the journal of Family Practice

Chris Clemow, MD, FACSM Brian Pope, MD, MPH Tools to speed H. E. Woodall, MD, FAAFP AnMed Health Family Medicine Residency, Anderson, SC your heel pain diagnosis [email protected] Quickly zero in on a diagnosis by using our handy “photo guide” and reference table

Practice recommendations what you expected. The pain is in the • Advise patients with wrong place for plantar and the to decrease physical activity, do patient’s history is atypical. How should stretching exercises (C), undergo you proceed? eccentric calf muscle® Dowden training (B), HealthKnowing Media the precise location of max- use heel lifts (C), modify shoe fit, and imum pain or tenderness (FIGURES 1A–1C) take nonsteroidal anti-inflammatory and pairing that with key findings from Copyrightdrugs (NSAIDs)For regularly personal for a use theonly exam and history (TABLE 1) can help few days, then as needed (B). you reach an accurate diagnosis and for- mulate proper treatment (TABLE 2). • The mainstay of treatment for calcaneal Each of the 3 general areas of heel In this Article apophysitis in children is rest (C). Other pain—posterior, plantar, and medial— options include heel lifts, stretching z Quick guide to programs, icing, gel heel cups, and figure 1 narrowing the anti-inflammatory agents (C). diagnosis • Treatment options for Common causes of heel pain by location Page 717 include NSAIDs, stretching exercises, z Rating the gel cups, arch supports, night splints, Posterior view steroid injections, extracorporeal a treatment options shock wave therapy, and surgery (B). Page 719 Noninsertional Strength of recommendation (SOR) Achilles tendinopathy A Good-quality patient-oriented evidence B Inconsistent or limited-quality patient-oriented evidence C Consensus, usual practice, opinion, disease-oriented Posterior Insertional impingement Achilles (os trigonum) ne of your patients, a 40-year- tendinopathy old woman, recently began an Retrocalcaneal exercise program, and she now Calcaneal O apophysitis says she has persistent heel pain. Your first suspicion is “another plantar fasci- Calcaneal itis case.” However, after asking a few stress fracture (squeeze test) questions and performing a brief exami- nation, you realize the problem is not

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For mass reproduction, content licensing and permissions contact Dowden Health Media. introduces a unique differential. Bilateral tients, too, whether they have recently symptoms or multiple joint involvement, taken a fluoroquinolone antibiotic. This of course, raises the possibility of associ- drug class is known to increase the risk ated systemic disease. of both tendonitis and tendon rupture,4 and in July of this year the FDA directed drug manufacturers to add a black-box z Posterior heel pain warning to that effect.5 The common causes of posterior heel Evaluation of noninsertional tendinop- pain are Achilles tendinopathy, retro- athy. Tenderness is usually located 2 to calcaneal bursitis, calcaneal apophysitis, 6 cm above the Achilles insertion. Nodu- posterior impingement (FIGURE 1A), and larity, swelling, or fluctuance of the ten- strain or rupture. Rarer don may be evident. Diagnosis generally causes are sciatica, peroneal tendonitis, can be made clinically. If confirmation Haglund’s deformity, pump bump, and is needed, consider ultrasonography or systemic disorders. The patient’s history magnetic resonance imaging. and precise location of maximal tender- Treatment. Advise patients to decrease ness1 differentiates these problems. physical activity and do stretching exer- cises, undergo eccentric calf muscle train- Achilles tendinopathy (tendonitis): ing, use heel lifts, modify shoe fit, and Is the patient an athlete? use systemic or topical nonsteroidal anti- Insertional and noninsertional Achil- inflammatory drugs (NSAIDs) regularly les tendinopathy are the most common for a few days, then as needed. Refractory causes of persistent posterior heel pain.2,3 cases may require surgery.6 New therapies The inflammatory process occurs in the that have proven effective include extra- fatty tissue surrounding the Achilles ten- corporeal shock wave therapy (ESWT), don (the paratenon) rather than in the prolotherapy (dextrose injections), and tendon itself. Patients tend to be highly local application of nitroglycerin patches active (often athletes) and may have re- or gel.7-18 ESWT can be expensive and is cently increased their activity. Ask pa- not widely available. Prolotherapy can be

