& BIOMECHANICS

When Is Not Plantar

Consider the wide variety of differential diagnoses.

By Paul Scherer, DPM

linicians can consider the fails. None of these diagnoses is com- differential diagnoses be- patible with mechanical control. fore making a pair of or- thotics for Alternative Etiologies to Heel Pain or after the orthotic fails • (SpA) 89 Cto relieve the symptoms. Before is • (RA) always better and more efficient, but • Rheumatoid arthritis (JRA) everyone must accept the premise • Systemic lupus erythematosus that there are zebras when treating (SLE) this condition. • Neuropathy For several years, I attended at a • Vascular impairment special problems clinic that allowed • Trauma podiatrists to send their patients for • Gout Figure 1: Enthesis in a young patient with anky- losing spondylitis (Scherer) consultation when their orthotics did • Tumors not work for pathologies that usu- • Calcaneal cyst lower back, along with enthesis of ally responded to custom orthotics. the medial tubercule of the The majority of these patients were Spondyloarthropathy (Figure 1). A 1995 paper presented treated for heel pain and plantar fas- This is a group of so-called sero- three cases of young males with heel ciitis but did not improve. Some of these patients had clearly received inappropriate or poorly casted and manufactured orthotic devices but Few podiatrists do a proper surprisingly, many of the patients when encountering heel pain because it is had good orthotics but did not in fact have plantar fasciitis. such a common disorder. Few podiatrists do a proper dif- ferential diagnosis when encounter- ing heel pain because it is such a negative , all of which pain who were treated with injec- common disorder. It is an accepted present with heel pain in various tions and orthoses for approximately concept in medicine, “If you hear forms and ages. The following is a one year before the HLA-B27 test was hoof beats, think horses, not zebras.” brief discussion of each and what the performed and the patients properly But that doesn’t mean there are no literature tells us about this disorder diagnosed and treated.1 zebras in our world and maybe you and heel pain. should know what they look like and where they come from. This disorder was called Reiter’s In the world of heel pain, here This is a strongly genetic disorder syndrome until Dr. Reiter was rec- is the zebra list that every student that the literature suggests occurs ognized as an individual who per- in the special problems clinic was when the HLA-B27 gene is turned on formed human experimentation on required to learn. You can either re- by klebsiella or another GI infection. prisoners at the Buchenwald concen- view it before making the diagno- The pathology is joint fusion and tration camp. sis and orthotic, or after the orthotic bone production, particularly in the Continued on page 90

