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Heel pain in rheumatology outpatients. A review of 100 cases
Letters to the Editor 3 Collins SL, Moore RA, McQuay HJ. The visual analogue pain intensity scale : what is moderate pain in millimetres? Pain 1997 ; 7 : 95-7. S1297319X02003846/COR Joint Bone Spine 2002 ; 69 : 234–5
Heel pain in rheumatology outpatients. A review of 100 cases Selma El Hassani, Mahfoud Filali Sawsen, Niamane Radouane, Najia Hajjaj-Hassouni Rheumatology Department B, El Ayachi Hospital, Salé, Ibn Sina Teaching Hospital, Morocco
Heel pain is a symptom that should prompt a search for a cause. Because the foot, and more specifically the heel, can be affected in many disorders, careful evaluation of heel pain can provide valuable diagnostic orientation. We conducted a 6-month prospective study to determine the prevalence and causes of heel pain among rheumatology outpatients in Morocco. PATIENTS AND METHODS All the study patients underwent a thorough physical evaluation, examination of both feet on a podoscope, and a plain lateral radiograph of the heel to look for a calcaneal spur. A broad-based ill-defined spur suggests inflammation and a well-defined spur mechanical stress. The following data were obtained in all patients: age, sex, body weight, height, body mass index (BMI, body weight in kg divided by height in m2), time pattern of the heel pain, alignment of the foot with special attention to the hindfoot, type of footwear, and occupational risk factors. RESULTS Of the 6367 patients seen at the El Ayachi Hospital rheumatology outpatient clinic during the 6-month study period, 100 (1.3%) had heel pain. Mean age in these 100 patients was 37.48 ± 11.09 years (range, 16–75). There was a slight female predominance (42 males and 58 females, M/F ratio 0.72). The pain was in the posterior heel in 78 patients, the posterolateral heel in 12 patients, and the plantar heel in 10 patients.
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Twenty patients had pain in both heels. The time pattern was inflammatory in six patients and strictly mechanical in 94. Pes cavus was found in 45 cases and pes planus in 23. Varus of the hindfoot was noted in 34 patients and valgus in 20. Among risk factors, standing more than 8 hours a day was noted in 30 patients. Eight patients (80%) were overweight; the BMI was greater than 25 in 75 patients, of whom 58 (77%) were women. Of the 34 patients who wore shoes without a counter, 30 had plantar heel pain. The lateral radiograph was normal in 42 patients but showed a mechanical spur in 49, an inflammatory spur in six, Haglund’s syndrome in four, and reflex sympathetic dystrophy in one. Six patients had spondyloarthropathy, including two in whom the heel pain was the inaugural symptom. One patient had goutrelated Achilles tendinopathy and experienced complete relief from the heel pain under treatment with allopurinol and colchicine. DISCUSSION Heel pain is common in podiatry, yet its prevalence in patients with any form of disease has apparently not been evaluated [1]. We found that 1.3% of rheumatology outpatients attending a hospital-based clinic in Morocco had heel pain. The overwhelming majority of our patients (94%) reported a mechanical time pattern of their heel pain. However, bilateral heel pain with morning stiffness can suggest or inaugurate an inflammatory joint disease: in particular, this combination has been reported to indicate a spondyloarthropathy in 20 to 25% of cases [2, 3]. Our six patients with inflammatory heel pain had pain in both heels and met at least eight of Amor’s criteria for spondyloarthropathy [4]. This proportion is far smaller than expected based on previously published data. Mild to moderate heel pain can be a symptom of metabolic diseases such as gout (one case in our series), chondrocalcinosis, or hypercholesterolemia [5]. Severe refractory heel pain should prompt investigations for severe spondyloarthropathy or a bone abnormality such as a calcaneal stress fracture or a bone infection [6, 7]. Mechanical heel pain results from excessive stress, which is often related in part to misalignment of the foot, a feature found in 64% of our patients. Pes cavus was common. The combination of pes cavus, varus of the hindfoot (34 of our patients), and tightness of the continuous structure formed by the sural fascia, Achilles tendon, and plantar fascia increases