Common causes of heel pain by location

Plantar-surface view Medial view b c

Fat pad syndrome

Plantar fasciitis

Posterior tibial tendon dysfunction Tarsal tunnel syndrome

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performed with minimal training, but is Calcaneal apophysitis still relatively new. Topical nitroglycerin affects highly active kids is affordable, but beware of such side ef- Calcaneal apophysitis (Sever’s disease) fects as headache and hypotension. is a painful inflammation in the heels of Evaluation of insertional tendinopathy. skeletally immature children where the Inflammation occurs at the tendon’s in- Achilles tendon inserts in the calcaneus sertion to bone (). Pain typically apophysis. is at the midline and is reproduced by Evaluation. Associated with peak palpating the tendon insertion or by pas- growth rate and high activity level, this sively stretching the heel. The presenta- inflammatory process usually occurs tion may be difficult to distinguish from in boys between the ages of 10 and 12 (discussed below). years, and in girls between the ages of 8 Treatment is similar to that used for and 10 years.21 The process is similar to noninsertional tendinopathy. However, that occurring at other sites of traction if insertional tendinopathy occurs in apophysitis, such as Osgood-Schlatter conjunction with a Haglund’s deformity disease at the tibial tuberosity. Children (bony overgrowth of the calcaneus), sur- most susceptible are highly active, wear gery may be indicated, because noninva- poorly fitting footwear, run frequently sive measures tend to fail.19 on hard surfaces, and have tight Achilles Use steroid injections with extreme tendons. Clinical diagnosis usually suffic- caution due to the theoretical risk of es, although plain x-ray films can verify tendon rupture.20 Injections are effective an active apophysis and rule out other when directed at concomitant inflamma- sources of pain, such as tarsal coalition, tion of the retrocalcaneal bursa, but accu- calcaneal stress fractures, or infection.22 rate positioning and careful postinjection Treatment. Calcaneal apophysitis is care are paramount. After an injection, typically self-limiting, and the mainstay a patient may need absolute rest or even of treatment is rest. Heel lifts, stretching immobilization to protect from tendon programs, icing, gel heel cups, and anti- fast track rupture. Emphasize a careful return to ac- inflammatory agents may also be used.23 The pain of plantar tivity or athletic training. Posterior impingement: fasciitis is worst Retrocalcaneal bursitis: Pain with full plantar flexion with the first step Look for subtle swelling Posterior impingement at the ankle joint of the morning, The retrocalcaneal bursa lies between the may be self-originating or arise as a con- and lessens with Achilles tendon and the calcaneus near sequence of an os trigonum, a posterior the tendon’s insertion. This bursa may sesamoid bone of the talus that exists as activity become inflamed with repetitive stress or a normal variant. In some cases, this bone with insertional Achilles tendinopathy. creates a barrier to full plantar flexion at Evaluation. Swelling is usually present the ankle joint and creates pain at the but may be subtle. Pain is located just lat- posterior heel. eral to the midline of the posterior heel at Evaluation. Pain with full plantar the superior angle of the calcaneus, and flexion is a critical distinguishing fea- it may also be medial to the tendon op- ture, because most other pathologies in posite the lateral location. the posterior heel cause pain with dor- Treatment. The bursitis often responds siflexion at the ankle.24,25 Patients often to icing and ice massage, shoe-fit adjust- are involved in activities that require ments, heel lifts, Achilles stretching pro- forced plantar flexion, such as gymnas- grams, and systemic or topical NSAIDs.2 tics or dancing. Diagnosis is clinical for Steroid injections are likely beneficial, the most part, but plain x-ray films may but use them with caution and take care confirm the presence of an os trigonum. to avoid the Achilles tendon insertion. Magnetic resonance imaging (MRI) is

