A Synopsis of AFP's "Heel Pain"

A synopsis of; Diagnosis of Heel Pain
PRISCILLA TU, DO, and JEFFREY R. BYTOMSKI, DO, Duke University, Durham, North Carolina
http://www.aafp.org/afp/2011/1015/p909.pdf
Am Fam Physician. 2011 Oct 15;84(8):909-916


      This is a review of an article discussing some of the mechanical causes of heel pain. It is broken up into plantar heel pain, posterior heel pain, and midfoot heel pain. The most common cause of plantar heel pain is plantar fasciitis. There is a more extensive review of plantar fasciitis in an earlier post (plug!). The pain occurs after a long rest or when first getting out of bed in the morning. Pain is worse with passive dorsiflexion of the foot or toes. Tenderness is found at the medial calcaneal tuberosity and plantar fascia. Ultrasound may show a heel aponeurosis of at least 5 mm. Treatment consists of rest, stretching, exercise, pain medication, anti-inflammatory meds, and ice. Orthotics, heel cups and night splints are available over the counter. Steroid injections or extracorporeal shock wave therapy are other options, as well as surgical transection of the plantar aponeurosis. If treatment is not working, a neuroma should be considered.  It presents similarly to plantar fasciitis, but the pain is characterized as burning or tingling. It may feel like a "painful lump" on palpation.
     Calcaneal stress fractures are the second most common stress fracture in the foot (metatarsal fracture is the first). Pain is seen with weight bearing activity or when walking on a hard surface. It is common in soldiers who do a lot of marching and in people who enjoy running on the road. Unlike plantar fasciitis, the patient will have pain at rest. There may also be swelling, point tenderness or ecchymosis on the posterior portion of the heel. Imaging will not show the fracture for about 2-3 weeks, when healing occurs. Treatment consists of not bearing weight on the area, and rest. Orthotic devices, such as heel pads or walking boots may help.
     Heel pad syndrome presents as a deep soreness upon palpation of the middle of the heel. It is worse when walking barefoot, on hard surfaces, or during periods of prolonged weight bearing. Treatment consists of rest, ice, anti-inflammatory medications, or pain medications. Taping, heel cups and proper footwear will help as well.
     HPV can present as a plantar wart. It should be evident on inspection. Treatment consists of topical medication, laser therapy, cryotherapy, or shaving it off.
     The causes of posterior heel pain are achilles tendinopathy, a haglund deformity, or sever disease. Achilles tendinopathy is pain at the insertion point or in the belly of the tendon. It can be caused by wearing high heels, fluoroquinolone use, running, or calf overuse. The pain may feel achy or sharp, and it will worsen with activity or with passive foot dorsiflexion. The tendon will be tender to palpation. Ultrasound may show thickening of the tendon. X ray may show calcification. Treatment can be done with pain and anti-inflammatory medications, orthotic devices, and muscle lengthening through eccentric stretching. Nitroglycerin patches and injections of platelet rich plasma can help as well. Surgery may be necessary if debridement is needed. Tendinopathies can also occur at the insertion of the posterior tibialis, flexor digitorum longus, flexor hallucis longus or peroneal tendons.  This would cause medial or lateral heel pain, depending on which tendon is involved. Treatment is the same as for the achilles.
     Haglund deformity is a bony prominence that forms on the posterior portion of the calcaneus. It is commonly called "pump bump" because young women who wear high heels or poorly fitting shoes develope inflammation and swelling in the area. It can lead to bursitis between the calcaneus and achilles tendon (retrocalcaneal). Treatment consists of turning in the heels for some open heeled shoes, corticosteroid injections, pain medications and anti-inflammatories. PT can also reduce the pain. Surgery may be needed to remove the deformity.
     Sever disease is where the achilles tendon pulls away from its insertion to the bone. It is more common in young, growing children. The combination of bone growth occurring faster than the muscles and tendons, with the repetitive running and jumping activities in a childs life, create microtrauma in the area. The patient will present with pain, swelling and tenderness at the insertion point of the tendon. Treatment consist of....you guessed it.... ice, pain meds, anti-inflammatories, stopping the offending activity, as well as stretching and strengthening the calf muscle.  Don't let me forget about orthotics!
     Along with tendinopathy, the midfoot heel pain syndromes are the tarsal tunnel syndrome and sinus tarsi syndrome. The tarsal tunnel is the the space consisting of the flexor retinaculum, medial calcaneus, posterior talus, and medial malleolus. Pain and numbness of the posteriormedial ankle and heel occurs when the posterior tibial nerve is compressed when passing through this tunnel. Pain is worse with standing, walking, or running. It is better with rest or with comfortable footwear. Patients who are flat footed (pes planus deformity) may be at increased risk. Tinel sign will be positive. Passively causing the nerve to stretch or flex may exacerbate the pain. Treatment consists of orthotics, anti-inflammatories, activity modification, steroid injections, TCA's and antiepileptics.
     The sinus tarsi is a tunnel that runs laterally to medially (or medially to laterally if you are are lefty) though your heel. The borders of the tunnel consist of the calcaneus,  talus, talocalcaneonavicular joint, and subtalar joint. Pain is located on the lateral part of the ankle. It is worse after exercise or walking on uneven surfaces. It can be exacerbated by multiple episodes of foot hyperpronation or lateral ankle sprains. You can only guess what the treatment is.