Heel Pain

Chapter 140
Heel Pain
David R. Richardson, MD
E. Greer Richardson, MD
I. Overview and Epidemiology
A. General characteristics—Heel pain (subcalcaneal
pain syndrome) is the most common foot-related
symptom leading patients to seek medical care for
the feet.
B. Epidemiology
1. Heel pain may occur at any age. The peak inci-
dence occurs between ages 40 and 60 years.
2. Middle-aged women appear to have the highest
incidence of heel pain.
3. Race and ethnicity play no role in this entity.
Figure 1
4. Stress fractures are more common in women than
in men; they are also more common in military
recruits than in the general population.
Clinical photograph shows the points of maximal tenderness in relation to the most common
causes of heel pain. The foot is shown with the
toes to the right and the medial aspect of the
foot and ankle at the top.
C. Etiology—Heel pain has various etiologies, includ-
ing trauma, disease, and the degenerative processes
of aging.
Differential Diagnosis of Heel Pain
1. History and physical examination
a. The history and physical examination are ex-
tremely important when evaluating heel pain
because imaging and laboratory studies may
be of limited value.
b. The foot should be examined for the point of
maximal tenderness (Figure 1).
2. Differential diagnosis (Table 1)
a. Plantar fasciitis is the most common cause of
heel pain.
Plantar fasciitis
Plantar fascia rupture
Fat pad atrophy
Fat pad contusion
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D. Evaluation
Table 1
Calcaneal stress fracture
Entrapment of the first branch of the lateral plantar nerve
Calcaneal apophysitis (Sever disease)
Tumor (for example, osteoid osteoma)
Tarsal tunnel syndrome
b. Central heel pain, calcaneal stress fracture,
and entrapment of the first branch of the lateral plantar nerve also should be high in the
differential.
c. A high index of suspicion is needed to diag-
Gout
Inflammatory arthropathies (for example, psoriatic arthritis)
Spondyloarthropathies (for example, Reiter syndrome)
Infection
Radiculopathy
Neither of the following authors nor any immediate family
member has received anything of value from or has stock or
stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter: Dr.
David R. Richardson and Dr. E. Greer Richardson.
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ORTHOPAEDIC SURGEONS
Paget disease
Neuropathy
Foreign body reaction
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nose the less common causes of heel pain syndrome, such as tumor or infection.
d. Heel pain in the elderly and patients with atyp-
ical presentations should be investigated to
rule out insufficiency fractures and tumors.
II. Plantar Fasciitis
A. Overview and epidemiology
1. Over all age ranges, plantar fasciitis occurs
equally in men and women.
2. Risk factors include limited ankle dorsiflexion
due to tightness of the Achilles tendon, obesity
(body mass index >30), and prolonged weight
bearing.
3. Plantar fasciitis also may be associated with ana-
tomic variations (for example, pes planus, pes cavus, or excessive femoral anteversion).
4. A heel pain triad of tibalis posterior tendon dys-
function, plantar fasciitis, and tarsal tunnel syndrome has been described.
5. Although 50% of patients with plantar fasciitis
have a plantar heel spur, typically located in the
origin of the flexor hallucis brevis, heel spurs are
not considered the cause of heel pain in such patients.
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B. Pathogenesis—The etiology of plantar fasciitis is re-
petitive microtrauma to the plantar fascia causing
microtears and periostitis.
C. Evaluation
1. History and physical examination
a. The patient with plantar fasciitis will most of-
ten report “start-up” inferior heel pain and
may prefer to walk on the toes for the first few
steps.
b. The pain usually lessens with ambulation and
then increases with activity, especially on hard
surfaces.
c. A traumatic tear of the plantar fascia may oc-
cur in the midfoot region.
d. The point of maximal tenderness is located at
the proximal medial origin of the plantar fascia (Figure 1).
e. Palpation of the plantar fascia with the toes
and ankle in dorsiflexion increases the sensitivity of the examination.
f. The ankle should be examined for tightness of
the Achilles tendon.
2. Imaging and other studies
a. Radiographs—Weight-bearing lateral and ax-
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Figure 2
Photograph demonstrates plantar fascia–
specific stretch.
ial views of the hindfoot may be used to assess
for arthritic changes, structural abnormalities,
or bony pathology. They are not necessary on
the initial visit.
b. A bone scan may help quantitate inflammation
and guide treatment.
c. CT is not necessary.
d. MRI may be beneficial before surgical release.
e. Laboratory studies are not necessary unless
other etiologies are suspected (for example, inflammatory arthritis, infection).
