diagnosis of heel pain - aafp home2011/10/15 · heel pads or walking boots nerve entrapment...

October 15, 2011 ◆ Volume 84, Number 8 www.aafp.org/afp American Family Physician 909

Diagnosis of Heel PainPRISCILLA TU, DO, and JEFFREY R. BYTOMSKI, DO, Duke University, Durham, North Carolina

The differential diagnosis of heel pain is extensive (Table 1), but a mechanical etiology (Table 2) is most common. Obtaining a

patient history, performing a physical exami-nation of the foot and ankle (see http://www.youtube.com/watch?v=kdGSGofCa9I), and ordering appropriate imaging studies, if

indicated, are essential to making the cor-rect diagnosis and initiating proper treat-ment. Location of pain can be a guide to the diagnosis. Figures 1 and 2 include common causes of heel pain by anatomic location.

Plantar Heel PainPLANTAR FASCIITIS AND HEEL SPURS

Every year, as many as 2 million persons present with plantar heel pain,1 with men and women affected equally.2 Plantar fas-ciitis is the most common cause of plantar heel pain. Historically, plantar fasciitis was considered an inflammatory syndrome; however, recent studies have demonstrated a noninflammatory, degenerative process,3 leading some to use the term plantar fascio-sis. Regardless, the condition usually stems from multiple causes and can be debilitating for the patient.

Plantar fasciitis causes throbbing medial plantar heel pain that is worse with the first few steps in the morning or after long periods of rest. The pain usually decreases after further ambulation, but can return

Heel pain is a common presenting symptom in ambulatory clinics. There are many causes, but a mechanical etiology is most common. Location of pain can be a guide to the proper diagnosis. The most common diagnosis is plantar fasciitis, a condition that leads to medial plantar heel pain, especially with the first weight-bearing steps in the morning and after long periods of rest. Other causes of plantar heel pain include calcaneal stress fracture (progressively worsen-ing pain following an increase in activity level or change to a harder walking surface), nerve entrapment (pain accompanied by burning, tingling, or numbness), heel pad syndrome (deep, bruise-like pain in the middle of the heel), neuromas, and plantar warts. Achilles tendinopathy is a common condition that causes posterior heel pain. Other tendinopathies demonstrate pain localized to the insertion site of the affected tendon. Posterior heel pain can also be attributed to a Haglund deformity, a prominence of the calcaneus that may cause bursa inflammation between the calcaneus and Achilles tendon, or to Sever disease, a calcaneal apophysitis in chil-dren. Medial midfoot heel pain, particularly with continued weight bearing, may be due to tar-sal tunnel syndrome, which is caused by compression of the posterior tibial nerve as it courses through the flexor retinaculum, medial calcaneus, posterior talus, and medial malleolus. Sinus tarsi syndrome occurs in the space between the calcaneus, talus, and talocalcaneonavicular and subtalar joints. The syndrome manifests as lateral midfoot heel pain. Differentiating among causes of heel pain can be accomplished through a patient history and physical examination, with appropriate imaging studies, if indicated. (Am Fam Physician. 2011;84(8):909-916. Copy-right © 2011 American Academy of Family Physicians.)

Table 1. Differential Diagnosis of Heel Pain

Arthritic

Gout

Rheumatoid arthritis

Seronegative spondyloarthropathies

Infectious

Diabetic ulcers

Osteomyelitis

Plantar warts

Mechanical

See Table 2

Neuropathic

Lumbar radiculopathy

Nerve entrapment (branches of posterior tibial nerve)

Neuroma

Tarsal tunnel syndrome (posterior tibial nerve)

Trauma

Tumor (rare)

Ewing sarcoma

Neuroma

Vascular (rare)

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Table 2. Mechanical Etiologies of Heel Pain by Location

Etiology Clinical features Initial treatment

Plantar

Plantar fasciitis/fasciosis Pain with first steps in the morning or after long periods of rest