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Heel Pain (from page 89) en pox or herpes simplex. The liter- gins between the ages of 7–12. The ature shows that often the patient same joint pathology as RA exists The disorder is an autoimmune will seek medical care for heel pain, and more often than not it involves reaction, possibly also related to the causing an antalgic gait, before seek- muscle spasm, which affects the HLA-B27 gene’s reaction to chlamyd- ing eye care for their uveitis.6 Heel lower extremity, producing a wide ia, gonorrhea, and more commonly pain, in children, is rarely mechani- variety of symptoms and deformity. HIV infection. Symptoms appear as cal; when associated with what ap- The most common is digital dorsal conjunctivitis, urethritis and arthri- tis. A 1983 review in International listed asymmetrical heel pain as the second most common Systemic lupus erythematosus affects nine times (44%) presenting symptom.2 A later more women than men and presents as a non-erosive 1993 paper of 143 patients demon- strated that 36% presented with uni- arthritis, a photo sensitivity cheek rash, lateral heel pain.3 This disorder is and a 35% chance of heel pain. why non-mechanical heel pain is list- ed as a presenting symptom of HIV infection. pears to be conjunctivitis, it must be subluxation in the and spindle Enteropathic Spondylitis investigated for this disorder. Treat- fingers in the hand. This disorder is recognized as ing the heel pain is of no value to the A 2010 Canadian cohort study an that is often concur- patient. of 319 patients with JRA demon- rent with inflammatory bowel dis- strated two important findings. First, 90 ease, ulcerative colitis, and Crohn’s Rheumatoid Arthropathies 95% of the patients had a presenting disease. The pathology is not fully (SeroPositive) symptom of a limp and 95% of the understood, but GI infection may ex- The American College of Rheu- patients had heel pain. Second, if a haust the largest immune system in matology in 2011 documented that patient presented with a symptom of the body, leading to bowel symptoms presently 7,416,000 individuals in the a limp, there was a short duration to and possibly arthritic symptoms. A United States are treated for one of confirming a diagnosis, while if they 2011 paper revealed that even before the five major presentations of these had heel pain, it took twice as long to diseases. This leaves 500 make the diagnosis of RA.8 Someone patients for each podiatrist had been dropping the ball. Children in the United States. Many between 7 and 12 do not get plantar present before diagnosis fasciitis. This is a huge clue to appro- with symptoms of heel priate diagnosis and treatment. pain, or heel pain becomes a significant part of their Systemic Lupus Erythematosus presentation after diagno- (SLE) sis. The following describe This “autoimmune” disease af- Figure 2: 50-year old patient with a 20-year history of psoriatic the diseases and the inci- fects nine times more women than arthritis (Scherer) dence of heel pain. men and presents as a non-erosive arthritis, a photo sensitivity cheek the GI infection is evident, or diag- Rheumatoid Arthritis (RA) rash, and a 35% chance of heel pain. nosed, patients present with knee This “autoimmune” arthritis pro- One study group suspected the heel pain (65%) upon their first step in duces , pannus formation pain was the result of calcaneal stress the morning (62%).4 and nodules (Figure 3) as a pathol- Figure 3: Rheumatoid nodules in the calcaneus ogy, causing joint destruction and causing heel pain (Source unknown) severe disability and deformity. This is another seronegative au- A 1979 survey demonstrated that al- fractures similar to those that occur toimmune reaction that researchers though the pathology occurs within in the vertebrae of patients with this suspect happens when there is a pep- the foot joints, 21% of the population disease.9 Many of these women are tide defect of the 6th chromosome. experience daily heel pain.7 immediately post-pubescent and Only 25% of the patients that have should not first be suspected of hav- the skin lesions develop arthritic Childhood Rheumatoid Arthritis ing plantar fasciitis, which is ex- symptoms, but of this group fully (JRA) tremely rare in this age and gender 54% report heel pain (Figure 2).5 The etiology of this disease in population. children continues to be a genetic Anterior Uveitis mystery. The term “autoimmune” is Neuropathy This is a rare arthropathy that is also applied to this predominantly This etiologic category contains associated with an eruption of chick- Caucasian female disease which be- Continued on page 91

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Heel Pain (from page 90) in 2002 identified heel pain as a con- Trauma sistent hallmark of TTS.10 This is The three traumatic events pro- one etiological factor that might be ducing heel pain are also familiar helped with orthotics, although it is to most podiatrists, but not always masquerading as plantar fasciitis. before first thinking plantar fasci- itis. Stress fractures (Figure 4), en- Neurilemmona thesopathy fractures (Figure 5), and This enlargement of Schwann apophysitis (Figure 6) all have a hall- cells in the myelin sheath of the tibial mark of progressive pain on walking, nerve has been suspected of causing where plantar fasciitis is quite the heel pain. It is suspected of that ir- opposite. ritation from repetitive motion and certain sporting activity causing the Gout Figure 4: of the calcaneus pseudo-tumor; the pressure on the Rarely do practitioners think of (Source unknown) axion causes the heel pain.11 gout when considering heel pain, but

Rarely do practitioners think of gout when considering heel pain, but this systemic disease is one of the most common camouflaged diagnoses. 91

Figure 5: fracture following a ver- Infracalcaneal Nerve Neuropathy this systemic disease is one of the tical fall (Scherer) In a study of twenty-two subjects most common camouflaged diagno- with acute and first-step heel pain, ses. The use of hydrochlorothiazide, EMG demonstrated obstructive sig- alcohol abuse, and renal failure often nals to the first branch of the lateral produce atypical gout pain in the plantar nerve.12 Often this is errone- heel with the hallmark that the pain ously referred to the medial calcaneal is the same intensity weight-bearing nerve, which has little to do with or not. heel pain. Heaslet, in a very inter- esting and important paper on heel Tumors pain, identified the entrapment of the Only 3% of osseous tumors occur lateral calcaneal nerve as producing in the foot, and benign lesions out- heel pain.13 number malignant lesions by 5:1. W B Kilgore’s text “Calcaneal Tumors Vertebral Stenosis and Tumor-Like Conditions” is the Foraminal obstruction at L4 and classic and still relevant guide to L5 produces lateral stenosis, which calcaneal tumors. Every podiatrist can put pressure on the proximal should possess a copy.15 sources of the saphenous nerve. This Figure 6: Apophysitis causing heel pain in an ad- produces pain at its terminal branch- Calcaneal Cysts olescent (Scherer) es near the heel, presenting as heel Should podiatrists take x-rays on pain in older mobile populations. all heel pain? The best evidence for four subjects that most podiatrists are This is usually accompanied by a doing so is not only the true tumors familiar with identifying before as- stocking-type . Straight leg of the foot that produce heel pain, suming that heel pain is the result of raises usually reproduce the pain and but also unicameral bone cysts, an- plantar fasciitis. The following review exacerbate the paresthesia. eurysmal bone cysts, and osteoid identifies the literature that may be osteomas. Although not particular- helpful in a greater understanding of Vascular Impairment ly dangerous, unicameral and aneu- how each etiology clinically presents. Vascular impairment to the calca- rysmal bone cysts can fracture, and neus is rare and usually obvious. The present as acute heel pain.16 PM (TTS) literature has reported vascular in- Non-weight-bearing dorsiflex- farcts to the calcaneus and occlusive References ion of the foot, when the patient claudication of the distal portion of 1 Riddle, D, Schappert,S. Volume of is prone, can reproduce heel pain the popliteal artery, producing acute ambulatory care visits and patterns of caused by TTS. One paper published heel pain.14 Continued on page 94 www.podiatrym.com SEPTEMBER 2016 | PODIATRY MANAGEMENT Orthotics & Biomechanics