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table 1

A quick guide to narrowing your heel pain diagnosis

Affected area Onset of pain History and key findings Likely diagnosis Posterior heel Acute • Audible “pop” Achilles rupture • Weak or absent plantar flexion • Defect in tendon • No audible “pop” Achilles strain • Intact plantar flexion Chronic • Recent increase in activity Achilles tendinopathy • Fluoroquinolone use • Pain adjacent and deep Retrocalcaneal bursitis to the Achilles tendon • Pain at Achilles insertion, Calcaneal apophysitis in boy (10-12 years) or girl (8-10 years) • Pain on full plantar flexion Posterior impingement Plantar surface Acute • High-impact trauma Calcaneal fracture • Positive squeeze test • Painful “pop” associated Plantar fascial rupture with acute stretch injury Chronic • Pain worst with first steps in Plantar fasciitis the morning, then diminishes with activity • Patient is distance runner who Calcaneal stress fracture recently increased activity • Positive squeeze test • Diffuse pain in fat pad Fat pad syndrome Medial heel Subacute • Overuse Posterior tibial tendonitis • No fallen arch fast track Chronic • Patient is overweight Posterior tibial tendon • Fallen arch dysfunction The pain of a • Neuropathic pain to arch Tarsal tunnel syndrome calcaneal stress • Positive Tinel’s sign fracture typically worsens with warranted for patients with persistent in sports requiring loading and sudden activity and symptoms; it may reveal a hypertrophied contraction of the calf muscles, such as synovial lining or other pathology (such basketball or football, although injuries lessens with rest as osteochondritis). MRI is also indicat- may occur in a variety of other settings. ed before more invasive therapies, such A strain of the Achilles tendon should be as steroid injections or surgery. carefully differentiated from a complete Treatment. Advise rest with or with- rupture. While strains can be treated sim- out immobilization, NSAIDs, or local ilarly to Achilles tendinopathy, complete steroid injections. Severe impingement rupture is a much larger concern. or recalcitrant cases may require surgical Evaluation. When the Achilles ten- release of the posterior synovium or re- don ruptures, patients describe sudden moval of an os trigonum.24,25 pain and a pop that is often audible. Poor plantar flexion of the foot ensues.26 Achilles strain and rupture: Telltale signs on examination are a posi- Middle-aged men are susceptible tive Thompson’s test (little or no plantar The Achilles tendon is most susceptible to flexion with a calf squeeze) and a visible injury in middle-aged men who are active defect in the tendon. The rupture site is