Tenderness on medial calcaneal tuberosity and along plantar fascia

Relative rest

Stretching/strengthening exercises

Anti-inflammatory/analgesic medication

Ice

Arch support

Heel spur Radiographic findings at site of pain Decrease pressure to affected area

Calcaneal stress fracture Follows increase in weight-bearing activity or change to harder walking surfaces

Pain with activity progressively worsens to include pain at rest

Diagnosed with imaging

Decrease in activity level, and occasionally no weight bearing

Heel pads or walking boots

Nerve entrapment (medial or lateral plantar nerve, nerve to abductor digiti minimi)

Sensations of burning, tingling, or numbness

Occasionally preceded by increased activity or trauma

Rest


Decrease pressure to affected area


Ice

Heel pad syndrome Deep, bruise-like pain, usually in middle of the heel

Rest



Heel cups

Taping

Posterior

Achilles tendinopathy Achy, occasionally sharp pain

Worsens with increased activity or pressure to area

Tenderness along Achilles tendon

Occasional palpable prominence from tendon thickening

Eccentric exercises


Heel lifts, other orthotic devices


Haglund deformity Pain caused by retrocalcaneal bursitis

Positive findings on radiography



Retrocalcaneal bursitis Pain, erythema, swelling between the calcaneus and Achilles tendon

Tender to direct palpation



Corticosteroid injections (preferably ultrasound-guided)

Sever disease (calcaneal apophysitis)

Pain in children and adolescents

Worsens with increased activity

Tenderness at Achilles insertion

Pain with passive dorsiflexion

Avoid pain-inducing activities


Ice


Orthotic devices

Midfoot (medial)

Posterior tibialis tendinopathy

Tenderness at navicular and medial cuneiform Eccentric exercises



Flexor digitorum longus tendinopathy

Tenderness posterior to medial malleolus, and obliquely across sole of foot to base of distal phalanges of lateral toes

Eccentric exercises



Flexor hallucis longus tendinopathy

Tenderness posterior to medial malleolus and on plantar surface of great toe

Eccentric exercises



continued


throughout the day with continued weight bearing. Tenderness is noted on the medial calcaneal tuberosity and along the plantar fascia (Figure 2). Pain often increases with stretching of the plantar fascia, which is

achieved by passive dorsiflexion of the foot and toes. Radiography is usually not neces-sary, although weight-bearing radiography can help rule out other causes of heel pain. Approximately 50 percent of patients with

Table 2. Mechanical Etiologies of Heel Pain by Location (continued)

Etiology Clinical features Initial treatment

Midfoot (medial) (continued)

Tarsal tunnel syndrome Pain and numbness in posteromedial ankle and heel (may extend into distal sole and toes)

Worsens with standing, walking, or running

Examination positive for Tinel sign

Muscle atrophy may occur if severe

Avoid pain-inducing activities

Orthotic devices

Neuromodulator/anti-inflammatory medication

Corticosteroid injection

Midfoot (lateral)

Peroneal tendinopathy Tenderness in lateral calcaneus along path to base of fifth metatarsal

Eccentric exercises



Sinus tarsi syndrome

Pain in lateral calcaneus and ankle

Worse after exercise or when walking on uneven surfaces

May have history of repeated ankle sprains or repeated hyperpronation of the foot

Orthotics

Physical therapy


Corticosteroid injection

Etiologies of Heel Pain

Figure 1. Algorithm for diagnosing etiologies of heel pain.

