Peripheral neuropathy can also be a factor in heel pain. A patient’s perception of the exact location of pain may vary, depending on activity or the time of day. Compression of the medial and lateral calcaneal nerves can cause inferior heel pain, and is not considered specific. Medial heel pain can be related to compression of the medial or lateral plantar nerve.
A nerve compression test of direct pressure to the point of nerve compression produces radiating pain. The plantarflexion/inversion test can produce neurogenic pain by increasing pressure in the porta pedis, affecting the posterior tibial nerve and its branches. Nerve percussion can also help localize the area of pain. A positive Tinel’s sign can support diagnosis of a peripheral nerve compression cause. Conservative treatments of entrapment neuropathies include: cortisone injections, NSAIDs, orthotics, physical therapy and casting. Surgical release or decompression may be indicated in more serious cases.
Systemic causes of heel pain. Systemic causes of heel pain may include rheumatoid arthritis, psoriatic arthritis, Reiter’s syndrome, hematogenous osteomyelitis, seronegative arthritis, metastatic disease, gout, sarcoidosis, infectious diseases, sickle cell anemia, Paget’s disease, inflammatory bowel disease and hyperparathyroidism. As most heel pain initially responds to conservative treatment, if the heel pain is recalcitrant, then one should consider other causes with appropriate lab work and radiological studies.
Tumors. Most tumors and tumor-like conditions initially present with pain as the primary complaint. A solitary bone cyst is the most common tumor or tumor-like condition in the calcaneus.
Calcaneal fractures. Calcaneal fractures can be grouped into traumatic and fatigue type fractures. One can use Essex-Lopresti and Rowe classifications to classify traumatic fractures. Insufficiency fractures are due to the bone being deficient in mineral or elastic resistance when subjected to normal stresses. Underlying conditions such as osteopenic disorders, osteoporosis, rheumatoid arthritis, neurologic disorders, diabetes and prolonged immobilization can all lead to insufficiency.
An Overview Of Treatments For Heel Pain
If heel pain is related to excessive pronatory forces — which would be the case in plantar fasciosis, calcaneal apophysitis and some cases of Achilles tendonitis (related to excessive pronation) — then you should consider low Dye strapping with felt padding (Cobra or longitudinal arch pad), shoe recommendations/modifications, and a removable molded heel pad/sleeve for Haglund’s deformity or exostosis.
Consider custom functional orthotics for chronic heel pain if low Dye strapping significantly relieves symptoms and allows an earlier return to activity. Consider medial heel skives, deep heel cups and a semi-flexible device. Shoes are critical to help support and cushion the heel. When combined appropriately with an orthotic device, shoes provide optimum control and support for your patient.
As for physical therapy, modalities include stretching (both eccentric and concentric) and strengthening the plantar fascia, Achilles tendon, peroneals and posterior tibial muscles. One should also review prescription goals and objectives in regard to activity level, restrictions, frequency, etc. Physical therapy should be two to three times per week for at least three to four weeks. Then one should reassess progress. It is a good idea to give the patient home exercises to do on a regular basis. Patients can incorporate cross-training during the course of physical therapy.
There is a two-pronged approach to treatment: treat the symptoms and the cause. If you address just one and not the other, your patient will probably take longer to recover. It is important to educate your patient on the importance of the two-pronged approach. Reviewing options with your patient and explaining the value of the treatment will help increase patient adherence with the treatment regimen.
If you are thinking of custom orthotics, make sure that patient responds to low-Dye strapping and that he or she will follow shoe recommendations. As the saying goes, “The orthotic is only as good as the shoe that you put it in.”