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Inferior heel pain
FOOT AND ANKLE
Inferior heel pain
This review focuses solely on inferior heel pain, and therefore will not discuss insertional Achilles tendinopathy, which usually presents as posterior heel pain. The commonest conditions encountered are (Figure 1): plantar fasciitis and related pathologies tarsal tunnel syndrome and entrapment neuropathies stress fractures and other bone pathologies.
Barry Rose Dishan Singh
Abstract Inferior heel pain affects up to 10% of the population. There are multiple pathologies and these can be considered by the anatomical structure affected (i.e. bone, nerve, ligamentous and other soft tissues). The most common pathology is in ligamentous and soft tissue. The plantar fascia may be degenerate (fasciosis), torn or enthesopathic, or there may be peri-fascial oedema. Soft tissue conditions include heel pad bruising and atrophy and tumours. Neurological causes are probably the next most common and include tarsal tunnel syndrome, nerve to abductor digiti quinti neuropathy, medial calcaneal neuropathy and lumbo-sacral radiculopathy. Bony pathologies include calcaneal stress fracture, calcaneal bone marrow oedema, tumours and osteomyelitis. The presenting features of each of these conditions are discussed, followed by the treatment options. The multitude of modalities used to treat plantar fascia-related pain are discussed in greater detail. The management of inferior heel pain involves a careful history and clinical examination. Not all heel pain is simply related to the plantar fascia. Without considering the other potential sources of pathology for which treatments may be markedly different, the clinician may easily unwittingly discount these. It is therefore incumbent to be clinically prudent, having a logical approach to assessment and diagnosis, prior to embarking on an appropriate course of treatment.
Plantar fasciitis The plantar fascia originates from the plantar tuberosity of the calcaneus, fanning out into medial, central and lateral bands before inserting into the bases of the phalanges. It is also intrinsically connected to the gastro-soleus complex. It acts by the windlass mechanism to help maintain the medial longitudinal arch. Dividing the entire plantar fascia may therefore lead to a flatfoot deformity. Heel spurs are present in up to 25% of the population. It is a misconception that heel spurs signify plantar fascia pathology. The plantar fascia does not attach to a heel spur, but rather it attaches to the calcaneum running superficial to any spur. A heel spur, if present, will usually have the flexor digitorum brevis attached to it. Pathology of the plantar fascia may be secondary to excessive load being passed through the fascia, or excessive stretching of the fascia. Increased load may be the result of obesity, prolonged standing, or a fit individual undertaking excessive activity. This results in micro-tears within the plantar fascia that do not heal, as the primary cause continues to be provocative either in the form of increased load or continued excessive activity. The pathophysiology may be exacerbated by a tight gastro-soleus complex, which has been reported in 83% of individuals presenting with pathology of the plantar fascia.2,3 This limits ankle dorsiflexion, contributing to greater forefoot loading which places increased strain on the plantar fascia as a result of the windlass mechanism. As a result the ankle adopts a protective equinus position, further compounding the tight gastro-soleus. The mean age of presentation of plantar fascia pathology is in the sixth decade. It occurs more commonly in females.2 Obesity is common, and strongly predicts the degree of disability experienced. Pain is characteristically focussed to the medial aspect of the inferior heel. The pain is classically worst with the first step in the morning (commonly called ‘start-up’ pain) because the plantar fascia and Achilles tendon tighten whilst asleep with the foot in an equinus position. The pain improves throughout the day, but may worsen again at the end of the day or after rigorous exercise. Pain often recedes overnight. The pain may radiate around the heel or down the path of the plantar fascia. Patients localize the pain to the medial calcaneal tubercle and into the proximal plantar fascia. This is worse on direct palpation, and is exacerbated by the Jack test to dorsiflex the hallux, thus tightening the plantar fascia via the windlass mechanism. Tightness of the gastro-soleus complex should be identified by assessing dorsiflexion at the ankle, commonly performed using €ld’s test. In some cases, the plantar fascia may be Silfverskio tender in the instep rather than the inferior heel. Classically, the diagnosis is based on history-taking and examination. Plain radiographs are unhelpful. With improved
Keywords entrapment neuropathy; heel; osteomyelitis foot; plantar fasciitis; stress fracture
Introduction Inferior heel pain is a common complaint and can be debilitating. Heel pain in general is estimated to affect 10% of the population.1 In many cases patients’ symptoms are simply attributed to ‘plantar fasciitis’, which is the commonest pathology seen but is only one of a wide number of potential diagnoses for inferior heel pain. A wider understanding of these will enable the clinician to evaluate patients on an individual basis, investigate them accordingly and make an informed diagnosis. Getting the right diagnosis then allows effective treatment and makes the best use of resources.