Location of heel pain

Plantar

Type of pain

Burning/tingling Sharp/achy

Nerve entrapment

Neuroma

Timing of pain

With first weight-bearing steps after rest

With prolonged weight-bearing

At rest

Plantar fasciitis Heel pad

syndromePlantar wart

Calcaneal stress fracture

Posterior

Age of patient

AdultChild/adolescent

Sever disease (calcaneal apophysitis)

Location around Achilles tendon

Insertional Surrounding

Achilles tendinopathy

Haglund deformity with or without bursitis

Midfoot

Lateral Medial

Insertional Involving the ankle

Tarsal tunnel syndrome

Peroneal tendinopathy Sinus tarsi

syndrome

Heel Pain

912 American Family Physician www.aafp.org/afp Volume 84, Number 8 ◆ October 15, 2011

plantar fasciitis have heel spurs,4,5 but they are most often an incidental finding and do not correlate well with the patient’s symptoms. Ultrasonography can demonstrate a thicker heel aponeurosis of greater than 5 mm.4,5

Treatment of plantar fasciitis is typically conservative, although resolution can take months to years.4,6,7 First-line therapies include relative rest, stretching before ini-tial weight bearing, strengthening exercises, anti-inflammatory or analgesic medications, and ice. Arch taping, over-the-counter shoe inserts, custom orthotics, or supportive shoes may be helpful.4,8 Night splints, cor-ticosteroid injections, and formal physical therapy have been used for more recalcitrant cases.2,4,8 Extracorporeal shock wave therapy may also be of benefit.9,10 Surgery to transect the plantar aponeurosis is used only when other treatments have been ineffective.4,6,8

CALCANEAL STRESS FRACTURE

Calcaneal stress fracture is the second most common stress fracture in the foot, follow-ing metatarsal stress fracture.6 A calcaneal

stress fracture is usually caused by repetitive overload to the heel, and most commonly occurs immediately inferior and poste-rior to the posterior facet of the subtalar joint.7 Patients often report onset of pain after an increase in weight-bearing activ-ity or change to a harder walking surface. The pain initially occurs only with activity, but often progresses to include pain at rest. Examination may reveal swelling or ecchy-mosis; point tenderness at the fracture site is usually indicative of a calcaneal stress frac-ture. Because radiography often does not initially reveal the fracture, bone scans or magnetic resonance imaging (Figure 3) may be needed.6,7

Early treatment of a calcaneal stress frac-ture involves decreasing activity level and possibly no weight bearing. Heel pads or walking boots are also used.

NERVE ENTRAPMENT

Heel pain that is accompanied by burning, tingling, or numbness may suggest a neuro-pathic etiology. These symptoms most com-monly indicate nerve entrapment caused by overuse, trauma, or injury from previous surgery. Affected nerves leading to plantar heel pain are typically branches of the poste-rior tibial nerve, including the medial plan-tar nerve, the lateral plantar nerve, or the nerve to the abductor digiti minimi. Neuro-pathic heel pain is usually unilateral; there-fore, underlying systemic illnesses should be ruled out in those with bilateral pain.7,11 Lumbar radiculopathy of L4-S2 must also be considered in the diagnosis of neuro-pathic heel pain.

Initial treatment of heel pain caused by nerve entrapment includes rest, ice, Figure 2. Common sites of heel pain with corresponding diagnoses.

Posterior tibial nerve

Haglund deformity

Plantar fasciitis

Medial plantar nerve

Tarsal tunnel syndrome

Flexor retinaculum

Figure 3. Magnetic resonance image of calca-neal stress fracture (arrow).

ILLU

STR

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BY

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Heel Pain


anti-inflammatory or analgesic medications, relief of pressure at the site of pain, and stretching exercises. If conservative measures are ineffective after six to 12 months, surgi-cal decompression should be considered.

HEEL PAD SYNDROME

Pain from heel pad syndrome is often erroneously attributed to plantar fasciitis. Patients with heel pad syndrome present with deep, bruise-like pain, usually in the middle of the heel, that can be reproduced with firm palpation. Walking barefoot or on hard surfaces exacerbates the pain. The syn-drome is usually caused by inflammation, but damage to or atrophy of the heel pad can also elicit pain. Decreased heel pad elasticity with aging and increasing body weight can also contribute to the condition.12 Treatment is aimed at decreasing pain with rest, ice, and anti-inflammatory or analgesic medications. Heel cups, proper footwear, and taping can also be used.

