CONDITIONS AND TREATMENTS

MEDICAL AND SURGICAL TREATMENT OF HEEL PAIN

Plantar Fasciitis

Plantar fasciitis is by far the most common etiology of heel pain, but it can have several causes and treatment may vary depending on the underlying pathology. The plantar fascia is a thick ligament that essentially runs from the calcaneal tubercles to the metatarsal heads plantarly. It is comprised of three distinct bands, of which only the medial and central bands are involved in plantar fasciitis. We usually see plantar fasciitis develop as a result of chronic strain to the plantar fascial ligament from a hyperpronated foot type. The excessive pronation need not be severe to cause plantar strain. The majority of patients simply strain their plantar fascia with every step they take, and eventually perifascial inflammation develops. Most patients have this strain occurring all their lives without symptoms, until some minor sentinel event occurs which causes the inflammatory cascade to begin. Plantar fasciitis can also be seen in pes cavus, or high arched, foot types. Here, the pathology develops because a pes cavus foot cannot absorb the ground shock of ambulation sufficiently, as this is a function of pronation which is limited in high arch feet. The shock essentially transfers through the proximal arch, causing inflammatory changes to the plantar fascial origin and midsubstance. A less common cause is blunt force trauma to the fascia itself, as seen when stepping on a rock, or even with strain from ladder or repetitive stair climbing.


Treatment is fairly consistent across all causative pathologies for plantar fasciitis. The first goal is to reduce inflammation through a combination therapy of NSAIDs, corticosteroid injections, and stretching/icing, as well as ancillary structural therapy such as night splints when indicated, and even physical therapy. It is absolutely essential that the underlying cause be addressed within this treatment course. For hyperpronators, properly casted (subtalar joint neutral) prescription orthotics are vital to prevent reoccurrence, along with stiffer shoes. For pes cavus patients, increased shock absorption is required, either from a quality OTC insert, or a prescription orthotic. Shock absorbing shoes are also necessary to prevent reoccurrence. In the case of trauma, the causative activity simply needs to be avoided, although prior plantar fascial injury can place the foot at risk for easier development of further fascial pathology.


At times, surgery may be required if conservative treatment fails. In our experience, this is rarely necessary. Dr. Kilberg has well over a 99% conservative success rate for plantar fasciitis. When surgery is indicated, it usually consists of an excision of a wedge of the plantar fascia medially, with scar tissue eventually filling in the defect and thus effectively elongating the fascia to reduce strain. Traditionally, calcaneal spurs are removed at this time as well. The spur is not causative for the heel pain, but its continued presence post-operatively once the wedge is removed near the calcaneal tubercle may provide a source of continued irritation. Another procedure that has gained popularity is the use of radioablation to stimulate tissue healing via internal angiogenesis, as it converts the fascia from a chronic inflammatory state to an acute inflammatory state. This does not require a fasciectomy, and keeps the fascia integrity intact. Other surgeons prefer to use shockwave therapy to stimulate a healing response, which allows for faster recovery but may need to be repeated. Recovery for all procedures includes protected weightbearing, as incision site dehiscence can be problematic.


Neuritis and Tarsal Tunnel Syndrome

Not all heel pain is strictly due to musculoskeletal causes. Nerve entrapment and irritation cause a number of heel pain cases in our practice. Several nerves factor into this clinical picture. The most common neurogenic cause of heel pain is due to entrapment or neuropraxia of the posterior tibial nerve. Tarsal Tunnel Syndrome is a result of either chronic hyperpronation-related strain to the ligamentous structure covering the Tarsal Tunnel, or a space occupying mass. The hyperpronated foot sees excessive medial foot and ankle strain forces, which can result in thickening of the ligamentous structures that cover the posterior tibial nerve as it courses through the Tarsal Tunnel on the way to the plantar foot from the medial ankle. Fibrous thickening and adhesions can irritate the posterior tibial nerve and its distal branches which may split proximal to the Tarsal Tunnel. This effectively causes neuropraxia, and can refer pain to the medial heel or plantar foot. Adjacent posterior tibial vein varicosities can also cause these symptoms if they place pressure on the nerve, and space occupying masses such as cysts and connective tissue tumors can also apply pressure.


The medial calcaneal nerve branch proximal to the Tarsal Tunnel can also become entrapped in the medial heel tissue against any fibrous adhesions, causing medial heel pain.


Treatment for local neurogenic causes of heel pain includes inflammation reduction via NSAIDs, icing, and corticosteroid injections at the focal entrapment site. Support of the ankle and any structural abnormalities such as hyperpronation via braces or prescription orthotics is vital to controlling the underlying etiology. At times, physical therapy or immobilization may be employed to some success. However, a number of these patients will require a decompressive surgery to release or remove the overlying compressive tissue. Generally, this is very successful.

