Heel pain, especially in the athlete, can have a wide range of potential etiologies. This author discusses pearls for getting to the root of plantar and posterior heel pain, and reviews appropriate conservative and surgical treatment options.
Heel pain is an obviously common occurrence in a podiatric practice. In a sports medicine practice, we see it frequently in all age groups. Accordingly, let us take a closer look at keys to addressing plantar and posterior heel pain that you encounter in your practice.
The majority of heel pain has a mechanical etiology but can also be related to other causes, such as neurologic, arthritic, traumatic and other etiologies. For the purposes of this article, I will focus on overuse type of musculoskeletal conditions.
The patient history is very important in working up a differential diagnosis of posterior heel pain. When you are talking to the patient, you want to ascertain the onset, duration and nature of the pain as well as modifying factors and previous treatment. Here are some key questions:
• How did it happen?
• When did you first notice it?
• Has there been any change in shoe gear or activity level?
• What about a change in job duties?
• Has it happened before?
• Is it worse with exercise/activity?
• What relieves pain or discomfort?
• Do you have any medical conditions?
• Are you taking any current medications?
• Do you have any allergies?
The objective exam should be systematic with vascular, neurological and dermatological exams.
Vascular. Check for pedal pulses and capillary refill time as well as general signs of circulation (hair, temperature, etc.).
Neurological. Check for pain from percussion over nerves to rule out neuritis or a nerve entrapment causing heel pain. Rule out radiculopathy causes.
Dermatological. Check temperature, texture and turgor. Also check for the presence of any hyperkeratotic lesions or warts.
Musculoskeletal/biomechanical. This consists of palpation of the painful area to help localize problems to the bursa, tendon, nerve or muscle pain. It is important to try to identify the biomechanical cause as the treatment approach focuses more on the patient’s response to taping and motion control in shoe gear. A visual gait analysis is a must in order to check heel contact, equinus, excessive pronation, etc. One can use a pinch test for Haglund’s deformity, which occurs posterior and superior to the pinch test for a calcaneal stress fracture. A squeeze test (medial/lateral compression) can help identify calcaneal stress fracture or calcaneal apophysitis. Radiating pain on palpation can indicate a neurogenic cause.
Tests/consults. Review pertinent lab work, radiology studies (X-rays, MRI, bone scans), nerve conduction studies and consults.
Pertinent Insights On Diagnosing And Treating Plantar Heel Pain
When it comes to the differential diagnosis of plantar heel pain, possibilities may include plantar fasciosis/heel spur syndrome, heel pad syndrome and calcaneal apophysitis/Sever’s disease.
Plantar heel pain is one of the most common patient complaints and includes plantar fasciitis, heel spur syndrome and plantar fasciosis. Heel spur syndrome is really a catchall term as many patients will have an asymptomatic spur on X-ray and the spur itself is a result of excessive traction from the chronic pull of the tendon. Also, plantar fasciitis is better termed plantar fasciosis as it describes the degenerative nature histologically and the inflammatory component has been de-emphasized in recent years.
The pain is commonly along the proximal aspect of the fascia in the calcaneal tuberosity region at the plantar fascia origin. The windlass mechanism and the tension on the fascia during activity can lead to a biomechanical overstressing.