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the forces applied to the plantar fascia. Similarly, pes planus with valgus of the hindfoot (20 patients) stretches the plantar fascia at its attachment to the calcaneus [2, 3]. Overweight promotes or exacerbates heel pain, particularly in patients with abnormal foot alignment. Eight percent of our patients had a BMI greater than 25. Jobs requiring prolonged standing are known to increase the risk of heel pain [8, 9]. We noted that all the patients who wore shoes without counters, particularly the traditional flat Moroccan slippers, had pain at the underside of the heel. Flat footwear may promote collapse of the medial arch, thereby stretching the plantar fascia at its attachment to the calcaneus and causing pain at the underside of the heel. Radiographs readily show the bone lesions responsible for diffuse heel pain and are useful for ruling out trauma-related calcaneal fractures. The lateral radiograph was normal in 40% of our patients. A mechanical spur at the inferior aspect of the calcaneus denotes increased stress on the plantar fascia at this site: the spur is not the cause of the heel pain but merely a consequence of the tissue lesions [3]. REFERENCES 1 Wending D, Kremer P. Les talalgies. JIM 1994 ; 322 : 23-5. 2 Guaydier Souquières G. Talalgies plantaires d’origine mécanique. In: Bouysset M, Ed. Le pied en rhumatologie. Paris: Springer; 1998. p. 275-83. 3 Claustre J. Les talalgies. Rev Prat 1985 ; 35 : 3071-8. 4 Amor B, Dougados M, Mijiyawa M. Critères diagnostiques des spondylarthropathies. Rev Rhum Mal Ostéoartic 1990 ; 57 : 85-9. 5 Gerster JC. Les talalgies en pratique médicale courante. Schweiz Rundschau Med 1977 ; 66 : 1604-9. 6 Gerster JC, Saudan Y, Fallet GH. Talalgia. A review of 30 severe cases. J Rheumatol 1978 ; 5 : 210-6. 7 Gibbon WW, Cassar-Pullicino. Heel pain. Ann Rheum Dis 1994 ; 53 : 344-8. 8 Claustre J. Le pied douloureux. Prat Med 1984 ; 3 : 11-32. 9 Lelièvre J. Talalgies. In: Lelièvre J, Lelièvre JF, Eds. Pathologie du pied. Paris: Masson; année. p. 561-71. S1297319X02003809/COR Joint Bone Spine 2002 ; 69 : 235–6
Multiple enchondromatosis: a case report Karima Benbouazza, Selma El Hassani, Hasnae Hassikou, Najat Guedira, Najia Hajjaj-Hassouni Rheumatology department B, hôpital El Ayachi, CHU Avicenne, Rabat-Salé, Morocco
benign bone tumors / enchondromatosis / Ollier’s disease
Multiple enchondromatosis is a rare disease characterized by multiple skeletal enchondromas. We report a case in a 40-year-old woman admitted in 1998 for a 10-year history of generalized bone pain. Her height was 154 cm and she had limb deformities with increased local warmth. Serum and urinary levels of calcium and phosphate were normal. Plain radiographs disclosed multiple, large defects expanding the cortex of the epiphyses, metaphyses, and diaphyses. The defects were located in the tubular bones of the limbs and hands and contained microcalcifications. A technetium 99m bone scan showed foci of hyperactivity matching the radiographic defects. Histology was typical for enchondromatosis. Symptomatic treatment was given. At last follow-up 3 years later, the clinical and radiographic abnormalities were unchanged. Unusual features in this patient include the nearly symmetric distribution of the lesions to all tubular limb and hand bones and the extension of the defects to the epiphysis, metaphysis, and diaphysis of each affected bone. Lifelong monitoring is imperative in patients with multiple enchondromatosis given the risk of malignant bone lesion transformation and of extraskeletal cancer. To date, only palliative treatment is available. CASE REPORT This 40-year-old woman was admitted to our rheumatology department in December 1998 for a 10-year history of generalized bone pain in the hands, forearms, legs, and feet. She had three children, all delivered by cesarean section because of a tight pelvis. The bone pain was mechanical, moderate, and partly alleviated by analgesics and nonsteroidal anti-inflammatory drugs. There were no constitutional symptoms. Physical findings included short stature (152 cm), moderate pain upon pressure on the bones, deformities of the limbs with a hard swelling expanding the diameter of the lower third of each forearm and hard painful swellings
