Plantar fasciitis diagnosis
25. Mrs H says a GP dismissed her mother’s symptoms as plantar fasciitis. She says this meant Mrs A experienced unnecessary pain and did not get the help she needed.
26. In its response the Practice said Mrs A reported heel pains between 17 November and 9 December. It said on 21 December Mrs A had a face-to-face appointment with a GP who noticed the sole of her foot was tender.
27. The GP said it was likely Mrs A had plantar fasciitis. They noted Mrs A was using gel inserts, an appropriate treatment for plantar fasciitis.
28. The Practice acknowledges Mrs A reported foot pain among other symptoms between October 2020 and June 2021. It says several assessments of Mrs A’s foot suggested she had plantar fasciitis so the GP recommended treatment for this.
29. GMC guidance on good medical practice says doctors must provide a good standard of practice and care. If they assess, diagnose or treat patients they must adequately assess the patient’s conditions and examine them if necessary.
30. Doctors must promptly give or arrange suitable advice, investigations or treatment where necessary. They must refer a patient to another practitioner when this serves the patient’s needs.
31. When giving clinical care doctors must only prescribe drugs or treatment when they are satisfied these serve the patient’s needs. They must give effective treatment based on the best available evidence.
32. The NHS.UK web page on plantar fasciitis says the main symptom of the condition is pain on the bottom of the foot, around the heel and arch. It says patients can ease this themselves and recommends seeing a GP if it does not ease after two weeks.
When a patient sees a GP they will usually suggest: • resting and raising the foot on a stool • using an ice pack • wearing shoes with cushioned heels • using insoles or heel pads • regular gentle stretching exercises and • taking painkillers like paracetamol and ibuprofen.
33. If plantar fasciitis does not get better a GP may refer the patient to a physiotherapist or podiatrist. A physiotherapist can show them exercises to help ease symptoms. A podiatrist can recommend things like insoles and the right shoes to wear.
34. Mrs A’s records show she reported pain around her foot and heel between November and December 2020.
35. The first instance was on 17 November 2020 when she told a GP she had been experiencing breathlessness and pains in her chest, right heel and leg since having COVID-19 in October. The GP noted Mrs A’s energy levels were ‘ok’ and she was able to walk. They told her recovery could often take two months and to contact the Practice if she was still unwell in late December.
36. On 9 December Mrs A told a nurse practitioner she still had pain in her right heel as well as pain in her right shoulder. She told the nurse she was on her feet all day at work and walked around six kilometres a day. The nurse said the pain was likely job-related musculoskeletal pain and recommended trying exercises for around a month. Mrs A did not want to try exercises as they were too painful.
37. Mrs A spoke to a GP by phone on 15 December as her heel and shoulder were still painful. Notes from her medical records suggest the GP was already considering plantar fasciitis. The GP invited her for a face-to-face appointment on 21 December.
38. On 21 December a GP examined Mrs A’s foot and noted tenderness. We can see the GP said they considered she had plantar fasciitis, discussed the use of gel insoles and recommended taking painkillers.
39. Mrs A now has a diagnosis of fibromyalgia as well as osteoarthritis. The NHS.UK web page on fibromyalgia explains it is a long-term condition causing pain all over the body. Diagnosis can be difficult as there is no specific test to diagnose the condition. The symptoms of fibromyalgia vary from person to person and are similar to those of several other conditions.
40. The NHS.UK web page on osteoarthritis explains this condition causes joints to become painful and stiff, most often the knees, hips and small joints of the hands.
41. The NHS.UK web page on the long-term effects of coronavirus explains the most common symptoms of long COVID are: • extreme tiredness • shortness of breath • loss of smell and • muscle aches.
42. But there are lots of other symptoms people may get after a COVID-19 infection, including: • brain fog • chest pain or tightness • difficulty sleeping • joint pain and • depression.
43. In considering this complaint we obtained clinical advice from a GP (our adviser). They said it can take clinicians a long time to diagnose fibromyalgia. Typically, a patient’s path to a fibromyalgia diagnosis consists of multiple consultations about various symptoms followed by a doctor diagnosing the condition.
44. Our adviser explained fibromyalgia causes widespread pain all over the body. Other symptoms include: • brain fog • low mood • fatigue and • lack of sleep.
45. Our adviser said Mrs A’s medical records show a typical patient journey to a diagnosis of fibromyalgia. Her symptoms in November and December 2020 were breathlessness, chest pains and leg and foot pain as well as shoulder pain. Our adviser noted Mrs A had COVID-19 in October, which was likely the cause of her ongoing breathlessness and chest pain.
46. Our adviser noted Mrs A’s leg, foot, and shoulder pain. They said these are symptoms of many conditions and would not necessarily lead to a diagnosis of fibromyalgia or osteoarthritis on their own. our adviser explained Mrs A had yet to report other symptoms of fibromyalgia such as brain fog and low mood. Nor had she reported joint pain in her knee, hip or hand to lead clinicians to suspect osteoarthritis.