 

Heel Spurs

Calcaneal exostosis formation is a potential cause of heel pain, although the posterior aspect of the heel is the usual site of symptoms rather than plantar. The presence of an inferior calcaneal spur is not causative for heel pain, as the exostosis is nearly always parallel with the weightbearing surface, and simply represents traction-related periostitis and calcification of the plantar fascial origin when the fascia is chronically strained. The plantar fascia is causative for heel pain in these cases, and needs to be treated according. The inferior exostosis itself is simply of radiographic interest, and not clinical concern. That being said, certain conditions like rheumatoid arthritis and the seronegative arthropathies can cause tufting of the plantar calcaneus which faces inferior to the bone, and not parallel to the weightbearing surface. This directly inferior bone deposition can be symptomatic, but its presentation is uncommon. Treatment of the underlying disease and possible spur resection is needed in those cases.


The posterior heel can develop exostosis as a result of traction of the Achilles tendon, which in turn can become symptomatic, especially in conjunction with Achilles tendonitis. Occasionally this retrocalcaneal exostosis can fracture, resulting in significant posterior heel pain. It should be noted, however, that calcific Achilles tendonopathy can mimic a spur fracture if the calcification is close to the calcaneus, resulting in many unnecessary fracture treatments. Treatment for retrocalcaneal exostosis involves inflammation reduction of the overlying soft tissue through NSAIDs, icing, and stretching. Corticosteroid injections are discouraged due to the potential for Achilles tendon rupture. Immobilization and physical therapy are also employed. Often surgery is required to remove the exostosis, and recovery can take 3-5 months if the Achilles tendon requires removal to facilitate spur access.


Another posterior calcaneal abnormality causing pain is the so-called 'pump bump', or Haglund's deformity. This is clinically an enlargement of the posterior superior calcaneus, not an exostosis. Seen often with shoes that exert high posterior heel pressure, this enlargement generally needs resection if shoe modification or Achilles mobilization fails to alleviate pain.

 

Subcalcaneal Bursitis

Under the calcaneus, a small bursal sac is found. Although usually asymptotic, this bursal sac can become inflamed. Often seen with plantar fascitis, the likely biomechanical origin of this inflammation may lie in the valgus rotation of the calcaneus in a hyperpronated foot, in which a medial spine on the undersurface of the calcaneus may rotate more centrally and irritate the bursa. Treatment of this inflammation is concurrent with plantar fascitis treatment. Occasionally, bursitis can be found as the solitary cause of heel pain, and treatment requires specific corticosteroid injection placement into the bursa. Gel heel pads to reduce heel shock are also helpful. Surgical excision is not indicated, and can be problematic.


Lumbar-Mediated Heel Pain

Lumbar herniations and arthropathy are the cause of a number of heel pain cases misdiagnosed as plantar fasciitis. Spinal nerve pathologies can cause referred neuralgia which can mimic local foot pain. The hallmarks of distinguishing a proximal neuritic cause of heel pain from local fasciopathy, or even Tarsal Tunnel syndrome include pain that is present even at rest, with some increase while seated or lying down. The pain is often burning or tingling, and may have a pattern reminiscent of a horseshoe shape around the plantar posterior heel, or vaguely around the plantar heel. Activity may not necessarily worsen the pain. Clinical exam features include a lack of definitive pain or limited pain on exam compared with the patient's subjective complaints, and occasionally a straight leg raise test will be positive or some part of the sensory exam will be deficient. Treatment obviously requires identifying the specific lumbar or sacral pathology. Podiatric care can be supportive, but ultimately ineffective for full pain relief, unless the lumbar irritation is secondary to hyperpronation related leg and back strain. A podiatry consult, however, is advised to ensure no local foot pathologies are concomitant, as numerous causes of heel pain may be present at once.


Less Common Heel Pain Causes

There are a number of less common causes of heel pain which deserve mention. Of course, there is always the possibility that the calcaneus may be fractured, or has sustained a stress fracture. Standard imaging (MRI in the case of an early stress fracture) can rule this out. As mentioned before, arthropathies and autoimmune disease can be an uncommon source of heel pain. Conditions such as rheumatoid arthritis, Reiter's syndrome, ankylosing spondylitis, psoriatic arthritis, sarcoidosis, and Behcet's syndrome may all present with heel pain. Gout and pseudogout may present with heel pain, although this is rare. Inflammatory bowel diseases such as ulcerative colitis and Crohn's also have heel pain components. Very rarely, metabolic diseases such as osteoporosis, hypertrophic osteoarthropathy, renal osteodystrophy, and Paget's disease of bone can present with heel pain. Even less commonly, primary or secondary calcaneal tumors, and tuberculosis infections may be the source of heel pain. It is important to identify the exact etiology of heel pain when it presents in a non-classical manner, or if it is not responding well to conservative or surgical therapy.