HEEL PAIN BY

Dr.Soham Patel D.Y.Patil medical college, Navi Mumbai

INTRODUCTIONThe foot is really unique to human being. The structure of the foot allows

the foot to sustain large weight bearing stresses under a variety of surfaces and activities that maximize stability and mobility.

Pain in the heel may occur from conditions from posterior and plantar

aspect, and from calcaneum, tendoachilles.

Anatomy

The heel fat pad has many fat globules enclosed by multiple fibroelastic septa

Biomechanics• The calcaneum is elevated anteriorly so that during heel

strike, the posterior tubercle contacts the ground 1st and transmits full body weight.

• This make the calcaneum vulnerable to trauma or micro trauma

• Plantar fascia 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.

• , is under constant traction as it is pulled distally around the metatarsal heads (drum of the windlass). This tightening elevates the longitudinal arch, inverts the hind foot and externally rotates the leg. This mechanism is passive and depends entirely on bony and ligamentous instabilty.

Windlass mechanism of the plantar fascia• As the toes are dorsiflexed

plantar fascia is under constant traction as it is pulled distally around the metatarsal heads (drum of the windlass).

• This tightening elevates the longitudinal arch, inverts the hind foot and externally rotates the leg. This mechanism is passive and depends entirely on bony and ligamentous instabilty.

PLANTAR FASCIA

• The plantar fascia is the thick connective tissue which supports the arch on the bottom of the foot

• It runs from the tuberosity of the calcaneus forward to the heads of the metatarsal bones

Body weight120 pounds

Rt. Foot - Talus60 pounds Lt. Foot - Talus

60 pounds

Rt. Calcaneus30 pounds

Heads of 5 Meta tarsals

30 pounds

6 Bearing points4 metatarsals + 2

sesmaoids under halluxEach 5 founds

123

45

6

Causes of heel pain• Plantar fasciitis• Heel pad fat atrophy• Achilles tendinopathy• Traumatic causes• Retrocalcaneal bursitis• tendoachilles bursitis.• Achilles tendinopathy• Abnormal arches of foot.• Tarsal tunnel syndrome.• Calaneal Epiphysitis• Haglund’s deformity• Medial/lateral plantar nerve entrapment• Exostosis of calcaneum.• Xanthoma of achilles tendon.• Obesity• Tumours and cyst(rare)

Plantar fasciitis• Plantar fasciitis is a painful foot condition caused by

inflammation of insertion of the plantar fascia on the medial process of the calcaneal tuberosity.

Aetiology• AGE:Plantar fasciitis is most common between the ages of

40 and 60.• SEX:Women are more likely to develop plantar fasciitis when

compared to men.• CERTAIN TYPES OF EXERCISE: Activities that place a lot of

stress on heel tissue-such as long distance running, ballet dancing and aerobics can contribute to an earlier onset of plantar fascitis.

• FAULTY FOOT MECHANICS:Being flat-footed, having a high arch or even having an abnormal pattern of walking can adversely affect the weight distribution when standing, and walking.

• Mechanical overload of the plantar fascia • Damaged by direct impact or repetitive trauma

• Mechanical overload of the plantar fascia • Damaged by direct impact or repetitive trauma • Common among military personal• Poor arch support in the shoe• Prolonged standing• Over use may cause microtears and inflammation• Obesity

• In case of gastro soles shortness,-there is limited range of dorsi-flexion and these short musculature don’t allow tibia to glide anteriorly.

• This can be compensated by pronation of the subtalar joint.• This pronated foot causes lots of stress over the plantar fascia

during the push of phase of gait. • That will lead to plantar fasciitis.

• Absence of windlass mechanism• During propulsive phase of gait cycle dorsiflexion of the 1stmtp will occur. • That’s winds the plantar fascia around the head of the meta tarsal causing

calcaneal inversion,shortening the truss and lead to subtalar jt supination. • Absence of this mechanism affects the subtalar jt supination that will lead to

plantar fasciitis.

• Tibialis posterior weakness The tibialis posterior eccentrically control pronation during

footflat and midstance phase of gait cycle. • Weakness of this muscle can cause excessive pronation of

the subtalar joint and this can also leads to plantar fasciitis.

• Excessive walking and running on hard surfaces: This increases the strain on the plantar fascia.

• obesity: Being overweight increases the level of stresses applied to the fascia due to the added body weight on the foot, increasing the strain on the plantar fascia.

People having BMI >30 are prone to get plantar fasciitis.

• High arched foot: • A high arched foot lacks the normal joint mobility which reduces the

foot’s ability to absorb shock from the ground, thereby increasing the stresses on the plantar fascia.

• ill-fitting or worn out shoes: • Wearing ill-fitting or worn out shoes may change the foot

biomechanics, causing undue strain on the plantar fascia.

Clinical features• Pain under the heel

• Severe pain & inability to walk in morning after getting from sleep or after sitting for long time and getting up to walk.

• Pain gets better after taking few steps• Worsening of pain after prolonged standing or walking

• Localized tenderness over inferomedial aspects of anterior part of calcaneal tuberosity.

• Passive dorsiflexion of toes accentuates the pain.

