Chapter 140 Heel Pain

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1 Chapter 140 Heel Pain David R. Richardson, MD E. Greer Richardson, MD I. Overview and Epidemiology A. General characteristics Heel pain (subcalcaneal pain syndrome) is the most common foot-related symptom leading patients to seek medical care for the feet. B. Epidemiology 1. Heel pain may occur at any age. The peak incidence occurs between ages 40 and 60 years. 2. Middle-aged women appear to have the highest incidence of heel pain. 3. Race and ethnicity play no role in this entity. 4. Stress fractures are more common in women than in men; they are also more common in military recruits than in the general population. C. Etiology Heel pain has various etiologies, including trauma, disease, and the degenerative processes of aging. D. Evaluation a. The history and physical examination are extremely important when evaluating heel pain because imaging and laboratory studies may be of limited value. b. The foot should be examined for the point of maximal tenderness (Figure 1). 2. Differential diagnosis (Table 1) a. Plantar fasciitis is the most common cause of heel pain. b. Central heel pain, calcaneal stress fracture, and entrapment of the first branch of the lateral plantar nerve also should be high in the differential. c. A high index of suspicion is needed to diag- Neither of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter: Dr. David R. Richardson and Dr. E. Greer Richardson. Figure 1 Table 1 Clinical photograph shows the points of maximal tenderness in relation to the most common causes of heel pain. The foot is shown with the toes to the right and the medial aspect of the foot and ankle at the top. Differential Diagnosis of Heel Pain Plantar fasciitis Plantar fascia rupture Fat pad atrophy Fat pad contusion Calcaneal stress fracture Entrapment of the first branch of the lateral plantar nerve Calcaneal apophysitis (Sever disease) Tumor (for example, osteoid osteoma) Tarsal tunnel syndrome Gout Inflammatory arthropathies (for example, psoriatic arthritis) Spondyloarthropathies (for example, Reiter syndrome) Infection Radiculopathy Paget disease Neuropathy Foreign body reaction 2014 AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS AAOS COMPREHENSIVE ORTHOPAEDIC REVIEW

2 Section nose the less common causes of heel pain syndrome, such as tumor or infection. d. Heel pain in the elderly and patients with atypical presentations should be investigated to rule out insufficiency fractures and tumors. II. Plantar Fasciitis A. Overview and epidemiology 1. Over all age ranges, plantar fasciitis occurs equally in men and women. 2. Risk factors include limited ankle dorsiflexion due to tightness of the Achilles tendon, obesity (body mass index >30), and prolonged weight bearing. 3. Plantar fasciitis also may be associated with anatomic variations (for example, pes planus, pes cavus, or excessive femoral anteversion). 4. A heel pain triad of tibalis posterior tendon dysfunction, plantar fasciitis, and tarsal tunnel syndrome has been described. 5. Although 50% of patients with plantar fasciitis have a plantar heel spur, typically located in the origin of the flexor hallucis brevis, heel spurs are not considered the cause of heel pain in such patients. B. Pathogenesis The etiology of plantar fasciitis is repetitive microtrauma to the plantar fascia causing microtears and periostitis. C. Evaluation a. The patient with plantar fasciitis will most often report start-up inferior heel pain and may prefer to walk on the toes for the first few steps. b. The pain usually lessens with ambulation and then increases with activity, especially on hard surfaces. c. A traumatic tear of the plantar fascia may occur in the midfoot region. d. The point of maximal tenderness is located at the proximal medial origin of the plantar fascia (Figure 1). e. Palpation of the plantar fascia with the toes and ankle in dorsiflexion increases the sensitivity of the examination. f. The ankle should be examined for tightness of the Achilles tendon. 2. Imaging and other studies Figure 2 a. Radiographs Weight-bearing lateral and axial views of the hindfoot may be used to assess for arthritic changes, structural abnormalities, or bony pathology. They are not necessary on the initial visit. b. A bone scan may help quantitate inflammation and guide treatment. c. CT is not necessary. d. MRI may be beneficial before surgical release. e. Laboratory studies are not necessary unless other etiologies are suspected (for example, inflammatory arthritis, infection). D. Treatment 1. Nonsurgical Photograph demonstrates plantar fascia specific stretch. a. NSAIDs, stretching exercises (weight-bearing and non weight-bearing), night splints, overthe-counter heel cups, and reduced activity all may be used initially. b. A non weight-bearing, plantar fascia specific stretching exercise program (Figure 2) and Achilles tendon stretching appear to be more effective than the traditional program of weight-bearing Achilles tendon stretching exercises. c. A short leg cast worn for 8 to 10 weeks may be necessary. d. Corticosteroid injections should be used sparingly because they may increase the risk for plantar fascia rupture or fat pad atrophy. e. The FDA recently approved the use of electrohydraulic and electromagnetic extracorporeal shock wave therapy for chronic plantar heel pain that lasts longer than 6 months and when other treatment options have failed; however, the efficacy of such therapy remains controversial. It is a safe treatment option, with several 1526 AAOS COMPREHENSIVE ORTHOPAEDIC REVIEW AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS

3 Chapter 140: Heel Pain studies supporting its use and showing improvement in patients pain scales. 2. Surgical a. Indication Continued pain after 9 months of nonsurgical treatment b. Contraindications Absolute contraindications: Vascular insufficiency, active infection Relative contraindications: History of hypersensitivity, complex regional pain syndrome (CRPS), heavy smoker, obesity, concomitant medical condition contributing to pain (neuropathy, fibromyalgia, and so forth) c. Surgical procedures The medial one-third to two-thirds of the plantar fascia is incised through an open or endoscopic procedure. When evidence of plantar fasciitis and compression neuropathy is present, an open procedure must be performed. This procedure consists of a distal tarsal tunnel decompression and partial plantar fascia release. Success rates for distal tarsal tunnel decompression and partial plantar fascia release are reported to be from 70% to 90%. Some authors report successful treatment of recalcitrant foot pain such as plantar fasciitis with isolated gastrocnemius recession. d. Complications include damage to the lateral plantar nerve, complete fascia rupture with resultant loss of the medial longitudinal arch, stress reaction of the dorsolateral midfoot, and continued pain. III. Calcaneal Stress Fracture A. Overview and epidemiology 1. The calcaneus is the largest tarsal bone. It is composed primarily of cancellous bone. 2. On average, the calcaneus absorbs a force equal to 110% of body weight during walking and 200% of body weight during running. 3. A calcaneal stress fracture is usually oriented vertically or obliquely in the tuberosity of the calcaneus. 4. Women appear to be more prone to stress fractures than men. Menstrual disturbances leading to estrogen or other hormonal deficiencies, inadequate caloric intake, decreased bone density, limb-length discrepancy, and muscle weakness are risk factors. Figure 3 B. Pathogenesis The etiology of calcaneal stress fracture is repetitive loading resulting in fatigue of the bone. C. Evaluation a. Patients usually report an insidious onset of pain that improves with rest and intensifies with activity. Often, patients report a recent increase in physical activity. b. The female athlete triad (disordered eating, amenorrhea, and osteoporosis) should be kept in mind during the evaluation. c. The point of maximal tenderness is obtained with medial and lateral compression of the calcaneus on the weight-bearing heel (Figure 1). d. Diffuse swelling may be present. 2. Imaging Lateral radiograph of the calcaneus shows a line of increased density, indicating a stress fracture. a. Radiographs Initial radiographs are usually normal. Two to 4 weeks after the onset of symptoms, a band of increased density may be noted in the posterior aspect of the calcaneus (Figure 3). b. A bone scan or MRI is useful when radiographs are normal AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS AAOS COMPREHENSIVE ORTHOPAEDIC REVIEW

4 Section Figure 4 A, Photograph of the medial aspect of the ankle shows the anatomic locations of the tibial nerve (A), the flexor retinaculum (laciniate ligament) (B), the lateral plantar nerve (C), the first branch of the lateral plantar nerve (D), the medial plantar nerve (E), and the medial calcaneal nerve (F). B, Photograph of a cadaver foot with the tibial nerve (A), the lateral plantar nerve (B), the first branch of the lateral plantar nerve (C), and the medial plantar nerve (D) exposed. D. Treatment 1. Nonsurgical a. Restriction of painful activity for 4 to 6 weeks and placement of a cushioned insert is the standard treatment. b. If the patient has pain with normal walking, a short leg cast or boot should be placed. The patient is then allowed to return to activity gradually as the pain resolves. c. The patient may need a referral to an endocrinologist if metabolic abnormalities are suspected. 2. Surgical Calcaneal stress fractures do not require surgical treatment unless displacement occurs. IV. Entrapment of the First Branch of the Lateral Plantar Nerve A. Overview and epidemiology 1. The lateral plantar nerve is a branch of the tibial nerve. 2. The first branch of the lateral plantar nerve is a mixed (sensory and motor) nerve (Figure 4). Branches of the nerve pass deep to the deep fascia of the abductor hallucis and flexor hallucis brevis, immediately distal to the medial process of the calcaneal tuberosity. The nerve innervates the periosteum of the calcaneus, the flexor digitorum brevis, and the abductor digiti quinti (Figure 5, A). The nerve runs plantar to the quadratus plantae (Figure 5, B). 3. Entrapment of the first branch of the lateral plantar nerve is more common in athletes who are on their toes for a substantial amount of time (for example, sprinters, ballet dancers). B. Pathogenesis The etiology of entrapment of the first branch of the lateral plantar nerve is compression between the deep fascia of the abductor hallucis and the inferomedial margin of the quadratus plantae. C. Evaluation a. The diagnosis of entrapment of the first branch of the lateral plantar nerve is based on clinical findings. b. Patients usually report pain radiating distally and proximally from the medial aspect of the heel, and they may report paresthesias. c. Pain may radiate proximally into the calf (Valleix phenomenon). d. A positive Tinel sign (percussion of the irritated nerve causing tingling or numbness radiating in the nerve s distribution) may be present. e. Atrophy of the abductor quinti may be present, but it is difficult to detect. f. The point of maximal tenderness is located on the medial heel (Figure 1). g. Dorsiflexion and eversion of the ankle may exacerbate symptoms. 2. Imaging and other studies a. Imaging studies are not indicated unless a space-occupying lesion is suspected, in which case MRI should be obtained AAOS COMPREHENSIVE ORTHOPAEDIC REVIEW AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS

5 Chapter 140: Heel Pain b. Electromyography and nerve conduction velocity studies are not consistent. D. Treatment 1. Nonsurgical a. Nonsurgical treatment should be attempted for at least 6 months. Rest, activity modification, NSAIDs, stretching, and ice are the first line of treatment. b. Shock-absorbing inserts with a medial longitudinal arch support may reduce the pressure in the area of entrapment. 2. Surgical a. Indications Continued pain after 9 months of nonsurgical treatment A space-occupying lesion confirmed by MRI b. Contraindications Absolute contraindications: Vascular insufficiency, active infection Relative contraindications: History of hypersensitivity, CRPS, heavy smoker, obesity, concomitant medical condition contributing to pain (for example, neuropathy, fibromyalgia) c. Surgical procedures Open decompression should be performed. Figure 5 Illustrations show the course of the first branch of the lateral plantar nerve. A, Branches of this nerve innervate the periosteum of the calcaneus (1), as well as the flexor digitorum brevis (2) and the abductor digiti quinti (3) muscles. B, The course of the nerve is shown with parts of the abductor hallucis (1) and the flexor digitorum brevis (2) muscles removed. Branches of the nerve also run plantar to the quadratus plantae (3) and innervate the abductor digiti quinti (4) muscle. The medial third of the plantar fascia is often incised if concomitant proximal plantar fasciitis is suspected. The deep fascia of the abductor hallucis muscle is released. Top Testing Facts 1. Heel pain in the elderly and patients with atypical presentations should be investigated to rule out insufficiency fractures and tumors. 2. Although 50% of patients with plantar fasciitis have a plantar heel spur, typically located in the origin of the flexor hallucis brevis, heel spurs are not considered the cause of heel pain in such patients. 3. The patient with plantar fasciitis will most often report start-up inferior heel pain and may prefer to walk on the toes for the first few steps. 4. Corticosteroid injections should be used sparingly in the treatment of plantar fasciitis because they may increase the risk for plantar fascia rupture or fat pad atrophy. 5. With calcaneal stress fractures, pain is elicited when compressing the heel medial/lateral. 6. The etiology of entrapment of the first branch of the lateral plantar nerve is compression of the nerve between the deep fascia of the abductor hallucis and the inferomedial margin of the quadratus plantae. 7. The first branch of the lateral plantar nerve innervates the abductor digiti quinti muscle. When entrapment of this nerve occurs, nonsurgical treatment should be attempted for at least 6 months AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS AAOS COMPREHENSIVE ORTHOPAEDIC REVIEW

6 Section Bibliography DiGiovanni BF, Nawoczenski DA, Lintal ME, et al: Tissuespecific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain: A prospective, randomized study. J Bone Joint Surg Am 2003;85-A(7): Digiovanni BF, Nawoczenski DA, Malay DP, et al: Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis: A prospective clinical trial with two-year follow-up. J Bone Joint Surg Am 2006; 88(8): Haake M, Buch M, Schoellner C, et al: Extracorporeal shock wave therapy for plantar fasciitis: Randomised controlled multicentre trial. BMJ 2003;327(7406):75. Jahss MH, Kummer F, Michelson JD: Investigations into the fat pads of the sole of the foot: Heel pressure studies. Foot Ankle 1992;13(5): Labib SA, Gould JS, Rodriguez-del-Rio FA, Lyman S: Heel pain triad (HPT): The combination of plantar fasciitis, posterior tibial tendon dysfunction and tarsal tunnel syndrome. Foot Ankle Int 2002;23(3): Maskill JD, Bohay DR, Anderson JG: Gastrocnemius recession to treat isolated foot pain. Foot Ankle Int 2010;31(1): Resnick RB, Hudgins LC, Buschmann WR, Kummer FJ, Jahss MH: Analysis of the heel pad fat in rheumatoid arthritis. Foot Ankle Int 1999;20(8): Riddle DL, Pulisic M, Pidcoe P, Johnson RE: Risk factors for Plantar fasciitis: A matched case-control study. J Bone Joint Surg Am 2003;85-A(5): Rompe JD, Schoellner C, Nafe B: Evaluation of low-energy extracorporeal shock-wave application for treatment of chronic plantar fasciitis. J Bone Joint Surg Am 2002;84-A(3): Tisdel CL, Donley BG, Sferra JJ: Diagnosing and treating plantar fasciitis: A conservative approach to plantar heel pain. Cleve Clin J Med 1999;66(4): Wang CJ, Wang FS, Yang KD, Weng LH, Ko JY: Long-term results of extracorporeal shockwave treatment for plantar fasciitis. Am J Sports Med 2006;34(4): Watson TS, Anderson RB, Davis WH, Kiebzak GM: Distal tarsal tunnel release with partial plantar fasciotomy for chronic heel pain: An outcome analysis. Foot Ankle Int 2002; 23(6): AAOS COMPREHENSIVE ORTHOPAEDIC REVIEW AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS