Diagnosis and Management of Heel and Plantar Foot Pain Gregory A. Sawyer, MD, Craig R. Lareau, MD, and Jon A. Mukand, MD, PhD  In t r o d u c t i o n attempted for at least six months and may Treatment consists of NSAIDs and Heel pain is a common complaint require up to 18 months.1 Conservative shoes with adequate heel padding. Cor- encountered by primary care physicians. measures include non-steroidal anti-in- ticosteroid injections are contraindicated Misdiagnosis is not uncommon because flammatory drugs (NSAIDs), stretching as they can cause atrophy of the plantar of the intricate anatomy of the heel, where exercises, physical therapy, orthoses (night fat.5 Surgery cannot restore the normal many structures lie in close proximity to splints, cast immobilization), cortisone architecture of the heel pad. In addition, one another. While there are traumatic injections, and extracorporeal shock wave the plantar skin is prone to wound-healing (high-energy), infectious, oncologic, therapy, all with varying success.1,2 If problems. vascular and systemic causes of heel pain, conservative therapy fails, surgery may be this article will focus on the most com- considered. Plantar fascial release, either Ac h i l l e s Te n d o n Dy s f u n c t i o n mon ones: repetitive microtrauma and open or endoscopic, is the procedure of Achilles tendon disorders include a compression of structures within confined choice, with success rates of 70-90%.2 spectrum from chronic degenerative inju- spaces. Pathologic causes can be broadly ries to acute tendon ruptures. The stron- categorized as degenerative, neurologic, He e l Pa d Sy n d r o m e gest and thickest tendon in the human or traumatic. The heel pad beneath the calcaneus body, it is the insertion of the gastrocne- consists of adipose tissue within fibrous mius and soleus muscles onto the posterior Pl a n t a r septae and allows repetitive load bearing. calcaneal tuberosity.6 “” The is an aponeurosis It is less elastic in elderly and diabetic is a misnomer as the tendon itself does of collagen fibers that originate from the patients, which leads to inflammation not undergo inflammation.7 The tendon’s anteromedial calcaneus, course distally and edema. Diabetic plantar tissue is blood supply is provided by a paratenon, a on the plantar foot, and divide into five stiffer than healthy tissue and has a lower single layer of cells encasing the structure,7 insertions on the proximal phalanx of each capacity to withstand compressive and as well as by the musculotendinous junc- digit.1 The fascia helps maintain the arch shear stresses. Heel pad atrophy is often tion.8 Plain radiographs can identify both of the foot and serves a dynamic function contributory. This diagnosis is more calcific tendinous changes and Haglund during the gait cycle.1 The most com- common in obese patients due to higher deformities (discussed below). Ultrasound mon cause of heel pain, loads.4 is safe, quick and effective but variable is due to inflammation at the calcaneal operator skills may limit its use in the com- 7 origin,1,2 resulting in fascial degeneration Achilles tendon munity. MRI provides the most detailed and microtears.1 information about the Achilles tendon and Approximately two million people, disorders include surrounding and bony struc- 7 typically 40 to 60 years old, are treated a spectrum tures. One classification scheme divides annually in the United States for plantar Achilles tendon dysfunction into three heel pain.1,3 Their pain is typically worse from chronic categories: peritendinitis, tendinosis, and 9 with the first steps in the morning and degenerative peritendinitis with tendinosis. after prolonged standing. It is usually stab- Peritendinitis, also referred to as bing, non-radiating, and not associated injuries to acute paratenonitis, is inflammation of the 7 with neurologic symptoms.2 Risk factors tendon ruptures. surrounding paratenon. Common in for