SOFT TISSUE ETIOLOGIES

Neuromas may develop on the branches of the tibial nerve, causing plantar heel pain. Patients often present with symptoms simi-lar to plantar fasciitis, although pain can sometimes be a more burning or tingling sensation. Palpation may reveal a painful lump at the neuroma site. Neuromas should be considered when treatment for plantar fasciitis is ineffective.6,11,13

Plantar warts are sometimes a source of heel pain. They are raised skin lesions arising from direct contact with human papillomavirus. The lesion is noted on inspection of the heel and is tender to palpa-tion. Plantar warts are usually self-limited; however, patients often need quicker resolu-tion to return to activity. Over-the-counter topical medications, cryotherapy, laser ther-apy, and shaving the wart have been shown to be beneficial, but may worsen pain.

Posterior Heel PainACHILLES TENDINOPATHY

Achilles tendinopathy is usually caused by running, wearing high heels, and other activities associated with overuse of the calf

muscles. The achilles tendon is formed by the union of the gastrocnemius and soleus muscle tendons.6 The condition can be insertional or within the midsubstance of the tendon, leading to posterior heel pain that is achy, is occasionally sharp, and wors-ens with increased activity or pressure to the area, such as from contact with shoe back-ing.7 Fluoroquinolone use has also been shown to precipitate Achilles tendinopathy, particularly in older persons.14,15 Palpation reveals tenderness along the Achilles tendon and sometimes a palpable prominence from tendon thickening. Passive dorsiflexion of the foot increases the pain. Radiography may demonstrate spurring at the Achilles tendon insertion site or intratendinous calcifica-tions,7 whereas ultrasonography may show thickening of the tendon (Figure 4).

Figure 4. Ultrasound image showing (A) normal Achilles tendon (arrow) and (B) thickened Achil-les tendon (arrow) from Achilles tendinopathy.

B

A

Heel Pain


The most beneficial treatment of Achilles tendinopathy is eccentric exercises, which involve lengthening a muscle in response to external resistance.16 Initial treatment should also include reduction of pressure to the area, heel lifts or other orthotic devices, and anti-inflammatory or analgesic medi-cations. Nitroglycerin patches and platelet-rich plasma injections have shown benefit in some studies.17-20 Surgical debridement may be needed for severe cases.

HAGLUND DEFORMITY

A Haglund deformity is a prominence of the superior aspect of the posterior calcaneus (Figures 2 and 5). The condition can occur in anyone, but is most common in women who are in their twenties.21 Repeated pres-sure, from this deformity or from ill-fitting footwear, can cause inflammation and swell-ing between the calcaneus and Achilles ten-don, leading to retrocalcaneal bursitis.6,7,21,22 Patients with bursitis have erythema and swelling over the bursa and tenderness to direct palpation.

Treatment of Haglund deformity, with or without bursitis, targets decreasing the pressure and inflammation with open-heeled shoes, anti-inflammatory or analgesic

medications, and corticosteroid injections (ultrasound-guided injections are preferable to avoid disruption of the Achilles tendon). Physical therapy may also help reduce pain. In recalcitrant cases, surgery to remove the Haglund deformity may be necessary.7,22

SEVER DISEASE

Sever disease (calcaneal apophysitis) is the most common etiology of heel pain in chil-dren and adolescents, usually occurring between five and 11 years of age.23 Bones grow quicker than the muscles and tendons in these patients. The tight Achilles tendon begins to pull on its insertion site with repet-itive running or jumping activities, caus-ing microtrauma to the area. There may be swelling and tenderness around the Achilles tendon insertion site, and passive dorsiflex-ion may increase pain. Radiography is usu-ally normal and therefore does not aid in the diagnosis, but may reveal a fragmented or sclerotic calcaneal apophysis.23 Treatment involves decreasing pain-inducing activities, anti-inflammatory or analgesic medication if needed, ice, stretching and strengthening of the gastrocnemius-soleus complex, and some orthotic devices.