Barry Rose FRCS Tr & Orth, Consultant Orthopaedic Surgeon, Eastbourne Hospital NHS Trust, UK. Conflicts of interest: none declared. Dishan Singh FRCS Tr & Orth, Consultant Orthopaedic Surgeon, Royal National Orthopaedic Hospital NHS Trust, Stanmore, UK. Conflicts of interest: none declared.
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Please cite this article as: Rose B, Singh D, Inferior heel pain, Orthopaedics and Trauma, https://doi.org/10.1016/j.mporth.2019.11.002
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Figure 1 The differential diagnosis of inferior heel pain.
injected deep to the fascia, and may be guided by ultrasound to ensure accurate placement There is a small risk of plantar fascia rupture, fat pad atrophy or infection, especially with repeated injections.16 As a result of this, many clinicians do not use injections as first-line therapy. The risks may be reduced with the use of ultrasound. Extracorporeal shockwave therapy (ESWT) may produce improvement in some patients, by converting a chronic condition to an acute condition with the renewed presence of pro-inflammatory factors facilitating healing. The energy used may be high or low. High energy typically involves one treatment under general anaesthesia. Low-energy treatment is tolerable awake, usually over several weeks. The evidence is conflicting, with some studies showing a benefit, and others not so.17e19 Other techniques have been tried, with little supporting evidence: protein rich plasma, dry needling, prolotherapy, low-dose radiotherapy, Botox injections, whole blood injections.20 More than 90% of cases of plantar fascia pathology will heal with non-operative measures. One paper quotes a surgical rate of 3%.5 Surgery should be delayed until at least 12e18 months following onset of symptoms, and should only be considered if all non-operative measures have failed. In overweight individuals, weight loss should be achieved prior to considering surgery. Surgery generally involves a medial approach, although arthroscopic release is increasing in popularity.21 Most would advocate releasing only the medial half of the fascia to prevent arch collapse or lateral column overload.5,22 Other potential complications include nerve injury, persistent pain and chronic regional pain syndrome. Releasing the first branch of the lateral plantar nerve may be undertaken concurrently, with evidence that this combined approach achieves acceptable results. One study reports a good improvement in pain scores, but approximately half of patients still had ongoing symptoms.23 There is no good evidence that resecting a heel spur improves the results. Postoperatively patients may mobilize as tolerated to prevent stiffness.
diagnostics such as MRI, conditions related to the plantar fascia may be more definitively diagnosed including plantar fasciosis (thickening of the fascia is seen from a mean of 3 mm to a mean of 7 mm), peri-fascial oedema, calcaneal bone marrow oedema and a plantar fascia tear. There is strong evidence that conditions of the plantar fascia are self-limiting, resolving over a period of up to 18 months in 95% of individuals.4,5 Patents treated early will tend to be improved by 6 weeks.6 Patients should receive an information sheet describing the condition, and offering simple advice regarding obesity, footwear and analgesia. Treatment may consist of several different modalities depending on the underlying diagnosis. The optimal treatment algorithm however is still unknown. Ice and oral antiinflammatory medication may provide some symptomatic relief, but no good evidence exists to quantify the benefit. Gastro-soleus stretching exercises (Figure 2) are critical, with a success rate of 72%, and should be the first-line treatment in almost all cases.7,8 Different regimes are described, which are mostly equally successful.9 The addition of plantar fascia stretching exercises improves outcomes in the first 8 weeks, but by 2 years the outcomes are the same.10 Heel cushions may reduce the stretch on the Achilles tendon, and support the foot, as will the use of cushioned shoes. Prefabricated or custom orthoses are occasionally used as there is an unproven commonly-held belief that there is a relationship between plantar fascia pathology and over-pronation. The evidence is equivocal, especially in the longer-term. Night splints are used to prevent the ankle adopting an equinus position overnight, thus preventing tightness of the plantar fascia upon waking and pain with the first step. When added to standard multi-modal treatment, greater improvement may occur.11 This may lead to 80% improvement in chronic cases at 4 months.12 However there are studies suggesting the contrary. Patients prefer an anterior rather than posterior splint.13,14 Splints are generally however poorly tolerated. Steroid injections give 95% improvement initially, but less than half retain a long-term benefit.15 The steroid should be
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Please cite this article as: Rose B, Singh D, Inferior heel pain, Orthopaedics and Trauma, https://doi.org/10.1016/j.mporth.2019.11.002
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Figure 2 Gastro-soleus stretching exercises.
