How To Address Mechanically-Induced Subcalcaneal Pain

Author(s): 
By Paul R. Scherer, DPM, and Lori L. Waters, BSc, BEd

    Given the abundance of articles written about heel pain and plantar fasciitis, practitioners may wonder whether there is anything new to learn. The prevalence of this condition accounts for the amount of press that it gets, both in the medical community and in the news, but are all the articles and studies discussing the same thing? The numerous opinions and conflicting data may indicate that heel pain is more complicated than people realize. Perhaps some variable has been omitted in the research that contributes to the conflicting outcomes.

    Many terms are used interchangeably to describe heel pain. These terms include plantar fasciitis, plantar heel pain syndrome, heel bursitis, heel spur syndrome, subcalcaneal pain, chronic plantar heel pain and many others. Are all these terms truly discussing the same condition or are people using plantar fasciitis as a generic term for heel pain from different etiologies? Perhaps this is similar to how chondramalacia patellae became a catchall term for knee pain. Could this be why some patients respond well to your treatment regimen and others do not?

Establishing Clearer Terminology For Heel Pain

    Differentiating heel pain by its etiology is essential to successful treatment but this is not enough. We should establish clear definitions of the standard nomenclature in order to distinguish one type of heel pain from another. This can only help in future discussions, allowing practitioners and researchers to compare “apples to apples” and helping to reduce confusion regarding appropriate treatment choices for your patients. Even the names plantar fasciitis, plantar fascial strain, calcaneal bursitis and heel pain can cause confusion.

    In examining the etiology of heel pain, Lemont demonstrated that a histological examination of the most proximal aspect of the plantar fascia in patients who had plantar fasciotomies for symptoms showed no inflammatory cells.1 If there is no inflammation in the plantar fascia, should we call it plantar fasciitis? Shama reported a large prevalence of heel spurs and/or enthesopathies in patients who have no symptoms.2 If most patients with heel spurs do not have heel pain, why refer to heel pain as heel spur syndrome? Plantar heel pain is also called calcaneal bursitis. However, most anatomy texts do not show a bursa on the plantar aspect of the calcaneus.

    It should be apparent how these misnomers can cause confusion in discussions, research outcomes and treatment decisions.

Key Insights On Mechanically-Induced Subcalcaneal Pain

    To eliminate confusion when discussing heel pain, we suggest that the symptomatology that comes from a particular pathomechanics and produces a periostitis of the medial tubercle of the calcaneal tuberosity should be referred to as mechanically-induced subcalcaneal pain (MSC pain).

    MSC pain is defined by: 1) occurrence on the first step in the morning; 2) pain exacerbated by previous excessive activity; 3) improvement after walking; and 4) pain limited to the plantar area of the calcaneal tuberosity. Lastly, in order for heel pain to be MSC pain, the symptoms should not be related to other systemic seropositive/negative arthropathies or neuropathies, or to specific injury or trauma as determined by the patient history or examination.

    One aspect of our definition that we have not described is the particular pathomechanics that result in MSC pain. According to most articles, orthotic therapy can be successful in treating a significant portion of heel pain related to supination of the midtarsal joint and increased tension on the plantar fascia at its insertion. However, a brief summary of the suspected pathomechanics of MSC pain is in order to truly understand the parameters of treatment.

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