plantar fasciitis include running, flat athletes due to poor-fitting shoes, it in- foot deformity (pes planus), professions volves focal swelling, diffuse discomfort, requiring prolonged standing, obesity, Frequently misdiagnosed as plantar and tenderness to palpation. Conservative and limited ankle dorsiflexion.1 fasciitis, heel pad syndrome is character- therapy includes proper shoes, activity Patients generally have focal tender- ized by deep, non-radiating pain involv- modification, rest, and NSAIDs.7 Sur- ness over the plantar-medial calcaneus1 ing the weight-bearing portion of the gery involves excision of the thickened that worsens with passive toe dorsiflex- calcaneus. Symptoms worsen with walk- paratenon, but is rarely required.10 ion and a calf raise. Tightness of the ing barefoot or on hard surfaces and are Achilles tendinosis is a degenerative Achilles tendon is common. Imaging relieved in the absence of heel pressure. process related to aging and repetitive is not required for the diagnosis and is Typically, there is tenderness over the microtrauma and microtearing.7 Degen- recommended only for patients who fail plantar aspect of the calcaneal tuberosity. eration usually occurs in the hypovascular conservative management. Swelling is variably present and, unlike zone of the tendon, two to six centime- Nonsurgical treatment—successful plantar fasciitis, pain does not occur with ters proximal to the calcaneal insertion.7 in greater than 90% of cases—should be passive motion of the ankle or toes. Classically seen in middle-aged men with

125 Volume 95 No. 4 Ap r i l 2012 increased activity levels, tendinosis occurs athletes, particularly those involved with Ta r s a l Tu n n e l Sy n d r o m e gradually. Patients present with pain and uphill running, because ankle dorsiflexion The tarsal tunnel is a fibro-osseous nodular thickening of the middle-third compresses the bursa between the Achil- space formed by the flexor retinaculum of the tendon.8 Sharp pain may indicate les tendon and calcaneus. One should of the ankle, posterior and distal to the a partial tendon tear. If detected before be wary of a systemic diagnosis, such as medial malleolus. Often compared to tendon rupture, treatment is conserva- inflammatory arthritis, in a patient with carpal tunnel syndrome, it is an entrap- tive: activity modification, orthotics, and bilateral symptoms. ment neuropathy of the tibial nerve physical therapy for eccentric strength- Patients with retrocalcaneal resulting in pain and paresthesias at the ening and range of motion exercises.7 typically have bogginess along the me- plantar aspect of the foot.15 The tarsal Corticosteroid injections may further dial and lateral aspects of the Achilles tunnel also contains the posterior tibial weaken and rupture the tendon, so they tendon.12 Tenderness with the two-finger tendon, flexor digitorum longus tendon, are contraindicated.8 Surgery is needed squeeze test (medial and lateral pressure flexor hallucis longus tendon, and the in 25% of cases, for debridement of the anterior to the Achilles tendon above the posterior tibial artery and vein. The degenerative portion of the tendon.7 calcaneus) is a classic finding.7 Pain may most frequent causes of this neuropathy occur with passive ankle dorsiflexion include trauma, space-occupying lesions, Re t r o ca l ca n e a l Bursitis & and resisted ankle plantarflexion as these and foot deformity.15 Ha g l u n d De f o r m i t y motions decrease the space available for Complaints are often non-specific The retrocalcaneal bursa is located the bursa.12 and poorly localized, making the diag- between the posterosuperior aspect of Conservative treatment includes ice, nosis difficult. Pain and paresthesias are the calcaneal tuberosity and the Achil- activity modification, open-heeled shoes intermittent or constant, and frequently les tendon. A Haglund deformity is a and NSAIDs. Corticosteroid injections