A further surgical approach addresses the tight gastro-soleus complex (Figure 3). This may be lengthened at various levels within the musculo-tendinous unit. Most proximally, the medial head of the gastrocnemius may be released using a small transverse incision just distal to the popliteal fossa.23 This may provide a better outcome than the traditional plantar fascia release.24 The gastro-soleus complex may also be lengthened in the midcalf, using a Strayer or Vulpius release. Good results have been reported for the former.25 Distally, surgery at the level of the Achilles tendon may be utilised, either percutaneously (Hoke triple cut procedure) or open, but this comes with the attendant risk of reducing the power of the musculo-tendinous unit.
Enthesopathy Certain medical conditions may predispose to enthesopathy, such as ankylosing spondylitis, psoriatic arthritis, reactive arthritis and Reiter’s syndrome. A careful history will aid in the diagnosis. Patients may exhibit symptoms or signs of other inflamed joints or tendinosis. Enthesopathy should certainly be considered in bilateral cases. A careful systemic review may identify ophthalmic, dermatological or genitourinary symptoms. Blood tests for inflammatory markers and a rheumatology screen may prove helpful. Management is best undertaken by a rheumatologist and onward referral should be made.
Tarsal tunnel and other nerve conditions Plantar fasciosis This is best treated with a multi-modal approach, employing gastro-soleus stretching, plantar fascia stretching, oral analgesia, a heel cushion and a night splint. Custom orthoses may be useful in over-pronators to attain a neutral position. Steroid injections may be considered if these measures fail, but some would suggest that they are best avoided for simple fasciosis without evidence of inflammation. In recalcitrant cases, ESWT may be used. Rarely is surgery necessary.
Heel pain described as tingling, electric shocks or rest pain should alert the clinician to a potential neurological cause. Typically the nerve supply to the heel originates from terminal branches of the tibial nerve. Examination may reveal a positive Tinel’s test or altered sensation. Tarsal tunnel syndrome The tibial nerve passes posterior to the medial malleolus under the flexor retinaculum, which forms the roof of the tarsal tunnel. The tunnel also contains the tendons of tibialis posterior, flexor digitorum longus and flexor hallucis longus, as well as the posterior tibial artery. The nerve divides into the medial and lateral plantar nerves within the tunnel in the majority of cases, which enter the foot deep to abductor hallucis. Within the tunnel the nerve may become entrapped, producing symptoms related to it’s sensory distribution. The syndrome may be secondary to systemic conditions such as diabetes or other causes of neuropathy. Alternatively, local factors may be causative, with space-occupying lesions such as a ganglion, most commonly compressing the nerve. Other local predisposing factors may include trauma (e.g. calcaneal fractures) or hindfoot deformity (e.g. extreme hindfoot valgus). Classically patients may describe a burning pain or numbness in the sole of the foot or inferior heel. The symptoms may be specifically located within the distribution of the whole nerve or either of its medial or lateral plantar divisions. There may be a history of non-specific or vague pain on the sole of the foot or heel. A positive Tinel’s test directly over the nerve is present in many cases. Objective sensory deficit may be identified. However, the history and examination is notoriously variable and
Plantar fascia tear This is normally an acute event, with sudden onset of pain, often following sporting activity. There may be associated bruising and swelling, and an inability to toe-off, run or possibly even stand. Tears (Figure 4) may be secondary to injection. Radiographs may show a reduced calcaneal pitch. The diagnosis can be confirmed on ultrasound or MRI. The treatment for a plantar fascia tear is different to that of fasciosis, whereby patents are best rested by immobilization in a plaster cast until symptoms subside, followed by a period of time in a stiff-soled boot or shoe. This may take up to 6 weeks. Ice, elevation and anti-inflammatory medication should be utilised. There is no role for steroid injection. Peri-fascial oedema In the majority of cases, fascial thickening is seen on MRI but no significant oedema. When an MRI reveals florid peri-fascial oedema, the inflammatory process may be reduced by means of oral non-steroidal anti-inflammatory medication and/or an ultrasound-guided steroid injection above the fascia. This should be followed by a period of rest.