47. The GMC guidance says doctors must adequately assess and examine patients and give suitable advice and treatment quickly.
48. We consider Mrs A’s foot pain matches the definition of plantar fasciitis. This is why the GP suggested it as a diagnosis. The GP and nurse practitioner both recommended exercise, gel insoles and painkillers. This is in line with suggested treatment for the condition.
49. We recognise Mrs A feels the GP's initial diagnosis of plantar fasciitis delayed her eventual diagnosis. We recognise she was in pain during this period and do not dismiss how frustrating it was to have to wait nine months for a correct diagnosis. But the evidence suggests Mrs A’s symptoms between November and December matched plantar fasciitis, and this is why the GP recommended treatment for this condition.
50. The evidence indicates it is common for patients with fibromyalgia to receive other initial diagnoses before clinicians rule these out. We consider the GP acted in line with GMC guidance in suggesting a diagnosis and providing advice on treatment.
51. We do not consider it was possible for clinicians to diagnose Mrs A with fibromyalgia or osteoarthritis between November and December as she did not meet the criteria for either. There is no sign the Practice got anything wrong in this aspect of the complaint.
Treatment for pain and lack of referral
52. Mrs H tells us her mother repeatedly reported pain between November 2020 and June 2021. She feels the Practice gave incorrect advice and recommended inappropriate treatment for this.
53. Mrs H says a GP told her mother to pursue private treatment. She says her mother asked clinicians to refer her for further investigations but they refused to do so until she paid for private treatment. Mrs H feels her mother should have been referred to rheumatology much sooner.
54. In its response to the complaint the Practice acknowledges there was a long delay between the onset of Mrs A’s symptoms and her getting a diagnosis. It says her symptoms started as foot and back pain and developed into other joint pains, particularly in the hand, and then pains all over.
55. The Practice says Mrs A did not mention hand pain in any consultations until June 2021. The private consultant thought she had inflammatory arthritis but an NHS consultant disagreed with this after seeing her blood results and an ultrasound (a scan using high-frequency sound waves to assess organs and structures in the body) of her joints. The NHS consultant diagnosed her with fibromyalgia.
56. The Practice says based on Mrs A’s symptoms it was reasonable for clinicians to suggest exercise. It acknowledges Mrs A felt the GP ignored important symptoms. It explains long COVID can cause many of the symptoms she reported, and the GP was aware she was waiting for an appointment with the long COVID clinic.
57. The Practice adds it was not possible for the GP to refer Mrs A to rheumatology before July 2021. This was because she did not report multiple joint pains until June. The GP made an urgent referral when she did.
58. The NHS.UK web page on fibromyalgia says there is no cure for the condition. But there are treatments to help relieve some of the symptoms and make it easier to live with the condition. Treatment tends to be a combination of: • lifestyle changes such as exercise programmes and relaxation techniques • talking therapies such as cognitive behavioural therapy and • medicine such as antidepressants.
59. Exercise has several important benefits for people with the condition, including helping to reduce pain.
60. The NHS.UK web page on osteoarthritis says it is a long-term condition and cannot be cured. Several treatments are available to reduce the symptoms. These include: • regular exercise • losing weight if someone is overweight and • wearing suitable footwear.
61. It adds if symptoms are more severe additional treatments such as painkillers and a structured exercise plan with a physiotherapist may be needed. In a small number of cases, when these treatments have not helped or damage to the joints is severe, surgery may be necessary.
62. Mrs A’s medical records show she was in touch with the Practice ten times between first reporting her symptoms on 17 November 2020 and receiving a diagnosis of fibromyalgia and osteoarthritis on 23 August 2021.
63. Mrs A saw the Practice with: • chest, leg, and heel pains in November 2020 • heel and shoulder pain in December and • continuing foot pain in January 2021.
64. The last appointment she had with a GP was on 18 March, when she talked about the ongoing pain in her feet.
65. Between November 2020 and March 2021 the GPs and nurse practitioner she saw recommended exercise, gel inserts and painkillers to help Mrs A manage her pain. The NHS recommends all these for management of symptoms associated with osteoarthritis and fibromyalgia.
66. Mrs H says in a consultation on 18 March 2021 a GP told her mother to get private treatment. During this appointment Mrs A reported mild tenderness on her heel but had no swelling or tenderness in her calf. She had no leg tenderness.
67. The records show Mrs H asked a GP to send her mother for a scan to rule out DVT. The GP refused to refer Mrs A for a scan as she showed no signs of DVT but said they could pursue this privately if they wished.
68. The NHS.UK web page on DVT explains this is a blood clot in a vein, usually the leg. It can be dangerous. Symptoms of DVT are: • throbbing or cramping pain in one leg (rarely both legs), usually in the calf or thigh • swelling in one leg (rarely both legs) • warm skin around the painful area • red or darkened skin around the painful area • swollen veins that are hard or sore when touched.
69. The NHS.UK web page on referrals for specialist care explains patients are entitled to ask for a referral for specialist treatment on the NHS. But whether they will get the referral depends on what their GP feels is clinically necessary in their case.