associated with proximal or distal radia- prominence of the postero-superior lateral should be avoided in the posterior heel tion. Symptoms worsen with prolonged calcaneus. Due to these close anatomic as they increase the risk of Achilles ten- standing and exercise and are relieved by relationships, retrocalcaneal bursitis can don degeneration and rupture.13 Surgical elevation and rest. Night pain is also a be associated with a Haglund deformity procedures involve some combination of relatively common complaint. Physical and insertional Achilles tendonitis.11 resection of the calcaneal prominence, examination is often non-specific, but de- Retrocalcaneal bursitis causes pain retrocalcaneal bursectomy, and Achil- creased sensation over the plantar foot and anterior to the Achilles tendon, just les tendon debridement. Surgery is not a positive Tinel’s sign (paresthesias with proximal to its insertion. In contrast, always curative. In one series, symptoms percussion over the nerve) are pathogno- Haglund deformity tends to cause pain were completely relieved in only 69.4% mic.15 Weakness is not common, but when superolateral to the Achilles insertion. of patients and 14.3% became worse due present, indicates severe compression.15 The most common cause is irritation to infection, sural nerve injury or painful Weight-bearing radiographs evaluate caused by the shoe counter. It is seen in scar formation.14 foot deformity and traumatic injuries and

Heel pain flowchart. 126 Medicine & Health/Rhode Island the quadratus plantae, FDB, and abduc- tor digiti quinti (ADQ); it also supplies sensation to the calcaneal periosteum, the long plantar ligament, and the lat- eral plantar skin.17 Compression occurs deep to the abductor hallucis where the nerve turns and courses laterally. Patients complain of medial heel pain four to five cm anterior to the posterior aspect of the heel, or just distal to the medial calcaneal tuberosity.18 Burning pain can radiate into the tarsal tunnel (posteromedial ankle) or distally toward the plantar lateral foot. Hindfoot valgus, or pronation, and ankle plantarflexion (Achilles tendon con- tracture) can increase nerve compression. A recent cadaver study demonstrated that pressure in the lateral plantar tunnel is highest in pronation and plantarflexion.19 Tinel’s sign is positive if paresthesias are reproduced with tapping over the nerve beneath the abductor hallucis muscle. In chronic cases, patients may have di- minished sensation in the lateral plantar foot.18 In cases of bilateral neurologic findings, spinal pathology and systemic diseases must be ruled out. As this is primarily a clinical diagno- sis, imaging is not helpful. Non-specific atrophy of the ADQ is present in 6.3% of all patients who have an MRI.20 Electrodi- agnostic studies confirm the diagnosis and localize compression in the lateral plantar tunnel or more proximally in the tarsal tunnel, which would affect both the medial and lateral plantar nerves.18 Rest, ice and NSAIDs should be tried for at least six months. Surgical decompression involves releasing the nerve throughout its course along the medial heel by dis- secting the fascia overlying the FDB and quadratus plantae.21 Figure 1. Heel pain anatomy. Ca l ca n e a l St r e s s Fr ac t u r e MRI scans may reveal compressive soft pression may benefit from NSAIDs, rest, The calcaneus consists primarily tissue masses.15 Tibial motor and sensory and immobilization in a walking boot of less dense cancellous bone, which is nerve studies (latencies, amplitudes, con- or cast. Local corticosteroid injections susceptible to fractures. After the meta- duction velocities) are critical in the diag- may decrease inflammation, with careful tarsals, the calcaneus is the most common nosis and accurate in 90% of cases.16 avoidance of intra-tendinous and intra- location for a stress fracture in the foot.22 Treatment depends on the specific vascular injections.15 