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Figure 3 Gastro-soleus lengthening procedures. MHGC, medial head of gastrocnemius.
unpredictable and may only give partial symptomatic relief.26 Recurrence of symptoms is a significant concern.
often underwhelming, often making diagnosis difficult. Frequently, tarsal tunnel syndrome is considered a diagnosis of exclusion. Nerve conduction studies may provide assistance in confirming the diagnosis. MRI or ultrasound should be performed to identify any space-occupying lesion. Non-operative measures, including neuropathic analgesic agents, orthoses and injections may prove helpful, but there is no clear evidence to support this. Failure to improve is an indication for surgical intervention, particularly if a surgical target is identified, such as a space-occupying lesion that can be excised. In cases without a lesion, the nerve is decompressed within the tarsal tunnel, as are the two plantar nerves as they exit deep to abductor hallucis, where the fascia may be the cause of compression. Results of surgery are highly variable,
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Nerve to abductor digiti quinti neuropathy Baxter popularized the concept that inferior heel pain may be due to compression of the nerve to abductor digiti quinti, the first branch of the lateral plantar nerve, itself a division of the tibial nerve distal to the medal malleolus. The nerve may become entrapped between the two heads of the abductor digiti quinti muscle. Patients present clinically with infero-lateral heel pain. Nerve conduction studies may be unrewarding. It is often a diagnosis of exclusion and may be over-diagnosed. Non-operative measures such as orthotics and injections should be tried initially. Failure of conservative measures may sometimes
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or changing activity to a lower impact exercise. If relevant, new softer shoe-wear may be needed. Any underlying cause identified should be addressed. A return to normal activities and increasing exercise regime should then be gradually undertaken. Calcaneal bone marrow oedema Oedema at the site of insertion of the plantar aponeurosis may be seen in the absence of fracture or enthesopathy. The cause may be unclear, or may relate to minor repetitive trauma. This is often characterized by night pain and is identified on MRI. Management is rest and cushioning orthotics although there is some limited evidence for the use of extracorporeal shockwave therapy in this situation.28 Bone tumour Tumours whilst rare in the calcaneus, must be included in the differential, especially in patients with red flag symptoms such as unremitting night pain, unexplained weight loss and general malaise. An MRI is critical if a bone tumour is being considered. Benign pathologies seen in the calcaneus include unicameral bone cyst, aneurysmal bone cyst, enchondroma, osteoid osteoma, osteoblastoma, fibrous dysplasia and intraosseous lipoma. Malignant pathologies include chondrosarcoma, Ewing’s sarcoma, osteosarcoma and secondary metastases. If identified, onward referral to a specialist bone tumour unit is recommended.
Figure 4 MRI of plantar fascia tear.
indicate the need for surgical decompression. Good results for this have been reported, especially in combination with partial release of the medial plantar fascia.22 Medial calcaneal neuropathy The medial calcaneal branch has variable anatomy, but generally originates within the tarsal tunnel. Rarely, entrapment may result in altered sensation on the medial side of the heel. One study has shown a high association between medial calcaneal neuropathy and plantar fasciosis.27 Treatment should be expectant initially. Intractable cases can be explored surgically to either release the nerve, or perform neurotomy, burying the proximal stump.
Osteomyelitis Infection should be included in the differential diagnosis of all pain potentially originating in bone. Patients may have risk factors, both systemic (e.g. diabetes) or local (e.g. trauma). A careful history may give clues. Investigations include blood inflammatory markers, plain radiographs, bone scan and MRI. It is critical to obtain a tissue diagnosis to institute appropriate focused antibiotic therapy. This may take the form of an imageguided biopsy or open surgical debridement prior to the commencement of antibiotics. Multiple samples (at least five) should be sent to improve the accuracy of diagnosis and treatment. Microbiological advice should be sought on the basis of the cultures and sensitivities to plan an antibiotic regime. This may involve intravenous medication for many weeks, necessitating the placement of central venous access. Failed conservative management of chronic calcaneal osteomyelitis can be addressed surgically by sub-total or total calcanectomy, which have a variable outcome, or below knee amputation.