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usually 1 to 2 inches proximal to its in- The tender spot is the medial calcaneal sertion on the calcaneus. , with pain radiating through the Treatment. Most of these patients arch.1,28-30 should be seen by an orthopedic sur- Treatment. The many therapeutic mo- geon as soon as possible. For active and dalities—NSAIDs, stretching exercises, gel younger adults, treatment is almost al- cups, arch supports, night splints, steroid ways early surgical repair.27 For some injections, ESWT, and surgery—have been older individuals who are less active, extensively reviewed elsewhere, including nonsurgical management includes gradu- in a Cochrane review from 2005.31-33 ated casting, which progressively lessens plantar flexion over 6 to 10 weeks, fol- Calcaneal stress fracture: lowed by physical therapy. Suspect it in runners Calcaneal stress fractures are relatively 3 less common causes rare, but may occur in those who put of posterior heel pain significant stressors on their feet, such as Haglund’s deformity is an overgrowth avid runners or military recruits. of the calcaneus at the insertion of the Evaluation. Most patients report a re- Achilles tendon.3 Caused by overuse and cent increase in frequency or intensity of poorly fitted shoes, this condition com- activity, and runners can tell you when it monly requires surgical intervention. is during their run that the pain begins. Pump bump is an inflamed superficial As the stress fracture worsens, the pain bursa commonly associated with a Ha- begins earlier in the activity and eventu- glund’s deformity, and it may respond to ally is present with even minimal activity. NSAIDs, shoe-fit modification, ice mas- A key distinction from plantar fasciitis, in sage, or steroid injection. which pain lessens with activity, is that the Peroneal tendonitis is a tendinopathy pain of a stress fracture typically worsens of evertors and external rotators of the with activity and diminishes with rest.34 foot. The pain will follow the tendons Physical exam provides few clues fast track posterior to the lateral malleolus and ex- except for the “squeeze test” (FIGURE 1A) Plantar surface tend to the lateral midfoot. It is also treat- Putting pressure on both the medial and ed with rest, NSAIDs, icing, and physical lateral calcaneal tuberosities will cause pain following therapy. discomfort. Pain will be absent in the a painful “pop” posterior structures of the heel. Placing a associated with vibrating 128-cps tuning fork on the cal- trauma may z Plantar-surface heel pain caneus should also increase discomfort. The problems most likely to cause plan- Plain x-ray films may be falsely nega- indicate rupture tar-surface pain (FIGURE 1B) are plantar tive, especially during the first 2 to 3 of the fascia fasciitis, stress fracture of the calcaneus, weeks of pain. Three-phase bone scans are and fat pad syndrome. nearly 100% sensitive for detecting stress fractures, with changes evident in as little Plantar fasciitis: as 1 to 2 days after injury. The specificity Pain is worst in the morning of MRI scans is superior to that of bone This is by far the most common cause scans and can reveal alternate problems.35 of heel pain primary care physicians will Treatment. Activity modification re- see. Rarely, infection and neoplasia will duces trauma to the heel. Encourage pa- cause unilateral plantar heel pain.4 tients to walk if they are pain free and Evaluation. Tenderness localized to to increase activity as comfort allows. the plantar surface of the heel in adults Tell patients to stop activity if the frac- usually indicates plantar fasciitis. ture becomes symptomatic. Advanced Pain is worst with the first step of fractures demand an absolute absence the morning, and lessens with activity. of weight bearing.

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Pain can be controlled with NSAIDs table 2 and ice. Lab and animal data have suggest- Heel pain treatment options: A look at the evidence ed that NSAIDs may impede fracture heal- ing rates, but no similar data exist regarding Diagnosis Treatments SOR REFerence their effect on stress fractures.36 Symptoms Achilles NSAIDs B 18 abate within 2 or 3 weeks. Advise athletes tendinopathy Topical NSAIDs B 17 Eccentric calf muscle training B 12,18 to resume activity slowly in a stepwise pro- Stretching C 16,19 gression, letting them know that a return Heel lifts C 16,19 to full activity is likely within 6 to 8 weeks. Ice C 16,19 Topical nitrates B 7,10,18 Have runners restart their routine at half Prolotherapy (dextrose injections) B 15,18 their customary distance, increasing it by no ESWT B 9,18 more than 10% to 15% per week. Surgery C 19 Any medical condition that weakens Retrocalcaneal NSAIDs C 2 the bone may predispose a patient to stress bursitis Heel lifts C 2 Steroid Injections (with caution) C 2 fracture. To prevent primary and second- ary stress fractures, correct the patient’s Calcaneal Rest C 21,22 apophysitis NSAIDs C 21,22 underlying medical problems. Evaluate Heel lifts C 21,22 young, thin women with a stress fracture Stretching C 21,22 for the “female athlete triad” (osteopenia, Icing C 21,22 Gel heel cups C 21,22 disordered eating, menstrual irregularity). Posterior Rest C 24 The elderly are also at risk for stress frac- impingement NSAIDs C 24 tures due to osteopenia or osteoporosis. Steroid injections C 24 Surgery C 24 Fat pad syndrome: More diffuse Plantar NSAIDs B 28,31 pain than plantar fasciitis fasciitis Stretches B 28,31 Gel cups B 28,31 The plantar surface of the heel is pro- Steroid iontophoresis B 28,31 tected by a thick fat pad. Those at risk Arch supports B 28,31 of a thinned fat pad include the elderly ESWT B 28,31,33 Night splints B 28,33 (the pad thins with age), the obese (in- Steroid injections B 28,31 creased stress to the pad), and those who Surgery B 28,31 have previously received a corticosteroid Calcaneal stress NSAIDs C 34,36 injection in the pad. Cumulative or acute fracture Activity moderation C 34 trauma to the heel can also cause contu- Icing C 34 sion to the heel pad. Fat pad NSAIDs C 37 syndrome Rest C 37 Evaluation. Pain typically is located Gel heel cups C 37 more posteriorly than classic plantar fas- Icing C 37 ciitis pain and is more diffuse. Pain from Posterior tibial Weight loss C 40 the fat pad should not radiate toward the tendon Icing C 40 arch and is not exacerbated by dorsiflex- dysfunction Physical therapy C 40 1 Arch supports/bracing C 41 ion of the foot. NSAIDs C 38 Treatment. Recommend relative rest, Surgery B 38,39 37 gel heel cups, NSAIDs, and ice. Tarsal tunnel Arch supports C 1,43 syndrome NSAIDs C 42,43 Less common causes Activity modification C 42,43 Physical therapy C 42,43 of plantar-surface pain Neuromodulators C 42 Lateral plantar nerve entrapment may Steroid injections C 44 also cause neuropathic pain on the plan- Surgery B 46,47 tar surface. Patients who experience a ESWT, extracorporeal shock wave therapy; NSAIDs, nonsteroidal anti-inflammatory drugs. Strength of recommendation (SOR) painful pop in their heel associated with A Good-quality patient-oriented evidence trauma may have ruptured their plantar B Inconsistent or limited-quality patient-oriented evidence fascia. A fallen arch may also be noted C Consensus, usual practice, opinion, disease-oriented