It can occur in athletes participating in cause of the symptoms. For space-occu- sports with repetitive axial loading as pying lesions, surgery is often required Ba x t e r ’s Ne r v e En t r a p m e n t well as elderly patients with osteopenia. but can be treacherous due to the close Baxter’s nerve is the first branch It is typically an overuse injury that coin- proximity to the neurovascular bundle.15 of the lateral plantar nerve. It courses cides with an athlete changing to a more Patients with pes planus deformity that deep to the abductor hallucis and flexor strenuous exercise regimen. Diffuse heel stretches the tibial nerve may benefit digitorum brevis (FDB) and superficial pain (medial and lateral) worsens with from custom orthotics.15 Inflammatory to the quadratus plantae along the medial weight-bearing and may progress to being causing tibial nerve com- calcaneus. This mixed nerve innervates present at rest. 127 Volume 95 No. 4 Ap r i l 2012 The hallmark is a positive calcaneal 2 describes the anatomical locations of 18. Schon LC, Glennon TP, Baxter DE. Heel squeeze test, or pain with compressing the various etiologies. Regardless of the cause, pain syndrome: electrodiagnostic support 23 for nerve entrapment. Foot Ankle. Mar-Apr medial and lateral calcaneus. Depending however, conservative therapies should be 1993;14(3):129-135. on the acuity of the injury, there may be attempted for a reasonable period of time 19. Barker AR, Rosson GD, Dellon AL. Pressure swelling and ecchymosis. Radiographs before any surgical intervention. changes in the medial and lateral plantar and (lateral view) may demonstrate an altered tarsal tunnels related to ankle position: a cadaver study. Foot Ankle Int. Feb 2007;28(2):250- trabecular pattern, but are frequently Re f e r e n c e s 254. interpreted as normal. Sclerosis perpen- 1. Neufeld SK, Cerrato R. Plantar fasciitis: evalu- 20. Recht MP, Grooff P, Ilaslan H, Recht HS, ation and treatment. J Am Acad Orthop Surg. Sferra J, Donley BG. Selective atrophy of the dicular to the orientation of the trabeculae Jun 2008;16(6):338-346. 24 abductor digiti quinti: an MRI study. AJR Am indicates a healing fracture. Persistent 2. League AC. Current concepts review: plantar J Roentgenol. Sep 2007;189(3):W123-127. pain may necessitate an MRI or bone scan fasciitis. Foot Ankle Int. Mar 2008;29(3):358- 21. Fuhrmann RA, Frober R. Release of the lateral to detect an occult fracture. The former is 366. plantar nerve in case of entrapment. Oper Or- 3. Buchbinder R. Clinical practice. Plantar fascii- thop Traumatol. Jul 2010;22(3):335-343. preferable since it also evaluates soft tissue tis. N Engl J Med. May 20 2004;350(21):2159- 24 22. Narvaez JA, Narvaez J, Ortega R, Aguilera structures that can cause heel pain. 2166. C, Sanchez A, Andia E. Painful heel: MR If history and physical examination 4. Prichasuk S. The heel pad in plantar heel pain. imaging findings. Radiographics. Mar-Apr suggest a calcaneal stress fracture but the J Bone Joint Surg Br. Jan 1994;76(1):140-142. 2000;20(2):333-352. 5. Brinks A, Koes BW, Volkers AC, Verhaar diagnosis has not been confirmed, patients 23. Guhl JF, Parisien JS. Foot and ankle arthroscopy. JA, Bierma-Zeinstra SM. Adverse effects of New York: Springer; 2004. should decrease their activity level. If extra-articular corticosteroid injections: a 24. Spitz DJ, Newberg AH. Imaging of stress frac- symptoms persist and/or the diagnosis is systematic review. BMC Musculoskelet Disord. tures in the athlete. Radiol Clin North Am. Mar evident on imaging, patients should not 2010;11:206. 2002;40(2):313-331. 