Lumbar radiculopathy S1 radiculopathy may present with inferior heel pain. Upon formal neurological examination, patients may also show reduced sensation in the heel, reduced power in plantar flexion and hyporeflexia at the heel (although the latter two are supplied by S1 and S2, and this may appear unaffected clinically). A Sciatic stretch test may also be positive. If the diagnosis is suspected, a lumbar spine MRI should be arranged.
Bony calcaneal pathologies Stress fractures Stress fractures of the calcaneus present with pain whilst walking or running as opposed to the typical pain associated with the first step in the morning classically attributed to pain originating from the plantar fascia. The pain diminishes at rest. Risk factors include osteopenia, osteoporosis and vitamin D deficiency. They are typically the result of a repetitive activity or overuse. Patients may have recently increased their activity levels, or changed their exercise shoe-wear. The onset of pain is acute. On examination, the pain is reproducible by medio-lateral compression of the calcaneus (squeeze test, Figure 5). Plain radiographs may show a line perpendicular to the trabeculae (Figure 6). The diagnosis can be confirmed on MRI if plain radiographs are unremarkable. If indicated blood tests should be taken to exclude pathological fracture. Treatment involves rest for 6e8 weeks with possible immobilisation depending on symptoms. It is important to adapt the individual’s regular activity, such as by running on softer ground
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Miscellaneous conditions Heel bruise and atrophy The heel fat pad is a highly specialized structure that is tightly bound to the calcaneus by mooring ligaments. Loss of the cushioning will cause the fat pad to spread. The pain is usually centrally located, and may not be characterized by morning pain. Treatment is usually with heel cups that will contain the fat pad in situ. The usual regime of stretching exercises may not be helpful in this situation. Repeated steroid injections into the fat pad may lead to fat pad atrophy, and are therefore contraindicated.
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the other potential sources of pathology for which treatments may be markedly different, the clinician may easily unwittingly discount these. It is therefore incumbent to be clinically prudent, having a logical approach to assessment and diagnosis, prior to embarking on an appropriate course of treatment. A REFERENCES 1 DeMaio M, Paine R, Manguine RE, et al. Plantar fasciitis. Orthopaedics 1993; 16: 1153e63. 2 Riddle DL, Pulisic M, Pidcoe P, Johnson RE. Risk factors for Plantar fasciitis: a matched case-control study. J Bone Joint Surg Am 2003; 85-A: 872e7. 3 Patel A, DiGiovanni B. Association between plantar fasciitis and isolated contracture of the gastrocnemius. Foot Ankle Int 2011; 32: 5e8. 4 Wolgin M, Cook C, Graham C, Mauldin D. Conservative treatment of plantar heel pain: long-term followup. Foot Ankle Int 1994; 15: 97e102. 5 Sammarco GJ, Helfrey RB. Surgical treatment of recalcitrant plantar fasciitis. Foot Ankle Int 1996; 17: 520e6. 6 Singh D, Angel J, Bentley G, Trevino SG. Plantar fasciitis. Br Med J 1997; 315: 172e5. 7 Snook GA, Chrisman OD. The management of subcalcaneal pain. Clin Orthop Relat Res 1972; 82: 163e8. 8 Radford JA, Burns J, Buchbinder R, Landorf KB, Cook C. Does stretching increase ankle dorsiflexion range of motion? A systematic review. Br J Sports Med 2006; 40: 870e5. 9 Porter D, Barrill E, Oneacre K, May BD. The effects of duration and frequency of Achilles tendon stretching on dorsiflexion and outcome in painful heel syndrome: a randomised, blinded, control study. Foot Ankle Int 2002; 23: 619e24. 10 Digiovanni BF, Nawoczenski DA, Malay DP, et al. Plantar fasciaspecific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up. J Bone Joint Surg Am 2006; 88: 1775e81. 