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.
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.
Classically, patients complain of pain with the first step after periods of inactivity. Pain may decrease briefly with activity and then return with prolonged activity. This commonly occurs in patients with extreme foot types, such as pes cavus or pes planus, in which the fascia experiences more stress due to biomechanical forces.
During the physical exam, one can locate the maximum area of pain, determine the type of pain and the foot type, perform a gait evaluation (if not too antalgic), and check for edema and any neuritic pain.
Initial treatment can include: PRICE (protection, restricted activity, ice, compression and elevation); low Dye strapping/accommodative padding (Cobra, longitudinal arch pad, medial heel skive); prefabricated insoles; non-steroidal anti-inflammatory drugs (NSAIDs); cortisone injections; stretching; and shoe modifications/recommendations.
I strongly advise patients not to wear flip-flops during this initial period of time. Frequently, younger patients will spend a significant portion of time during the day in their favorite footwear.
I always recommend caution with starting stretching too soon in the acute phase as stretching can actually aggravate and prolong the recovery if one does this too early and too aggressively.
In the more chronic and recalcitrant cases, custom functional orthotics, night splints, physical therapy, cortisone injections (repeated) and possibly a walking boot may be indicated.
Surgical management is rarely necessary or indicated, but a plantar fasciotomy (endoscopic) or extracorporeal shockwave therapy (ESWT) could be alternatives. Usually, attempts at conservative care last for at least six months. If a patient is not improving after four to six weeks of conservative care, it is often necessary to rethink the diagnosis of heel pain as there are many causes.
Cross-training activities will help keep up a patient’s level of fitness as he or she will need to curtail weightbearing activities. Swimming, biking, using an elliptical trainer and doing circuit weight training are all good options for patients seeking to maintain their fitness level.
Other causes of plantar heel pain include stress fracture, tarsal tunnel syndrome, rheumatoid arthritis and infection. Clinicians also should consider the possibilities of calcaneal apophysitis and heel pad syndrome.
Calcaneal apophysitis/Sever’s disease. Also known as Sever’s disease, calcaneal apophysitis is another very common cause of heel pain in youth. This is a traction apophysitis at the calcaneus due to the pull of the Achilles tendon insertion and the origin of the plantar fascia. The pain can be on the plantar aspect of the heel, posterior aspect of the heel or in both areas. I will do a “squeeze test” with medial and lateral compression of the heel. Typically, we see this presentation in children participating in athletic activity. Possible causes include (but are not limited to): obesity/being overweight; an increase in activity, especially running and jumping; shoes with poor support and cushioning; posterior calf tightness; and equinus.
Usually, this condition will resolve on its own with time but it is best to treat the symptoms with taping, shoe recommendations, ice, stretching and cross-training. Return to activity depends on symptoms and conditioning. Custom functional orthotics with a deep heel cup, medial heel skive and slight heel lift can be helpful in young athletes, who frequently can participate in most of their activities after treatment concludes. Stretching the calf and arch are also very important when patients are asymptomatic.
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.
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
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.
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.
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.”
Exhaust all conservative care before considering surgery whenever possible. The sooner you can identify the cause of heel pain and start appropriate treatment, the better.
Return to activity guidelines should aim at “under promising and over delivering.” Usually, the longer the patient has had heel pain, the longer it will take to resolve. You will be a hero if the recovery is faster than anticipated.
If the patient is not progressing with the treatment plan and has been adherent, rethink the diagnosis as it may be one of the other many causes of heel pain. Order appropriate lab work and diagnostic studies, and use referrals. Often, the heel pain can be multifactorial in nature.
Remind the patient to wear supportive foot gear at all times and avoid flip-flops or sandals as much as possible as support and cushioning can be keys for the successful response of a treatment plan. Emphasize the importance of proper footwear and fit. Patients need to replace shoes on a regular basis.
Weight control and physical conditioning are critical to success for treating the mechanical causes of heel pain. If the patient is overweight, prescribe exercise (one may consult the primary care provider), recommend cross-training and give him or her guidelines to stay fit. Remember, exercise is medicine. Be a mentor and role model for your patients.
Dr. Dutra is an Assistant Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University. He is a podiatric consultant for Intercollegiate Athletics at the University of California, Berkeley. He has masters degrees in Kinesiology and Health Care Administration.
Dr. Dutra is a Fellow and Past President of the American Academy of Podiatric Sports Medicine. Dr. Dutra is also a Fellow of the American College of Sports Medicine, the American College of Foot and Ankle Orthopedics and Medicine, and the American Professional Wound Care Association. He is a Distinguished Practitioner of Podiatric Medicine with the National Academies of Practice.
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