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Diagnosis and Management of Heel and Plantar Foot Pain Gregory A

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Diagnosis and Management of Heel and Plantar Foot Pain Gregory A Diagnosis and Management of Heel and Plantar Foot Pain Gregory A. Sawyer, MD, Craig R. Lareau, MD, and Jon A. Mukand, MD, PhD INTRODU C TION 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 HILLES TENDON DYSFUN C TION 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, HEEL PA D SYNDROME 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 NT A R FASCIITIS septae and allows repetitive load bearing. calcaneal tuberosity.6 “Achilles tendinitis” The plantar fascia 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, plantar fasciitis 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 soft tissue 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 APRIL 2012 increased activity levels, tendinosis occurs athletes, particularly those involved with TA RS A L TUNNEL SYNDROME 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 bursitis 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, RETRO ca L ca NE A L BURSITIS & and resisted ankle plantarflexion as these and foot deformity.15 HA GLUND DEFORMITY 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-
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