11 Sheridan L, Lopez A, Perez A, John MM, Willis FB, Shanmugam R. Plantar fasciopathy treated with dynamic splinting: a randomized controlled trial. J Am Podiatr Med Assoc 2010; 100: 161e5. 12 Powell M, Post WR, Keener J, Wearden S. Effective treatment of chronic plantar fasciitis with dorsiflexion night splints: a crossover prospective randomized outcome study. Foot Ankle Int 1998; 19: 10e8. 13 Attard J, Singh D. A comparison of two night ankle-foot orthoses used in the treatment of inferior heel pain: a preliminary investigation. Foot Ankle Surg 2012; 18: 108e10. 14 Bordelon RL. Subcalcaneal pain. A method of evaluation and plan for treatment. Clin Orthop Relat Res 1983; 177: 49e53. 15 Crawford F, Atkins D, Young P. Steroid injection for heel pain: evidence of short-term effectiveness. A randomized controlled trial. Rheumatology 1999; 38: 974e7. 16 Acevedo JI, Beskin JL. Complications of plantar fascia rupture associated with corticosteroid injection. Foot Ankle Int 1998; 19: 91e7. 17 Ogden JA, Alvarez RG, Marlow M. Shockwave therapy for chronic proximal plantar fasciitis: a meta-analysis. Foot Ankle Int 2012; 23: 301e8. 18 Buchbinder R, Ptasznik R, Gordon J, et al. Ultrasound-guided extracorporeal shock wave therapy for plantar fasciitis: a randomized controlled trial. J Am Med Assoc 2002; 288: 1364e72.
Figure 5 The heel squeeze test.
Figure 6 Stress fracture of the os calcis.
Soft tissue tumours As with bone, soft tissue tumours, both benign and malignant, should be considered. They may be diagnosed on ultrasound or MRI. Any suspicious lesions should be referred on to a specialist tumour unit for ongoing investigation and treatment.
Conclusion The management of inferior heel pain involves a careful history and clinical examination. Not all heel pain is simply related to the plantar fascia, and even that which is may not simply be ‘fasciitis’, which in itself is an erroneous term. Without considering
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19 Rompe JD, Schoellner C, Nafe B. Evaluation of low-energy extracorporeal shock-wave application for treatment of chronic plantar fasciitis. J Bone Joint Surg 2002; 84: 335e41. 20 Lee TG, Ahmad TS. Intralesional autologous blood injection compared to corticosteroid injection for treatment of chronic plantar fasciitis. A prospective, randomized, controlled trial. Foot Ankle Int 2007; 28: 984e90. 21 Bazaz R, Ferkel RD. Results of endoscopic plantar fascia release. Foot Ankle Int 2007; 28: 549e56. 22 Davies MS, Weiss GA, Saxby TS. Plantar fasciitis: how successful is surgical intervention. Foot Ankle Int 1999; 20: 803e7. 23 Abbassian A, Kohls-Gatzoulis J, Solan MC. Proximal medial gastrocnemius release in the treatment of recalcitrant plantar fasciitis. Foot Ankle Int 2012; 33: 14e9.
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24 Monteagudo M, Maceira E, Garcia-Virto V, Canosa R. Chronic plantar fasciitis: plantar fasciotomy versus gastrocnemius recession. Int Orthop 2013; 37: 1845e50. 25 Maskill JD, Bohay DR, Anderson JG. Gastrocnemius recession to treat isolated foot pain. Foot Ankle Int 2010; 31: 19e23. 26 Pfeiffer W, Cracchiolo 3rd A. Clinical Results after tarsal tunnel decompression. J Bone Joint Surg Am 1994; 76: 1222e30. 27 Chang CW, Wang YC, Hou WH, Lee XX, Chang KF. Medial calcaneal neuropathy is associated with plantar fasciitis. Clin Neurophysiol 2007; 118: 119e23. 28 Maier M, Steinborn M, Schmitz C, et al. Extracorporeal shock wave application for chronic plantar fasciitis associated with heel spurs: prediction of outcome by magnetic resonance imaging. J Rheumatol 2000; 27: 2455e62.
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Inferior heel pain
This review focuses solely on inferior heel pain, and therefore will not discuss insertional Achilles tendinopathy, which usually presents as posterior heel pain. The commonest conditions encountered are (Figure 1): plantar fasciitis and related pathologies tarsal tunnel syndrome and entrapment neuropathies stress fractures and other bone pathologies.