Heel pain in rheumatology outpatients. A review of 100 cases Selma El Hassani, Mahfoud Filali Sawsen, Niamane Radouane, Najia Hajjaj-Hassouni Rheumatology Department B, El Ayachi Hospital, Salé, Ibn Sina Teaching Hospital, Morocco
Heel pain is a symptom that should prompt a search for a cause. Because the foot, and more specifically the heel, can be affected in many disorders, careful evaluation of heel pain can provide valuable diagnostic orientation. We conducted a 6-month prospective study to determine the prevalence and causes of heel pain among rheumatology outpatients in Morocco. PATIENTS AND METHODS All the study patients underwent a thorough physical evaluation, examination of both feet on a podoscope, and a plain lateral radiograph of the heel to look for a calcaneal spur. A broad-based ill-defined spur suggests inflammation and a well-defined spur mechanical stress. The following data were obtained in all patients: age, sex, body weight, height, body mass index (BMI, body weight in kg divided by height in m2), time pattern of the heel pain, alignment of the foot with special attention to the hindfoot, type of footwear, and occupational risk factors. RESULTS Of the 6367 patients seen at the El Ayachi Hospital rheumatology outpatient clinic during the 6-month study period, 100 (1.3%) had heel pain. Mean age in these 100 patients was 37.48 ± 11.09 years (range, 16–75). There was a slight female predominance (42 males and 58 females, M/F ratio 0.72). The pain was in the posterior heel in 78 patients, the posterolateral heel in 12 patients, and the plantar heel in 10 patients.
235
Twenty patients had pain in both heels. The time pattern was inflammatory in six patients and strictly mechanical in 94. Pes cavus was found in 45 cases and pes planus in 23. Varus of the hindfoot was noted in 34 patients and valgus in 20. Among risk factors, standing more than 8 hours a day was noted in 30 patients. Eight patients (80%) were overweight; the BMI was greater than 25 in 75 patients, of whom 58 (77%) were women. Of the 34 patients who wore shoes without a counter, 30 had plantar heel pain. The lateral radiograph was normal in 42 patients but showed a mechanical spur in 49, an inflammatory spur in six, Haglund’s syndrome in four, and reflex sympathetic dystrophy in one. Six patients had spondyloarthropathy, including two in whom the heel pain was the inaugural symptom. One patient had goutrelated Achilles tendinopathy and experienced complete relief from the heel pain under treatment with allopurinol and colchicine. DISCUSSION Heel pain is common in podiatry, yet its prevalence in patients with any form of disease has apparently not been evaluated [1]. We found that 1.3% of rheumatology outpatients attending a hospital-based clinic in Morocco had heel pain. The overwhelming majority of our patients (94%) reported a mechanical time pattern of their heel pain. However, bilateral heel pain with morning stiffness can suggest or inaugurate an inflammatory joint disease: in particular, this combination has been reported to indicate a spondyloarthropathy in 20 to 25% of cases [2, 3]. Our six patients with inflammatory heel pain had pain in both heels and met at least eight of Amor’s criteria for spondyloarthropathy [4]. This proportion is far smaller than expected based on previously published data. Mild to moderate heel pain can be a symptom of metabolic diseases such as gout (one case in our series), chondrocalcinosis, or hypercholesterolemia [5]. Severe refractory heel pain should prompt investigations for severe spondyloarthropathy or a bone abnormality such as a calcaneal stress fracture or a bone infection [6, 7]. Mechanical heel pain results from excessive stress, which is often related in part to misalignment of the foot, a feature found in 64% of our patients. Pes cavus was common. The combination of pes cavus, varus of the hindfoot (34 of our patients), and tightness of the continuous structure formed by the sural fascia, Achilles tendon, and plantar fascia increases
236
Letters to the Editor