Midfoot Heel Pain TENDINOPATHIES

Although less common, other tendinopathies can cause heel pain localized to the insertion site of the affected tendon. Medial heel pain may be triggered by the posterior tibialis, flexor digitorum longus, or flexor hallucis longus tendons.6 Lateral heel pain can origi-nate from the peroneal tendon. Musculo-skeletal ultrasonography of these tendons may aid in the diagnosis.24 Treatment is sim-ilar to that of Achilles tendinopathy.

TARSAL TUNNEL SYNDROME

The tarsal tunnel is a fibro-osseous space formed by the flexor retinaculum, medial calcaneus, posterior talus, and medial mal-leolus.25 Compression of the posterior tibial nerve most commonly occurs as it courses through this tunnel, causing neuropathic pain and numbness in the posteromedial ankle and heel (Figure 2), which may extend

Figure 5. Radiograph of Haglund deformity (arrow).

Heel Pain


into the distal sole and toes.6 Patients often report worsening of pain with standing, walking, or running, and alleviation of pain with rest or loose-fitting footwear. Physi-cal examination may reveal a pes planus deformity, which increases tension of the nerve with weight bearing,6,25 or muscle atrophy in more severe cases.13 Pain can be reproduced by tapping along the course of the nerve (Tinel sign) and with provocative maneuvers to stretch or compress the nerve (dorsiflexion-eversion test, plantar flexion-inversion test).6 Electromyography and nerve conduction studies may be useful to confirm the diagnosis.6,11,13

Treatment is mostly conservative, with activity modification, orthotic devices, neuromodulator medications (tricyclics or antiepileptics), or anti-inflammatory medi-cations. Corticosteroid injections into the tarsal tunnel may also be beneficial. Sur-gery is available if conservative measures are ineffective.13

SINUS TARSI SYNDROME

The sinus tarsi, or talocalcaneal sulcus, is an anatomic space bound by the calcaneus, talus, talocalcaneonavicular joint, and pos-terior facet of the subtalar joint. Pain from this location is usually felt in the lateral cal-caneus and ankle, and is worse immediately following exercise and when walking on an uneven surface.24 It can arise from repeated

lateral ankle sprains or from repeated hyper-pronation of the foot.24 Initial treatment includes managing the underlying causes with orthotics or physical therapy, although anti-inflammatory or analgesic medications and corticosteroid injections (Figure 6) may also be beneficial.

Data Sources: We searched Medline for heel pain and for each etiology discussed in the article, with occasional use of the keywords diagnosis, treatment, and manage-ment. We also searched Essential Evidence Plus, Cochrane Database of Systematic Reviews, and the Clinical Journal of Sports Medicine. Search dates: August and September 2010, February and May 2011.

Figure 6. Corticosteroid injection site in the treatment of sinus tarsi syndrome.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence rating References

Plain radiography is not helpful in diagnosing plantar fasciitis. C 4-8

A thickened heel aponeurosis of greater than 5 mm on ultrasonography is suggestive of plantar fasciitis.

C 4, 5

Bone scans or magnetic resonance imaging is often needed to diagnose a calcaneal stress fracture because plain radiography does not always reveal a fracture.

C 6, 7

Spurring at the Achilles tendon insertion site or intratendinous calcifications on plain radiography indicate Achilles tendinopathy.

C 7

Plain radiographs are usually not helpful in diagnosing Sever disease. C 23

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evi-dence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.

Heel Pain


The Authors

PRISCILLA TU, DO, CAQSM, is a team physician and medi-cal instructor in the Department of Community and Family Medicine at Duke University in Durham, N.C.

JEFFREY R. BYTOMSKI, DO, FAOASM, is head medical team physician and associate professor in the Department of Community and Family Medicine at Duke University.

Address correspondence to Priscilla Tu, DO, Duke Uni-versity, 2100 Erwin Rd., DUMC 3886, Durham, NC 27710 (e-mail: [email protected]). Reprints are not avail-able from the authors.

Author disclosure: No relevant financial affiliations to disclose.

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