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 tendinopathy wrong place for plantar fasciitis 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 plantar fasciitis Common causes of heel pain by location Page 717 include NSAIDs, stretching exercises, z gel cups, arch supports, night splints, Posterior view Rating the 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 bursitis 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 714 VOL 57, NO 11 / NOVEMBER 2008 THE JOURNAL OF FAMILY PRACtICE 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- Achilles tendon 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 www.jfponline.com VOL 57, NO 11 / NOVEMBER 2008 715 THE JOURNAL OF FAMILY PRACTICE 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 (enthesitis). 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 retrocalcaneal bursitis (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 716 VOL 57, NO 11 / NOVEMBER 2008 THE JOURNAL OF FAMILY PRACtICE Heel pain diagnosis t 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