Heel Pain (from page 91) 8 Thomas, WH. Rheumatoid arthritis 14 Kilgore WB, Parrish WM. Calcaneal of the ankle and foot. In: R.R. Cooper tumors and tumor-like conditions. Foot care for patients diagnosed with plantar (Ed.)AAOS Instructional course lectures. Ankle Clin, 2005,10(3):541-65. fasciitis. Foot and Ankle International. Vol.28. CV Mosby, St. Louis; 1979:325- 15 Madhuri V, Oommen AT, et al. 2004. 336. Benign tumors and tumor-like lesions of 2 Scherer, P, Gordon,D, Kashanian,A, 9 Shiff, NJ, Lix,LM,, et al. Chronic in- the calcaneus: a study of 12 cases. Indian Belvill, A. Misdiagnosed recalcitrant heel flammatory arthritis prevalence estimates Journal of Cancer, 2009, 46(3) pain associated with HLA-B27 antigen. for children and adolescents in three Ca- 16 Madhuri V, Oommen AT, et al. JAPMA, 85-10, 1995. nadian provinces. Rheumatol Int. 2015 Benign tumors and tumor like lesions of 3 Prakash,S, Bansal,R, et al. Immuno- Feb;35(2):345-350. the calcaneus: a study of 12 cases. Indian logical studies in seronegative spondyloar- 10 Mendoza-Pinto,C. Risk factors of Journal of Cancer, 2009, 46(3). thropathies. British Journal Rheumatolo- vertebral fractures in women with system- ic lupus erythematosus. Clinical Rheuma- gy, 1983, 22(3). Dr. Scherer is a Clin- 4 tology, 2009 May:28(5):579-85. Calmels,C, Eulry,F, et al. Involve- ical Professor at the 11 Labib,SA, Gould,JS, et al. Heel ment of the foot in reactive arthritis. A College of Podiatric pain triad (HPT): the combination of retrospective study of 105 cases. Review Medicine at Western plantar fasciitis posterior tibial tendon of Rheumatology—French Ed. 1993 May University of Health dysfunction, and tarsal tunnel syndrome. 60(5):324-9. Sciences. He is Board 5 Foot and Ankle International 2002, Veys,EM, Mielants,H. Enteropathic Certified both by ABPS 23(3):212-20. arthritis. Current Opinion Rheumatology. and ABPM and has held 12 Oztuna V, Ozge A, et al. Nerve 1993,5(4):454-60. several other academic 6 entrapment in painful heel syndrome. Bezza,A, Niamane,R, et al. In- positions including: im- Foot and Ankle International 2002, volvement of the foot in patients with mediate past Professor and Chairperson of the 23(3):208-11. psoriatic arthritis. Joint Bone Spine, Department of Applied Biomechanics at Samuel 13 Diard F., Hauger O, et al. Pseu- 2004;71(6):546-9. Merritt University; and Professor, Department 7 do-cysts, lipomas, Infarcts and simple 94 Moorthy,LN, Peterson,MGE. Bur- Chairperson, Vice President and Academic cysts of the calcaneus. Belgium Journal of den of childhood-onset arthritis. Pediatric Dean of the California College of Podiatric Radiology, 2007 90(5):315-24 Rheumatology online, 2010,8(8:20). Medicine. He is founder of ProLab Orthotics.

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