Heel Pain: Diagnosis and Treatment, Step by Step
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REVIEW JOSÉ ALVAREZ-NEMEGYEI, MD, MSc JUAN J. CANOSO, MD CME Unidad de Investigación en Epidemiología Clínica, Unidad Rheumatologist, American British Cowdray Medical CREDIT Médica de Alta Especialidad, Instituto Mexicano del Center, Mexico City, Mexico; Adjunct Professor of Seguro Social, Mérida, Yucatán, México Medicine, Tufts University School of Medicine, Boston, MA Heel pain: Diagnosis and treatment, step by step ■ ABSTRACT EEL PAIN COULD be a sign of spondy- H loarthropathy or gout, or even a clue to The differential diagnosis of heel pain is broad and hypercholesterolemia and sickle-cell disease. can be overwhelming if a systematic approach is not But most often it is an isolated, local com- used. Focused questions and physical examination can plaint that results from a deranged tendon, help identify heel pain as Achilles tendinopathy or plantar bursa, nerve, or bone. fasciitis, or as due to a less common cause such as gout, In this article, we offer a stepwise spondyloarthropathy, or hypercholesterolemia. approach to the diagnosis and management of heel pain, and we review what the medical lit- ■ KEY POINTS erature to date says about the effectiveness of current treatments. Noninsertional Achilles tendinopathy arises from tendon overuse or, less often, from fluoroquinolone antibiotic use. ■ THREE STEPS TO NARROW Key features are pain, swelling, and tenderness 2 to 6 cm THE DIAGNOSIS from the insertion of the Achilles tendon into the calcaneus. The differential diagnosis of heel pain is broad (TABLE 1) and can be overwhelming if a system- atic approach is not used.1 Many case reports have suggested an association As with any musculoskeletal problem, the between fluoroquinolone use and tendinopathy. In most first question to ask is, Where does it really hurt? instances the Achilles tendon was involved, The patient may point to the back of the heel, predominantly the noninsertional portion. the bottom of the heel, or around the ankle. Next is to look for any structural faults by Insertional Achilles tendinitis is caused by local assessing passive and resisted motion and pal- mechanical factors or enthesitis. Pain, swelling, and pating for the site of maximum tenderness. tenderness occur at the Achilles tendon insertion. Finally, further questions should be direct- Treatment depends on the cause. ed at uncovering inflammatory and metabolic diseases, in particular spondyloarthropathy Plantar heel pain in athletes is caused by overuse, while and gout, as well as recent use of a fluoro- in nonathletes the exact cause remains controversial. Pain quinolone antibiotic. and focal tenderness at the inferior heel are key features. ■ NONINSERTIONAL ACHILLES Treatments include risk factor modification, nonsteroidal TENDINOPATHY anti-inflammatory drugs, stretching, and orthotics. In noninsertional Achilles tendinopathy, the tendon is damaged 2 to 6 cm from its insertion into the calcaneus. It is not only the most fre- quent cause of posterior heel pain, but also the most common tendon disorder in athletes.2 It CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 73 • NUMBER 5 MAY 2006 465 Downloaded from www.ccjm.org on September 23, 2021. For personal use only. All other uses require permission. HEEL PAIN ALVAREZ-NEMEGYEI AND CANOSO TABLE 1 changes that occur when a tendon has failed to heal properly after an injury or after repeti- Differential diagnosis of heel pain tive microtrauma (overuse). Histologically, Posterior heel pain angiofibroblastic tendinopathy is character- Noninsertional Achilles tendinopathy ized by dense populations of fibroblasts, vascu- Overuse lar hyperplasia, and disorganized collagen. Fluoroquinolone-induced Thus, the term “tendinitis” is inappropriate for Dyslipidemia (xanthomas) noninsertional Achilles tendinopathy.3,4 Rheumatoid arthritis (nodules) In athletes, abnormal limb alignment, Gout (tophi) unequal leg length, lack of muscle flexibility, Insertional Achilles tendinitis faulty training, and inappropriate equipment Enthesitis: spondyloarthropathies are all risk factors for this condition. Evidence Fluoroquinolone-induced Dyslipidemia (xanthomas) suggests that sports-related noninsertional Isotretinoin-induced Achilles tendinopathy occurs when the ten- Fluorosis don is exposed to a workload that is beyond its Ochronosis physical capability. Excessive, repetitive loads Haglund deformity alter both tendon matrix and cells, cause Superficial retrocalcaneal bursitis microtears, and lead to incomplete healing. Deep retrocalcaneal bursitis Persistence of the causative factor or factors Spondyloarthropathies eventually results in tendon thickening, nodu- Rheumatoid arthritis larity, and in many cases a macroscopic tear.2,5 Crystal-induced (gout, calcium