Keys To Addressing Heel Pain In The Athlete

Tim Dutra, DPM

   Heel pad syndrome. Patients can present with deep, bruise-like pain in the center of the heel pad. This syndrome frequently results from inflammation due to walking barefoot or on hard surfaces. Obesity and age are also factors in the decreased elasticity of the heel pad. One should direct treatment toward reducing inflammation with ice, rest and NSAIDs. Also consider the use of heel cups, cushioned shoes and taping.

What You Should Know About Posterior Heel Pain

Common causes of posterior heel pain include insertional Achilles tendonitis/ enthesopathy, Haglund’s deformity, retrocalcaneal bursitis, gout, seronegative arthropathy, os trigonum and neurogenic causes.

   Insertional Achilles tendonopathy. Achilles tendonopathy is probably one of the most common posterior heel pain problems we see in practice. It occurs in all age groups and activity levels. Patients frequently present with an insidious onset of pain in the posterior of the heel and mild to moderate edema. Activity, especially jumping and running, typically aggravates the pain, commonly near the insertion of the tendon. The heel counter of the shoe (Achilles collar or pad area) can aggravate the insertion area with excessive pressure. There can also be associated pain in the retrocalcaneal bursa area. Patients with insertional tendonopathy have maximum pain in the central region and at the insertion of the tendon.

   The central portion of the tendon may have calcification visible on X-ray from the middle third of the calcaneus. Histologically, there is mucoid degeneration, hemorrhage, necrosis and calcification in the chronic cases. If there is swelling and tenderness away from the middle of the heel, it is likely a retrocalcaneal bursitis. Haglund’s deformity may be visible in a significant percentage of insertional tendonopathy cases.

   Initial treatment options consist of: modifying activity; heel lifts in both shoes to decrease the pull of the tendon and prevent a leg length difference; modifying the heel counter of shoe to eliminate friction; prefabricated insoles; taping; and physical therapy. Activity modification is probably the most important aspect of treatment. Stretching becomes important after the acute phase calms down. There should be an emphasis on eccentric stretching along with concentric stretching. Stretching needs to happen without aggravating the tendon. In my experience, non-insertional tendonopathy responds much better
to stretching.

   Haglund’s deformity. Also known as “pump bump,” Haglund’s deformity is a prominence of the posterior lateral process of the calcaneus with tenderness lateral to the tendon. This may include retrocalcaneal bursitis.

   Initial treatment options include: modification of the heel counter of the shoes to remove the contact point; adding a custom latex shield; physical therapy; or cortisone injections (with care to avoid tendons). Surgical resection of the prominence may be indicated in recalcitrant cases. I have found that modifying the heel counter along with using a latex shield is very effective in athletes with less chronic conditions.

   Neurogenic heel pain. Neurogenic heel pain involves a nerve entrapment or irritation of the nerve locally. Nerves that may be affected include the medial calcaneal, medial plantar, lateral plantar, posterior tibia and sural nerves.

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