the forces applied to the plantar fascia. Similarly, pes planus with valgus of the hindfoot (20 patients) stretches the plantar fascia at its attachment to the calcaneus [2, 3]. Overweight promotes or exacerbates heel pain, particularly in patients with abnormal foot alignment. Eight percent of our patients had a BMI greater than 25. Jobs requiring prolonged standing are known to increase the risk of heel pain [8, 9]. We noted that all the patients who wore shoes without counters, particularly the traditional flat Moroccan slippers, had pain at the underside of the heel. Flat footwear may promote collapse of the medial arch, thereby stretching the plantar fascia at its attachment to the calcaneus and causing pain at the underside of the heel. Radiographs readily show the bone lesions responsible for diffuse heel pain and are useful for ruling out trauma-related calcaneal fractures. The lateral radiograph was normal in 40% of our patients. A mechanical spur at the inferior aspect of the calcaneus denotes increased stress on the plantar fascia at this site: the spur is not the cause of the heel pain but merely a consequence of the tissue lesions [3]. REFERENCES 1 Wending D, Kremer P. Les talalgies. JIM 1994 ; 322 : 23-5. 2 Guaydier Souquières G. Talalgies plantaires d’origine mécanique. In: Bouysset M, Ed. Le pied en rhumatologie. Paris: Springer; 1998. p. 275-83. 3 Claustre J. Les talalgies. Rev Prat 1985 ; 35 : 3071-8. 4 Amor B, Dougados M, Mijiyawa M. Critères diagnostiques des spondylarthropathies. Rev Rhum Mal Ostéoartic 1990 ; 57 : 85-9. 5 Gerster JC. Les talalgies en pratique médicale courante. Schweiz Rundschau Med 1977 ; 66 : 1604-9. 6 Gerster JC, Saudan Y, Fallet GH. Talalgia. A review of 30 severe cases. J Rheumatol 1978 ; 5 : 210-6. 7 Gibbon WW, Cassar-Pullicino. Heel pain. Ann Rheum Dis 1994 ; 53 : 344-8. 8 Claustre J. Le pied douloureux. Prat Med 1984 ; 3 : 11-32. 9 Lelièvre J. Talalgies. In: Lelièvre J, Lelièvre JF, Eds. Pathologie du pied. Paris: Masson; année. p. 561-71. S1297319X02003809/COR Joint Bone Spine 2002 ; 69 : 235–6
Multiple enchondromatosis: a case report Karima Benbouazza, Selma El Hassani, Hasnae Hassikou, Najat Guedira, Najia Hajjaj-Hassouni Rheumatology department B, hôpital El Ayachi, CHU Avicenne, Rabat-Salé, Morocco
benign bone tumors / enchondromatosis / Ollier’s disease
Multiple enchondromatosis is a rare disease characterized by multiple skeletal enchondromas. We report a case in a 40-year-old woman admitted in 1998 for a 10-year history of generalized bone pain. Her height was 154 cm and she had limb deformities with increased local warmth. Serum and urinary levels of calcium and phosphate were normal. Plain radiographs disclosed multiple, large defects expanding the cortex of the epiphyses, metaphyses, and diaphyses. The defects were located in the tubular bones of the limbs and hands and contained microcalcifications. A technetium 99m bone scan showed foci of hyperactivity matching the radiographic defects. Histology was typical for enchondromatosis. Symptomatic treatment was given. At last follow-up 3 years later, the clinical and radiographic abnormalities were unchanged. Unusual features in this patient include the nearly symmetric distribution of the lesions to all tubular limb and hand bones and the extension of the defects to the epiphysis, metaphysis, and diaphysis of each affected bone. Lifelong monitoring is imperative in patients with multiple enchondromatosis given the risk of malignant bone lesion transformation and of extraskeletal cancer. To date, only palliative treatment is available. CASE REPORT This 40-year-old woman was admitted to our rheumatology department in December 1998 for a 10-year history of generalized bone pain in the hands, forearms, legs, and feet. She had three children, all delivered by cesarean section because of a tight pelvis. The bone pain was mechanical, moderate, and partly alleviated by analgesics and nonsteroidal anti-inflammatory drugs. There were no constitutional symptoms. Physical findings included short stature (152 cm), moderate pain upon pressure on the bones, deformities of the limbs with a hard swelling expanding the diameter of the lower third of each forearm and hard painful swellings