approach and treatment to heel pain

1. M. Dehnokhalaji
TUMS
March 2016

2. • In 1922, Stiell
– “painful heel appears to be a condition which is seldom efficiently treated, for the
simple reason that the causation is not exactly diagnosed.”
• 1965… Lapidus and Guidotti
– “the name of painful heel is used deliberately in preference to any other more precise
etiological diagnosis, since the cause of this definite clinical entity still remains
unknown.”
• Now, nearly 50 years later,
– we still do not know the precise, inclusive cause
of pain beneath the anteromedial prominence of
the calcaneal tuberosity
• A variety of other causes of heel pain are better understood,
– such as heel cord tendinitis,
– retrocalcaneal bursitis,
– peroneal, posterior tibial, and FHL tendinitis.
• However, the entity remains enigmatic and often
frustrating for both physician and patient.

3. • the two most common diagnoses considered in the first part of the twentieth
century, that is, gonorrhea and tuberculosis, have been minimized.
• the differential diagnosis of idiopathic heel pain
1. rheumatoid arthritis
2. ankylosing spondylitis
3. Reiter syndrome
4. Osteoarthritis
• especially in patients with diabetes deep soft tissue abscess
• In men < 40y with bilateral painful heels AS and Reiter syndrome
• Women with bilateral symptoms  RA
• more than 2 million patients are treated for plantar fasciitis every year and
estimated the cost of treatment in 2007 as ranging from $192 to $376 million.

5. ETIOLOGY
• The exact cause of painful heel is uncertain.
1. degenerative changes with increasing age are the most constant findings
in the elastic adipose tissue of the heel pad.
– Aging also brings about a gradual reduction in collagen and water content, as well as elastic fibrous
tissue.
– This degenerative process in the calcaneal heel pad can account in part for soreness under the heel.
2. the windlass mechanism of the plantar fascia as the toes are dorsiflexed.
– The plantar fascia
• originates from the anteromedial plantar aspect of the calcaneal tuberosity
• inserts through several slips into the plantar plates of the metatarsophalangeal joints, the flexor
tendon sheaths, and the bases of the proximal phalanges of the digits
–under constant traction as it is pulled distally around the
drum of the windlass (metatarsal heads).
– This tightening of the cable, elevates the longitudinal arch and in so doing
places traction on the origin of the plantar fascia

7. ETIOLOGY
3. “tennis heel”
• The most dense, unyielding section of the plantar
aponeurosis originates from the location on the
tuberosity of the calcaneus where the most
common point of local tenderness is found during
physical examination.
• Compare this to “tennis elbow.”
• undergoing microscopic tears and cystic degeneration
with aging and repeated trauma, repetitive traction in
the origin of the plantar fascia and the flexor
digitorum brevis immediately beneath the plantar
fascia

8. ETIOLOGY
4. entrapment of the first branch of the
lateral plantar nerve to the abductor digiti
minimi
• passes between the deep surface of the FDB and the “heel spur” and adjacent
quadratus plantae muscle.
• This small nerve and accompanying vessels with one or more periosteal branches
pass deep in this area of the heel as this nerve approaches the abductor digiti
minimi muscle, which it innervates.
• a few patients (1% to 2%) have a neurogenic pathological condition associated
with painful heel syndrome.
• differentiated neurogenic causes from others by
– localizing tenderness along the lateral plantar nerve inferior to the flexor retinaculum as the
nerve approaches the calcaneal tuberosity.
– Patients with plantar fasciitis describe, tenderness only at the medial tubercle
– but patients with a neurogenic component have tenderness all along this nerve.
• release of the deep fascial edge of the abductor hallucis muscle.

9. CLINICAL FINDINGS
• between 40 and 70 years of age
• male
• quite active
• unilateral symptoms
• a normally arched foot
• Obesity is a predisposing factor, and the symptoms are even more
difficult to control when a patient is overweight.
• It is uncertain if pes planus or pes cavus predisposes to this
condition.
• In a study of U.S. military personnel, Scher et al.
– a slightly higher incidence in women.
– Female sex, black race, and increasing age were among the risk
factors they identified for plantar fasciitis.

10. • The major complaint is pain
– beneath the heel
– worse on rising in the morning or after sitting for a while.
– After a few steps the pain diminishes
– the patient is reasonably comfortable during the day
– Toward the end of the day, the discomfort becomes more of an aching
that is relieved by absence of weight bearing.
• The most common physical finding
– localized tenderness at the inferomedial aspect of
the calcaneal tuberosity.
– mild swelling and erythema
– The duration of symptoms varies from a few weeks to several months
or even years.