pyrophosphate dihydrate) Hypovascularity was once thought to be a Plantar heel pain major pathogenic factor, but flow analysis and Plantar fasciopathy power Doppler ultrasonography have ruled this Enthesitis: spondyloarthropathies out.6,7 Calcaneal stress fracture or bone bruise Fat pad atrophy Diagnosis: More common in athletes Neuropathies Noninsertional Achilles tendinopathy occurs Tarsal tunnel syndrome most often in professional or recreational ath- Medial calcaneal branch of the posterior tibial nerve Abductor digiti quinti muscle nerve letes. It may arise acutely and feature pain, Soft-tissue tumors, primary or metastatic bone tumors swelling, and tenderness in the middle third of Paget disease of bone the Achilles tendon. More commonly, howev- Sever disease er, it presents in a subdued fashion with ten- Referred causes: S1 radiculopathy don pain and a feeling of hindfoot stiffness MODIFIED FROM BUCHBINDER R. PLANTAR FASCIITIS. N ENGL J MED 2004; 350:2159–2166; upon arising in the morning. Typically, symp- AND CANOSO JJ, ALVAREZ-NEMEGYEI J. SOFT TISSUE RHEUMATOLOGY. IN: LAHITA RG, toms fade after the first few steps. As the con- WEINSTEIN A, EDITORS. EDUCATIONAL REVIEW MANUAL IN RHEUMATOLOGY. 3RD EDITION. NEW YORK: CASTLE CONNOLLY GRADUATE MEDICAL PUBLISHING LTD, 2004 dition progresses, pain arises during the athlet- ic activity. Eventually, the pain may be present throughout the day.2 may result from overuse of the tendon, from Clinical diagnostic tests include direct use of a fluoroquinolone antibiotic, or from palpation, the arc sign test (the tendinous nodular formation within the tendon, as seen swollen area moves during dorsiflexion and in tophaceous gout, xanthomatosis, and plantarflexion of the ankle), and the Royal rheumatoid arthritis. London Hospital test. In the Royal London test, local tenderness is elicited by palpating An ‘angiofibroblastic’ rather than an the tendon with the ankle either in neutral inflammatory process position or with slightly plantar flexion. The In noninsertional Achilles tendinopathy due tenderness decreases significantly or disap- to overuse, histologic studies have not shown pears completely with ankle dorsiflexion. any inflammation. Instead, studies have con- In a recent study,8 the sensitivity and sistently found “angiofibroblastic tendinopa- specificity of these tests were 58% and 74% for thy,”3 a term that refers to degenerative direct palpation, 52% and 83% for the arc sign 466 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 73 • NUMBER 5 MAY 2006 Downloaded from www.ccjm.org on September 23, 2021. For personal use only. All other uses require permission. test, and 54% and 91% for the Royal London test. When the three tests were combined, sen- sitivity was 58% and specificity was 83%. Ultrasonography and magnetic reso- nance imaging (MRI) have both shown an excellent diagnostic performance in this con- dition,9 but ultrasonography is much less expensive, making it the choice of the two. Management based on some consensus Despite limited evidence of the effectiveness of one treatment vs another, some agreement has been reached about therapy for noninsertional Achilles tendinopathy.2,10 Initial measures include identification, suppression, and modifi- cation of predisposing factors, temporary sus- pension of sports activities, use of a non- steroidal anti-inflammatory drug (NSAID), FIGURE 1. A 60-year-old man developed and physiotherapy that includes stretching pain, swelling, and severe tenderness exercises, especially those that focus on the calf in both Achilles tendons while taking muscles. ciprofloxacin for recurrent urinary tract In refractory cases, a peritendinous gluco- infections. The severity of symptoms and corticoid injection is often used and may suspicion of a partial rupture prompted indeed be efficacious. Whether this procedure magnetic resonance imaging, which leads to tendon rupture has not been conclu- showed an intense, bright signal within sively shown. Patients whose condition fails the noninsertional region of the Achilles to improve with the above program should be tendon, suggesting rupture. During subsequent surgical exploration, the First ask, considered for surgical treatment. central portion of the tendon was found to be necrotic and was resected. Where does it Prognosis The patient’s recovery was slow but In a prospective study by Paavola et al,11 83 complete. really hurt? of 107 patients with noninsertional Achilles tendinopathy underwent conservative treat- ment. Of these 83, 24 (29%) required surgi- tendinopathy.12 In most instances the cal treatment, 70 (84%) returned to all Achilles tendon was involved, predominantly activities, and 78 (94%) were asymptomatic the noninsertional portion (FIGURE 1). or had mild pain during strenuous exercise. However, a comparison of the involved