• Plantar fasciitis have more tenderness in the plantar fascia when it is stretched and less tenderness when the fascia is relaxed.

INVESTIGATIONS

X-RAYS -An X-ray may be taken to rule out a stress fracture of the calcaneum

• X-rays reveal a calcification of the plantar aponeurosis at the origin on the calcaneus, commonly referred to as a calcaneum spur

• MRI: Show thickening of plantar fascia

• BONE SCAN: It show increase uptake at the calcaneus

plantar aponeurosis as uniform bandlike structure of low signal intensity.

thickening of central component of plantar aponeurosis . Extensive edema infiltrates perifascial soft tissue .

RETROCALCANEAL BURSITIS• Inflammation of bursa between anterior aspect of

tendoachilles and calcaneum.• Midline swelling present at level of shoe counter.• Swelling is tender• Dorsiflexion of foot increases the pain

FAT PAD ATROPHY• Elastic adipose tissue covers the plantar aspect of

calcaneum.• With advancing age it degenerates and get atrophied.• There is loss of shock absorbing capacity.• Pain present beneath the heel in posterior weight-bearing

portion of tuberosity, chiefly on standing.

TARSAL TUNNEL SYNDROME• It occurs due to entrapment of posterior tibial nerve within

tarsal tunnel.• Pain and paraesthesia in the distribution of tibial nerve.• Night pain may be present.• Causes-

• ill fitting footware• Post-traumatic fibrosis• Tendon sheath cyst• Thickened flexor retinaculum

HAGLUND’s DEFORMITY• Abnormal prominence of posterosuperior border of

calcaneus.• It is frequently a bony spur acquired as a result of poorly

fitting shoes or rubbing of counter of shoe.• Seen in Adolescent females, ice skaters, soccer players,

runners• It present as a bump located on postero superior aspect of

heel.

• Increasing heel height or one shoe size and using soft counter shoe relives the pain

CALCANEAL EPIPHYSITIS• It is mild traction injury.• During puberty epiphyseal junction is weak, so prone to calf

muscles pull ended by microscopic fracture separation.• Pain and tenderness is localized at tendoachilles insertion.• Pain aggravated by wearing low heel, pressure of rigid shoe

counter and relieved by resting with knee flexion and foot in equinus.

• Radiography-increased density of epiphysis and fragmentation of epiphysis.

• n

Achilles tendonopathy• It is classified by

• Tendinitis-Inflammation of tendoachilles• Tendinosis-Degenrative process occuring withing tendon itself.

• Tendoachilles is placed under extreme and rapid loading activities like running, basketball playing, soccer.

• Clinical features include gradual onset of pain and swelling 2-3cms proximal to TA insertion.

• Pain increases during running.• Tenderness is present 2-3cms proximal to TA insertion.

Traumatic heel pain• Heel contusion(blunt trauma)• Post traumatic calcaneum fracture.• Calcaneum stress fracture.

Calcaneum stress fracture• Stress fracture occurs after repeatative submaximal loading

of bone.• Causes are

• sudden increase of jogging or running distance.• Running on hard surface• Improper running shoes• Malalignment of lower extremity.• Abnormal arches of foot.

TREATMENT• Non operative-

• Activity modification• Rest• Ice packs.• Footwear modification• Weight reduction• Orthosis• NSAIDs• Corticosteroids.• PRP injections

Rest• Avoid

precipitating activity

• Take few days off jogging prolonged standing/walking.

• Can reduce severity of pain & allow inflammation to lower down.

Ice packs

• Can reduce inflammation and pain

• Usually helpful in acute conditions.

Anti inflammatory medications

• Decreases pain• Reduces

inflammation

FOOTWEAR MODIFICATION• Modified Foot wear can help to reduce pain.• Footwears that provide sock-absorbation and proper arch-

support.• Footwear having soft rubber healpad with concavity

scooped out.• Footwear with heel lift inside relives pain in bursitis,

haglund’s deformity and Achilles tendinitis.• High heel footwear transfer the w999Increasing shoe’s size

relives pain in haglund’s deformity.

Strengthening exercises• Towel curls• Marble pick-ups• Toe taps• Deep tissue Massage

ORTHOSIS

• Night splint is used for patient with symptoms greater than 6 months in duration.

• The desire length of time for wearing the splint is 1 to 3months.

• This splint maintain ankle in neutral position and toes in slight extension.

Shoe inserts

Stretching• Gastrocnemius and soleus

• Plantar fascia stretch

TAPING • Calcaneal taping or low-dye taping used for short-term pain

relief.• Taping does cause re-inforcing medial longitudinal arch and

calcaneal fat pad

Injection Therapy : Local corticosteroid injections can help to reduce inflammation and relieve pain.

ELECTROTHERAPY

Ultrasound therapy

Phonophoresis

Iontophoresis

Contrast bath

Operative treatment• Operative-(indicated in long term unresponsive cases or

when conservative management fails)• Plantar fascia release• Retrocalcaneal bursa excision• Resection of Hugland’s deformity• Drilling of multiple holes in calcaneum• Gastroc lengthening• Tarsal tunnel decompression