6. Mazzone MF, McCue T. Common conditions bear weight and are placed in a short leg 25. Ogden JA, Ganey TM, Hill JD, Jaakkola JI. of the achilles tendon. Am Fam Physician. May Sever’s injury: a stress fracture of the immature cast. Particularly in the high-level athlete, 1 2002;65(9):1805-1810. calcaneal metaphysis. J Pediatr Orthop. Sep-Oct this treatment should be continued until 7. Reddy SS, Pedowitz DI, Parekh SG, Omar IM, 2004;24(5):488-492. tenderness resolves. Wapner KL. Surgical treatment for chronic disease and disorders of the achilles tendon. J Am Acad Orthop Surg. Jan 2009;17(1):3-14. Gregory A. Sawyer MD, is a chief Se v e r ’s Di s e a s e 8. Heckman DS, Gluck GS, Parekh SG. Tendon resident in the Department of Orthopaedic Calcaneal apophysitis, or Sever’s disorders of the foot and ankle, part 2: achil- Surgery at the Warren Alpert Medical School les tendon disorders. Am J Sports Med. Jun disease, is a common cause of heel pain 2009;37(6):1223-1234. of Brown University. He is planning to sub- 25 in the pediatric athlete. The calcaneal 9. Puddu G, Ippolito E, Postacchini F. A classifica- specialize in sports medicine. apophysis is the site of insertion of the tion of Achilles tendon disease. Am J Sports Med. Craig R. Lareau MD, is a senior Achilles tendon. Causative theories in- Jul-Aug 1976;4(4):145-150. resident in the Department of Orthopaedic 10. Saltzman CL, Tearse DS. Achilles tendon clude traction and compression of the injuries. J Am Acad Orthop Surg. Sep-Oct Surgery at the Warren Alpert Medical School 25 growth plate, but there is no consensus. 1998;6(5):316-325. of Brown University. He is planning to sub- Patients have posterior heel pain that 11. Stephens MM. Haglund’s deformity and retro- specialize in foot and ankle. increases with activity. Examination calcaneal bursitis. Orthop Clin North Am. Jan Jon A. Mukand, MD, PhD, is Medical 1994;25(1):41-46. reveals tenderness at the Achilles ten- 12. Leitze Z, Sella EJ, Aversa JM. Endoscopic de- Director, Southern New England Rehabilita- don insertion, heel cord tightness, and compression of the retrocalcaneal space. J Bone tion Center; Clinical Assistant Professor at limited ankle dorsiflexion. Diagnosis is Joint Surg Am. Aug 2003;85-A(8):1488-1496. The Warren Alpert Medical School of Brown primarily clinical and the mainstay of 13. Hugate R, Pennypacker J, Saunders M, Juliano University; and the author of The Man with P. The effects of intratendinous and retrocalca- treatment is conservative therapy with rest neal intrabursal injections of corticosteroid on the Bionic Brain and Other Victories over and NSAIDs. Severe cases may require the biomechanical properties of rabbit Achilles Paralysis. a short period of immobilization. Both tendons. J Bone Joint Surg Am. Apr 2004;86- rehabilitation and preventative measures A(4):794-801. 14. Schneider W, Niehus W, Knahr K. Haglund’s Disclosure of Financial Interests include gascrocnemius/soleus stretching syndrome: disappointing results following The authors and/or their spouses/ and strengthening.25 surgery -- a clinical and radiographic analysis. significant others have no financial inter- Foot Ankle Int. Jan 2000;21(1):26-30. ests to disclose. 15. Lau JT, Daniels TR. Tarsal tunnel syndrome: o n c l u s i o n C a review of the literature. Foot Ankle Int. Mar Heel pain is a fairly common condi- 1999;20(3):201-209. Corresponden c e tion due to a variety of etiologies. The 16. Galardi G, Amadio S, Maderna L, et al. Jon A. Mukand, MD, PhD appropriate diagnosis and treatment can Electrophysiologic studies in tarsal tunnel Southern New England Rehabilitation syndrome. Diagnostic reliability of motor be difficult because of various bones, distal latency, mixed nerve and sensory nerve Center nerves and connective tissues confined conduction studies. Am J Phys Med Rehabil. 200 High Service Avenue to small spaces and subjected to weight Jun 1994;73(3):193-198. North Providence, RI 02904 bearing. An algorithm (Figure 1) offers 17. Rondhuis JJ, Huson A. The first branch of the phone: (401) 456-3801 lateral plantar nerve and heel pain. Acta Morphol a logical diagnostic approach and Figure Neerl Scand. 1986;24(4):269-279. e-mail: [email protected]

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