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on exam. Treatment of both of these transfer, calcaneal osteotomy, or tarsal conditions is similar to that of plantar bone fusion.38,39 fasciitis. Acute calcaneal fracture results from Tarsal tunnel syndrome: trauma, such as a fall from a height onto Pain can occur at night the soles of the feet. Look for localized Tarsal tunnel syndrome (TTS) is the most pain and swelling around the calcaneus common compression neuropathy of the and evaluate the neurovascular status lower extremity. The tarsal tunnel is a fi- of the foot. Initial treatment includes el- bro-osseous structure along the medial an- evating the foot, avoiding weight bear- kle that contains the tibial nerve, the pos- ing, applying ice, controlling pain, and terior tibial artery, and the tendons of the using a posterior splint. Many of these tibialis posterior, flexor digitorum longus, fractures require surgical fixation. and flexor hallucis longus. The posterior tibial nerve can become irritated as it runs through the tunnel. The inciting incident z Medial heel pain can be either a severe stretch to the nerve Posterior tibial tendonitis/dysfunction (from a medial ankle sprain) or from an and tarsal tunnel syndrome are best clas- anatomic compression. Pes planus foot sified as medial in location FIGURE( 1C). or posterior tibial dysfunction have also However, the pain is often more diffuse been implicated as common causes.1 and may radiate to either the posterior or Evaluation. Patients describe poorly plantar heel. localized pain with numbness and burn- ing along the medial ankle, arch, or heel, Posterior tibial tendonitis/ with radiation proximally.42,43 Symptoms dysfunction are linked to obesity are aggravated by exercise, and night Posterior tibial tendonitis (PTT) and pos- pain is not uncommon. The tenderness of terior tibial tendon dysfunction (PTTD) TTS is more diffuse than that from plan- are related diagnoses. PTTD refers to in- tar fasciitis, and symptoms are evident fast track creased laxity of the tendon resulting in directly over the tarsal tunnel itself. In tarsal tunnel flat foot and increased heel varus. It is The classic finding is a positive Tinel’s the most common cause of acquired flat sign (reproduction of symptoms by tap- syndrome, tapping foot in adults. PTT may exist separately ping over the posterior tibial nerve as it over the posterior or as part of PTTD. passes through the tarsal tunnel). Placing tibial nerve Evaluation. Patients complain of pain the foot in dorsiflexion and eversion may usually causes at the posterior edge of the medial mal- also reproduce symptoms.1 leolus that may extend toward the arch Imaging results are not always de- pain (positive of the foot.38,39 Patients may also experi- finitive, but can be helpful in determin- Tinel’s sign) ence swelling or redness in the area. Both ing the cause of the compression. Plain PTT and PTTD seem related to overuse films and CT can detect fracture or bony and obesity. Young or nonobese patients deformity, while MRI is more helpful in with PTT or PTTD often have underly- evaluating soft-tissue structures, such ing systemic .35 as ganglions or varicosities. Abnormal Treatment. Early treatment is neces- nerve conduction studies can be sugges- sary to prevent progression of tendon in- tive of TTS, but a normal result does competence. Interventions include weight not rule out the diagnosis. loss, NSAIDs, icing, physical therapy,40 Treatment follows a stepped progres- and orthotics or bracing for arch and an- sion. Initially try activity modification, kle support. You may also try immobili- orthotics, and physical therapy. Physi- zation in a short leg cast for 6 weeks.41 If cal therapy concentrates on medial arch conservative measures fail, surgery may strengthening, Achilles stretching, and be necessary for tendon repair, tendon ankle proprioception exercises.