D. Treatment
1. Nonsurgical
a. NSAIDs, stretching exercises (weight-bearing
and non–weight-bearing), night splints, overthe-counter heel cups, and reduced activity all
may be used initially.
b. A non–weight-bearing, plantar fascia–specific
stretching exercise program (Figure 2) and
Achilles tendon stretching appear to be more
effective than the traditional program of
weight-bearing Achilles tendon stretching exercises.
c. A short leg cast worn for 8 to 10 weeks may be
necessary.
d. Corticosteroid injections should be used spar-
ingly because they may increase the risk for
plantar fascia rupture or fat pad atrophy.
e. The FDA recently approved the use of electro-
hydraulic and electromagnetic extracorporeal
shock wave therapy for chronic plantar heel
pain that lasts longer than 6 months and when
other treatment options have failed; however,
the efficacy of such therapy remains controversial. It is a safe treatment option, with several
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ORTHOPAEDIC SURGEONS
Chapter 140: Heel Pain
studies supporting its use and showing improvement in patients’ pain scales.
2. Surgical
a. Indication—Continued pain after 9 months of
nonsurgical treatment
b. Contraindications
• Absolute contraindications: Vascular insuffi-
ciency, active infection
• Relative contraindications: History of hyper-
sensitivity, complex regional pain syndrome
(CRPS), heavy smoker, obesity, concomitant
medical condition contributing to pain (neuropathy, fibromyalgia, and so forth)
c. Surgical procedures
• The medial one-third to two-thirds of the
plantar fascia is incised through an open or
endoscopic procedure.
• When evidence of plantar fasciitis and com-
pression neuropathy is present, an open procedure must be performed. This procedure
consists of a distal tarsal tunnel decompression and partial plantar fascia release.
• Success rates for distal tarsal tunnel decom-
Figure 3
Lateral radiograph of the calcaneus shows a
line of increased density, indicating a stress
fracture.
pression and partial plantar fascia release
are reported to be from 70% to 90%.
• Some authors report successful treatment of
recalcitrant foot pain such as plantar fasciitis with isolated gastrocnemius recession.
plantar nerve, complete fascia rupture with resultant loss of the medial longitudinal arch,
stress reaction of the dorsolateral midfoot, and
continued pain.
III. Calcaneal Stress Fracture
ture is repetitive loading resulting in fatigue of the
bone.
C. Evaluation
1. History and physical examination
a. Patients usually report an insidious onset of
pain that improves with rest and intensifies
with activity. Often, patients report a recent increase in physical activity.
11: Foot and Ankle
d. Complications include damage to the lateral
B. Pathogenesis—The etiology of calcaneal stress frac-
b. The “female athlete triad” (disordered eating,
A. Overview and epidemiology
1. The calcaneus is the largest tarsal bone. It is com-
posed primarily of cancellous bone.
2. On average, the calcaneus absorbs a force equal
to 110% of body weight during walking and
200% of body weight during running.
3. A calcaneal stress fracture is usually oriented ver-
tically or obliquely in the tuberosity of the calcaneus.
4. Women appear to be more prone to stress frac-
tures than men. Menstrual disturbances leading
to estrogen or other hormonal deficiencies, inadequate caloric intake, decreased bone density,
limb-length discrepancy, and muscle weakness are
risk factors.
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ORTHOPAEDIC SURGEONS
amenorrhea, and osteoporosis) should be kept
in mind during the evaluation.
c. The point of maximal tenderness is obtained
with medial and lateral compression of the calcaneus on the weight-bearing heel (Figure 1).
d. Diffuse swelling may be present.
2. Imaging
a. Radiographs—Initial radiographs are usually
normal. Two to 4 weeks after the onset of
symptoms, a band of increased density may be
noted in the posterior aspect of the calcaneus
(Figure 3).
b. A
bone scan or MRI is useful when
radiographs are normal.
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Figure 4
A, Photograph of the medial aspect of the ankle shows the anatomic locations of the tibial nerve (A), the flexor
retinaculum (laciniate ligament) (B), the lateral plantar nerve (C), the first branch of the lateral plantar nerve (D),
the medial plantar nerve (E), and the medial calcaneal nerve (F). B, Photograph of a cadaver foot with the tibial
nerve (A), the lateral plantar nerve (B), the first branch of the lateral plantar nerve (C), and the medial plantar
nerve (D) exposed.
D. Treatment
1. Nonsurgical
a. Restriction of painful activity for 4 to 6 weeks
and placement of a cushioned insert is the
standard treatment.
b. If the patient has pain with normal walking, a
short leg cast or boot should be placed. The
patient is then allowed to return to activity
gradually as the pain resolves.
11: Foot and Ankle
c. The patient may need a referral to an endocri-
nologist if metabolic abnormalities are suspected.
2. Surgical—Calcaneal stress fractures do not re-
quire surgical treatment unless displacement occurs.
IV. Entrapment of the First Branch of the Lateral
Plantar Nerve
A. Overview and epidemiology
1. The lateral plantar nerve is a branch of the tibial
nerve.
2. The first branch of the lateral plantar nerve is a
mixed (sensory and motor) nerve (Figure 4).
Branches of the nerve pass deep to the deep fascia
of the abductor hallucis and flexor hallucis brevis, immediately distal to the medial process of
the calcaneal tuberosity. The nerve innervates the
periosteum of the calcaneus, the flexor digitorum
brevis, and the abductor digiti quinti (Figure 5,
A). The nerve runs plantar to the quadratus plantae (Figure 5, B).
3. Entrapment of the first branch of the lateral plan-
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tar nerve is more common in athletes who are on
their toes for a substantial amount of time (for
example, sprinters, ballet dancers).
B. Pathogenesis—The etiology of entrapment of the
first branch of the lateral plantar nerve is compression between the deep fascia of the abductor hallucis
and the inferomedial margin of the quadratus plantae.
C. Evaluation
1. History and physical examination
a. The diagnosis of entrapment of the first
branch of the lateral plantar nerve is based on
clinical findings.
b. Patients usually report pain radiating distally
and proximally from the medial aspect of the
heel, and they may report paresthesias.
c. Pain may radiate proximally into the calf (Val-
leix phenomenon).
d. A positive Tinel sign (percussion of the irri-
tated nerve causing tingling or numbness radiating in the nerve’s distribution) may be present.
e. Atrophy of the abductor quinti may be pres-
ent, but it is difficult to detect.
f. The point of maximal tenderness is located on
the medial heel (Figure 1).
g. Dorsiflexion and eversion of the ankle may ex-
acerbate symptoms.
2. Imaging and other studies
a. Imaging studies are not indicated unless a
space-occupying lesion is suspected, in which
case MRI should be obtained.
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ORTHOPAEDIC SURGEONS
Chapter 140: Heel Pain
b. Electromyography and nerve conduction ve-
locity studies are not consistent.
D. Treatment
1. Nonsurgical
a. Nonsurgical treatment should be attempted for
at least 6 months. Rest, activity modification,
NSAIDs, stretching, and ice are the first line of
treatment.
b. Shock-absorbing inserts with a medial longitu-
dinal arch support may reduce the pressure in
the area of entrapment.
2. Surgical
a. Indications
Figure 5
• Continued pain after 9 months of nonsurgi-
cal treatment
• A space-occupying lesion confirmed by MRI
b. Contraindications
• Absolute contraindications: Vascular insuffi-
ciency, active infection
Illustrations show the course of the first branch
of the lateral plantar nerve. A, Branches of this
nerve innervate the periosteum of the calcaneus (1), as well as the flexor digitorum brevis
(2) and the abductor digiti quinti (3) muscles.
B, The course of the nerve is shown with parts
of the abductor hallucis (1) and the flexor digitorum brevis (2) muscles removed. Branches of
the nerve also run plantar to the quadratus
plantae (3) and innervate the abductor digiti
quinti (4) muscle.
• Relative contraindications: History of hyper-
sensitivity, CRPS, heavy smoker, obesity,
concomitant medical condition contributing
to pain (for example, neuropathy, fibromyalgia)
c. Surgical procedures
• Open decompression should be performed.
• The medial third of the plantar fascia is of-
ten incised if concomitant proximal plantar
fasciitis is suspected.
• The deep fascia of the abductor hallucis
muscle is released.
11: Foot and Ankle
Top Testing Facts
1. Heel pain in the elderly and patients with atypical presentations should be investigated to rule out insufficiency fractures and tumors.
2. Although 50% of patients with plantar fasciitis have a
plantar heel spur, typically located in the origin of the
flexor hallucis brevis, heel spurs are not considered the
cause of heel pain in such patients.
3. The patient with plantar fasciitis will most often report
“start-up” inferior heel pain and may prefer to walk
on the toes for the first few steps.
4. Corticosteroid injections should be used sparingly in
the treatment of plantar fasciitis because they may
© 2014 AMERICAN ACADEMY
OF
ORTHOPAEDIC SURGEONS
increase the risk for plantar fascia rupture or fat pad
atrophy.
5. With calcaneal stress fractures, pain is elicited when
compressing the heel medial/lateral.
6. The etiology of entrapment of the first branch of the
lateral plantar nerve is compression of the nerve between the deep fascia of the abductor hallucis and the
inferomedial margin of the quadratus plantae.
7. The first branch of the lateral plantar nerve innervates
the abductor digiti quinti muscle. When entrapment of
this nerve occurs, nonsurgical treatment should be attempted for at least 6 months.
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Section 11: Foot and Ankle
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