11. RADIOGRAPHIC FINDINGS
• a calcaneal spur in about 50% of patients, but the exact
significance of this finding is uncertain.
• Although the diagnosis is a clinical one and basically one of
exclusion, a bone scan may be of some help.
– In a study of 36 patients with the diagnosis of unilateral painful
heel, scans were positive in all but one of the symptomatic
patients.
– The anteroinferior medial aspect of the calcaneus
demonstrated the most isotope uptake.
– Bone scanning has been helpful in patients with equivocal
diagnoses of painful heel to document the clinical impression
when symptoms are recalcitrant to routine treatment over an
extended period or to rule out stress fracture.

12. RADIOGRAPHIC FINDINGS
• MRI may be helpful in the evaluation of heel pain.
– In a review of 50 patients with persistent heel pain, MRI confirmed the
diagnosis in 38 (76%).
– Although it rarely changes the management of patients with typical
symptoms of plantar fasciitis, in patients with atypical heel pain MRI may
demonstrate other pathological processes such as plantar fascia tearing,
calcaneal edema, or arteriovenous malformation.
• Electromyography of the abductor digiti minimi muscle may be
helpful in the diagnosis if symptoms have been present for several weeks or
months and when nerve entrapment is suggested.
• The tibial nerve can be carefully palpated beneath the flexor retinaculum
by percussing it gently and rolling it back and forth beneath the examining fingers.
• If the tenderness at this location is significant, release of the nerves to the
abductor digiti minimi alone may not relieve the symptoms, and partial medial
plantar fasciotomy may be required

13. TREATMENT
• Rarely does a patient with a painful heel require surgery to relieve the
symptoms.

20. TREATMENT
• A prospective, randomized controlled trial comparing intralesional
autologous blood injection with corticosteroid
injection
– found that the blood injection was effective in reducing
pain and tenderness
– but that corticosteroid was superior in onset of relief.
• Reports in the literature indicate that more than 90% of patients with plantar
fasciitis can be successfully treated nonoperatively.
• High-energy extracorporeal shock wave treatment has been
reported to be effective for recalcitrant plantar fasciitis, but there are no large
randomized studies confirming its benefits.

21. TREATMENT
• In some patients, symptoms persist over an extended time
despite all forms of conservative management.
• If the patient is made fully aware of the
possibility that no improvement may
occur after surgery, then surgery can be
recommended.

22. TREATMENT
• Recommended procedures include
(1) elevation of the entire heel pad through a horseshoe incision around
the hindfoot, with release of all soft tissue origins from the anterior
aspect of the calcaneal tuberosity
(2) neurolysis of a single nerve
(3) osteotomy of the calcaneus
(4) excision of the medial inferior tuberosity of the calcaneus
(5) simple drilling of multiple holes in the calcaneus in a “decompressing operation.”
• If the procedure chosen does not involve removing the calcaneal spur, if
present, the patient must be informed of this before surgery to avoid
confusion, disappointment, and possibly a poor result from a psychological
perspective alone.

23. • endoscopy for plantar fascia release based on limited
release of the central cord of the fascia.
– an effective procedure with reproducible results, a low complication
rate, and little risk of iatrogenic nerve injury.
• We have no experience with endoscopic technique and prefer open
plantar fascia and nerve release.
• Most patients with heel pain syndrome who ultimately require surgery
have some evidence of entrapment of the first branch of the lateral
plantar nerve.
• For these few patients, the procedure which includes
1. decompression of the first branch of the lateral plantar nerve
2. removal of the insertion of a portion of the plantar fascia
3. removal of the heel spur,
– seems to be more of a complete procedure than a simple incision of the
plantar fascia with the endoscopic method.

24. Incision is made over first branch of lateral
plantar nerve
Superficial fascia of abductor hallucis
muscle is released
Abductor hallucis muscle is
reflected proximally
Abductor hallucis muscle is
retracted distally
PLANTAR FASCIA AND NERVE RELEASE

26. Resection of small medial portion of plantar fascia
Resect a 2 to 3 × 4-mm rectangle of medial plantar fascia.
An entire plantar fasciotomy may be performed in some nonathletic patients
who have pain throughout the entire insertion of the plantar fascia medially and
laterally.

27. • If a large spur is present preoperatively and is
thought to contribute to symptoms, resect
the spur by gently reflecting the flexor
digitorum brevis off the exostosis.
• Take care not to damage the first branch of
the lateral plantar nerve that lies just superior
to the spur.

28. POSTOPERATIVE CARE
• non–weight bearing for 2 weeks after surgery.
• The sutures are then removed
• gradual weight bearing to tolerance is begun.
• Resumption of heel cord stretching and
increased activity are encouraged.