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NSAIDs and neuromodulatory drugs 6. lebrun CM. Management of Achilles tendinopathy. (tricyclic antidepressants and antiseizure Clin J Sport Med. 2008;18:106-107. 7. Kane TP, Ismail M, Calder JD. Topical glyceryl medications) have shown some success. trinitrate and noninsertional Achilles tendinopathy: Steroid injections have been effective a clinical and cellular investigation. Am J Sports when given at the site of entrapment,44 Med. 2008;36:1160-1163. 8. Stergioulas A, Stergioula M, Aarskog R, et al. Ef- but care must be taken to avoid the pos- fects of low-level laser therapy and eccentric exer- terior tibial tendon. If patients do not cises in the treatment of recreational athletes with improve following these measures, they chronic Achilles tendinopathy. Am J Sports Med. 2008;36:881-887. 45 may require cast immobilization. 9. rompe JD, Furia J, Maffulli N. Eccentric loading Surgery is a possibility when other compared with shock wave treatment for chronic options fail. The cause of the neural insertional Achilles tendinopathy. J Bone Joint Surg Am. 2008;90:52-61. compression is identified in 60% to 10. Paoloni JA, Murrell Ga. Three-year follow up study 80% of cases.46,47 Success rates for vari- of topical glyceryl trinitrate treatment of chronic ous procedures of tarsal tunnel release noninsertional Achilles tendinopathy. Foot Ankle Int. 2007;28:1064-1068. and tibial nerve decompression range 11. mcLaughlan G, Handoll H. Interventions for treat- from 75% to 91%. If neural compres- ing acute and chronic Achilles tendonitis. Cochrane sion is absent, investigate other systemic Database Syst Rev. 2001;(2):CD000232. 12. Fahlstrom M, Jonsson P, Lorentzon R, et al. Chron- causes of peripheral neuropathy, such as ic Achilles tendon pain treated with eccentric calf- diabetes or alcoholism.4 muscle training. Knee Surg Sports Traumatol Ar- throsc. 2003;11:327–333. 13. Costa M, Shepstone L, Donnell S, et al. Shock wave therapy for chronic Achilles tendon pain. Clin z Systemic diagnoses Orthop. 2005;44:199–204. Bilateral heel pain, multiple joint involve- 14. Furia J. High-energy extracorporeal shock wave therapy as a treatment for insertional Achilles ten- ment, or fever suggests systemic disease. dinopathy. Am J Sports Med. 2006;34:733–740. Common diseases affecting the heel in- 15. maxwell NJ, Ryan MB, Taunton JE, et al. Sono- clude rheumatoid arthritis, ankylosing graphically guided intratendinous injection of hy- perosmolar dextrose to treat chronic tendinosis of spondylitis, , reactive ar- the Achilles tendon. Am J Roentgenol. 2007;189: thritis, and inflammatory bowel disease.1 W215-W220. Available at: http://www.ajronline. Successful treatment of these disorders org/content/vol189/issue4/. Accessed May 15, fast track 2008. should relieve associated heel pain. n 16. mcShane JM, Ostick B, McCabe F. Noninsertional Interested in Achilles tendinopathy: pathology and manage- Correspondence ment. Curr Sports Med Rep. 2007;6:288-292. patient handouts H. E. Woodall, MD, AnMed Health Family Medicine Res- 17. russell AL. Peroxicam 0.5% topical gel compared for the conditions idency, 2000 E Greenville Street, Suite 3600, Anderson, to placebo in the treatment of acute in- SC 29621; [email protected] juries: a double-blind study comparing efficacy and discussed here? safety. Clin Invest Med. 1991;1:35-43. Check out the Web table Disclosure 18. Glaser T, Poddar S, Tweed B. What’s the best way to treat Achilles tendinopathy? J Fam Pract. that accompanies this article The authors reported no potential conflict of interest rel- 2008;57:261-263. evant to this article. online at www.jfponline.com 19. Solan M, Davies M. Management of insertional ten- dinopathy of the Achilles tendon. Foot Ankle Clin N References Am. 2007;12:597-615. 1. Aldridge T. Diagnosing heel pain in adults. Am Fam 20. Hugate R, Pennypacker, Saunders M, et al. 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25. maquirriain J. Posterior ankle impingement syndrome. J Am Acad Or- thop Surg. 2005:13:365-371. 26. maffulli N. Chronic rupture of tendo Achillis. Foot Ankle Clin. 2007;12:583-596. 27. bhandari M, Guyatt GH, Siddiqui F, et al. Treatment of acute Achil- les tendon ruptures: a systematic overview and meta-analysis. Clin Orthop Relat Res. 2002;400:190-200. 28. Cole C, Seto C, Gazewood J. Plantar Fasciitis: Evidence based review of diagnosis and therapy. Am Fam Phys. 2005;72:2237-2242. 29. barrett SL, O’Malley R. Plantar fasciitis and other causes of heel pain. Am Fam Physician.1999;59:2200-2206. 30. Schroeder B. American College of Foot and Ankle Surgeons: diag- nosis and treatment of heel pain. Am Fam Physician. 2002;65:1686- 1687. 31. Crawford F, Thomson C. Interventions for treating plantar heel pain. Cochrane Database Syst Rev. 2003;(3):CD000416. 32. Pribut, SM. Current approaches to the management of plantar heel pain syndrome, including the role of injectable corticosteroids. J Am I,m getting Podiatr Med. 2007;97:68-74. 33. Porter MD, Shadbolt B. Intralesional corticosteroid injection versus extracoporeal shock wave therapy for plantar fasciopathy. Clin J aggressive with Sport Med. 2005;15:119-124. prehypertension, 34. Weber JM, Vidt LG, Gehl RS, et al. Calcaneal stress fracture. Clin Po- diatr Med Surg 2005;22:45-54. 35. Dodson NB, Dodson EE, Shromoff PJ. Imaging strategies for diag- naturally. nosing calcaneal and cuboid stress fractures. Clin Podiatr Med Surg. 2008;25:183-201. 36. Wheeler P, Batt ME. Do nonsteroidal anti-inflammatory drugs ad- ™ Introducing ameal bp – containing versely affect stress fracture healing? A short review. Br J Sports Med. the breakthrough, naturally derived 2005:39;65-69. active ingredient AmealPeptide®, 37. o’Connor FG, Sallis R, Wilder R, St. Pierre P. Sports Medicine: Just clinically shown to help maintain the Facts. 1st ed. New York: McGraw-Hill Professional; 2004:386, 504. healthier blood pressure.* 38. lake C, Trexler G, Barringer W. Posterior tibial tendon dysfunction: a review of pain and activity levels of twenty-one patients. J Prosth Start prehypertensive patients on Ortho. 1999;11:2-5. ™ ameal bp when you start them 39. bulstra G, Olsthoorn G, Niek van Dijk C. Tendonoscopy of the poste- on a diet and exercise program. rior tibial tendon. Foot Ankle Clin. 2006;11:421-427. 40. American College of Foot and Ankle Surgeons. Posterior tibial tendon dysfunction (PTTD). 2005. Available at: http://www.footphysicians. Stratified analysis of 8 clinical studies by start value of blood pressure (Post-hoc analysis, 606 subjects from 8 studies) com/footankleinfo/pttd.htm. Accessed October 1, 2008.

Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) 41. Thordarson D. Orthopaedic Surgery Essentials: Foot and Ankle. Phila- ~160 159~150 149~140 139~130 ~100 99~95 94~90 89~85 10 delphia: Lippincott Williams & Wilkins; 2004:176.

0 42. Stroud CC. Heel pain, plantar fasciitis, and tarsal tunnel syndrome.

-10 Curr Opin Ortho. 2002;13:89-92. ** ** *** ** -20 *** 43. Franson, J, Baravarian B. Tarsal tunnel syndrome: a compression ® *** *** AmealPeptide -30 Placebo neuropathy involving four distinct tunnels. Clin Podiatr Med Surg. 2006;23:597-609. Significant difference from placebo (t-test): **P<0.01, ***P<0.001. 44. Jolly GP, Zgonis T, Hendrix CL. Neurogenic heel pain. Clin Podiatr Reference: 1. Data on file. Post-hoc analysis adapted from AmealPeptide® clinical studies. Med Surg. 2005;22:101-103. 45. Juliano PJ, Harris TG. Plantar fasciitis, entrapment neuropathies, and tarsal tunnel syndrome: current up to date treatment. Curr Opin Orth. Visit www.amealbp.com for 2004;15:49-54. more information. 46. Gondring WH, Shields B, Wenger S. An outcomes analysis of surgi- cal treatment of tarsal tunnel syndrome. Foot Ankle Int. 2003;24:545- ameal bp™ is available online or at 550. major drugstores in easy-to-swallow 47. Sammarco GJ, Chang L. Outcome of surgical treatment of tarsal tun- capsules and chewable tablets. nel syndrome. Foot Ankle Int. 2003;24:125-131.

*This statement has not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease. Visit us at www.JFPonline.com

AmealPeptide® and ameal bp™ are trademarks of Calpis Co., Ltd., Tokyo, Japan ©2008 vol 57, No 11 / November 2008 The Journal of Family Practice Heel pain diagnosis t

table w1

Heel pain patient education Web sites

Click-and-print sites: These helpful handouts are easy to print out for patients

Achilles tendinopathy (tendonitis) http://orthoinfo.aaos.org/topic.cfm?topic=A00147 http://www.nlm.nih.gov/medlineplus/ency/article/001072.htm

Calcaneal apophysitis http://familydoctor.org/online/famdocen/home/healthy/physical/injuries/158.html (Spanish available) http://www.med.umich.edu/1libr/sma/sma_calcapop_sma.htm

Plantar fasciitis http://orthoinfo.aaos.org/topic.cfm?topic=A00149 http://familydoctor.org/online/famdocen/home/healthy/physical/injuries/140.html (Spanish available) http://www.nlm.nih.gov/medlineplus/ency/article/007021.htm

Retrocalcaneal bursitis http://www.nlm.nih.gov/medlineplus/ency/article/001073.htm

Tarsal tunnel syndrome http://www.footphysicians.com/footankleinfo/tarsal-tunnel-syndrome.htm

Multi-page sites: These aids are several pages long and require multiple clicks

Achilles tendinopathy (tendonitis) http://www.mayoclinic.com/health/achilles-tendinitis/DS00737 Plantar fasciitis http://www.mayoclinic.com/health/plantar-fasciitis/DS00508 Retrocalcaneal bursitis http://www.sportsinjuryclinic.net/cybertherapist/back/achilles/achillesbursitis.htm Tarsal tunnel syndrome http://www.podiatrychannel.com/tarsaltunnelsyndrome/index.shtml

www.jfponline.com vol 57, No 11 / November 2008 723