70. GMC guidance says doctors should examine and assess a patient’s condition and refer them to another practitioner when this serves the patient’s needs. We can see the GP examined Mrs A’s feet and legs and ruled out swelling and tenderness in Mrs A’s legs. We have seen nothing to suggest Mrs A was reporting any other symptoms of DVT.
71. We consider the GP assessed Mrs A in line with GMC guidance. We have seen nothing to suggest she had DVT so we would not expect the GP to refer her for a scan to check for this.
72. We acknowledge the GP did mention private treatment as an option. But the records show this referred to Mrs H’s request for a scan to check for DVT and not for the symptoms we now know are related to her current diagnoses.
73. Mrs A had an annual diabetic health check on 7 June 2021 with a nurse practitioner. Notes from this say ‘patient wanted to talk about her aches and pains, she is not happy with plantar fasciitis diagnosis for pain in her heels. She complains of pain in her bones, especially hands/fingers and wants a referral’.
74. Mrs A was due to have routine blood tests as part of her annual health check. Our adviser noted the nurse practitioner suggested adding tests to check for inflammatory arthritis to these. The nurse recommended Mrs A discuss her new symptoms with a GP.
75. Our adviser said the first time clinicians would have been able to consider a diagnosis of arthritis and/or fibromyalgia was during the appointment on 7 June as it was the first time Mrs A complained of widespread pain, including in her bones, hands and fingers. Our adviser explained prior to this appointment Mrs A’s symptoms did not reflect widespread pain.
76. We can see the nurse practitioner referred Mrs A back to her GP for consideration of her new symptoms. But we have been unable to confirm Mrs A asked to see a GP. She opted for private treatment, seeing a private consultant rheumatologist on 19 June and again on 3 July.
77. The private consultant assessed Mrs A, recommended blood tests and said she may have seronegative rheumatoid disease. They also prescribed medication to treat various forms of arthritis.
78. Our adviser explained in Mrs A’s case the private rheumatologist’s involvement complicated things. The private rheumatologist diagnosed her with inflammatory arthritis but this was ruled out by an NHS rheumatologist in August. Our adviser said it is likely the private consultant’s involvement delayed Mrs A’s diagnosis.
79. When Mrs A saw the NHS rheumatologist on 23 August she reported the same pains as before, but also: • brain fog • low mood • poor sleep patterns and • fatigue.
80. Our adviser explained taking the new symptoms together allowed the consultant to make a diagnosis of fibromyalgia. Mrs A’s blood tests showed no signs of inflammatory arthritis, leading the consultant to make a second diagnosis of osteoarthritis.
81. We understand Mrs H feels the Practice did not effectively manage her mother’s symptoms before diagnosis. Our adviser explained it is standard medical practice to recommend exercise and painkillers for joint and muscle pain. The evidence suggests it was not possible for clinicians to diagnose Mrs A until August 2021. We consider the GP and nurse practitioner managed Mrs A’s symptoms in line with GMC guidance up to this point.
82. We have seen no signs the Practice got anything wrong in the care of Mrs A. She made the decision to pursue private treatment. We have seen nothing to suggest Mrs A asked to see a GP to discuss her developing symptoms after speaking to a nurse practitioner on 7 June.
83. On balance, we consider if she had arranged a further appointment with a GP, they could have explored her spreading pain. It is likely Mrs A would also have reported her other symptoms such as brain fog and the GP would have made the referral to a rheumatologist sooner. We consider it likely Mrs A would have received a referral had she spoken to the GP again.
84. Our adviser made it clear the typical journey to a diagnosis of fibromyalgia is long and often involves multiple interactions with clinicians. There is an overlap between symptoms of fibromyalgia and long COVID.
85. Mrs A had COVID-19 in October 2020. Her medical records show she was still testing positive on 19 November 2020. She went to the local A&E department on 26 January 2021 and was referred to the long COVID clinic. Notes from her GP consultations between 3 February and 18 March show Mrs A was still waiting for a clinic appointment.
86. There is a clear overlap between Mrs A’s symptoms and those associated with long COVID. We accept practice staff suspected she was suffering from long COVID. On balance, we consider this impression did not change until she reported widespread pain in June. The evidence suggests the GP referred her for further investigation of this pain as soon as they could.
87. We recognise Mrs A’s journey to diagnosis was long and caused her distress. We do not dismiss the impact her symptoms had on her and how frustrating it must have been not to know what was causing these. We recognise she felt the need to pursue private treatment to get answers.
88. We consider the evidence suggests the GP would have referred her for further investigation if she had arranged an appointment after her diabetic health check. There is no sign the Practice got something wrong in how it handled Mrs A’s requests for referrals.
89. We consider the Practice gave advice and treatment in line with the relevant guidance. We have seen nothing to suggest any mistake on the Practice’s part led to a delay in diagnosis. We understand our decision may be disappointing to Mrs H and Mrs A. But we hope it reassures them the Practice offered the care and treatment we would expect, despite the lengthy journey to diagnosis.