is correct and all root causes have been identified - so we can then create a truly personalized treatment program for your symptoms.
A thorough Differential Diagnosis can only be performed when your healthcare provider is committed to listening to you, in a one on one setting, and spending uninterrupted time with you without patterning bias.
And this is what you can expect at Flow Physical Therapy and Wellness.
Click the button below if you've been struggling with stubborn heel pain that doesn't seem to improve with stretching or rest.
Dr. Patrick Thompson, PT, DPT, OCS, Dip. Osteopractic, FAAOMPT
Owner of Flow Physical Therapy and Wellness
832.299.5447
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