Barry Rose Dishan Singh
Abstract Inferior heel pain affects up to 10% of the population. There are multiple pathologies and these can be considered by the anatomical structure affected (i.e. bone, nerve, ligamentous and other soft tissues). The most common pathology is in ligamentous and soft tissue. The plantar fascia may be degenerate (fasciosis), torn or enthesopathic, or there may be peri-fascial oedema. Soft tissue conditions include heel pad bruising and atrophy and tumours. Neurological causes are probably the next most common and include tarsal tunnel syndrome, nerve to abductor digiti quinti neuropathy, medial calcaneal neuropathy and lumbo-sacral radiculopathy. Bony pathologies include calcaneal stress fracture, calcaneal bone marrow oedema, tumours and osteomyelitis. The presenting features of each of these conditions are discussed, followed by the treatment options. The multitude of modalities used to treat plantar fascia-related pain are discussed in greater detail. The management of inferior heel pain involves a careful history and clinical examination. Not all heel pain is simply related to the plantar fascia. Without considering the other potential sources of pathology for which treatments may be markedly different, the clinician may easily unwittingly discount these. It is therefore incumbent to be clinically prudent, having a logical approach to assessment and diagnosis, prior to embarking on an appropriate course of treatment.
Plantar fasciitis The plantar fascia originates from the plantar tuberosity of the calcaneus, fanning out into medial, central and lateral bands before inserting into the bases of the phalanges. It is also intrinsically connected to the gastro-soleus complex. It acts by the windlass mechanism to help maintain the medial longitudinal arch. Dividing the entire plantar fascia may therefore lead to a flatfoot deformity. Heel spurs are present in up to 25% of the population. It is a misconception that heel spurs signify plantar fascia pathology. The plantar fascia does not attach to a heel spur, but rather it attaches to the calcaneum running superficial to any spur. A heel spur, if present, will usually have the flexor digitorum brevis attached to it. Pathology of the plantar fascia may be secondary to excessive load being passed through the fascia, or excessive stretching of the fascia. Increased load may be the result of obesity, prolonged standing, or a fit individual undertaking excessive activity. This results in micro-tears within the plantar fascia that do not heal, as the primary cause continues to be provocative either in the form of increased load or continued excessive activity. The pathophysiology may be exacerbated by a tight gastro-soleus complex, which has been reported in 83% of individuals presenting with pathology of the plantar fascia.2,3 This limits ankle dorsiflexion, contributing to greater forefoot loading which places increased strain on the plantar fascia as a result of the windlass mechanism. As a result the ankle adopts a protective equinus position, further compounding the tight gastro-soleus. The mean age of presentation of plantar fascia pathology is in the sixth decade. It occurs more commonly in females.2 Obesity is common, and strongly predicts the degree of disability experienced. Pain is characteristically focussed to the medial aspect of the inferior heel. The pain is classically worst with the first step in the morning (commonly called ‘start-up’ pain) because the plantar fascia and Achilles tendon tighten whilst asleep with the foot in an equinus position. The pain improves throughout the day, but may worsen again at the end of the day or after rigorous exercise. Pain often recedes overnight. The pain may radiate around the heel or down the path of the plantar fascia. Patients localize the pain to the medial calcaneal tubercle and into the proximal plantar fascia. This is worse on direct palpation, and is exacerbated by the Jack test to dorsiflex the hallux, thus tightening the plantar fascia via the windlass mechanism. Tightness of the gastro-soleus complex should be identified by assessing dorsiflexion at the ankle, commonly performed using €ld’s test. In some cases, the plantar fascia may be Silfverskio tender in the instep rather than the inferior heel. Classically, the diagnosis is based on history-taking and examination. Plain radiographs are unhelpful. With improved
Keywords entrapment neuropathy; heel; osteomyelitis foot; plantar fasciitis; stress fracture
Introduction Inferior heel pain is a common complaint and can be debilitating. Heel pain in general is estimated to affect 10% of the population.1 In many cases patients’ symptoms are simply attributed to ‘plantar fasciitis’, which is the commonest pathology seen but is only one of a wide number of potential diagnoses for inferior heel pain. A wider understanding of these will enable the clinician to evaluate patients on an individual basis, investigate them accordingly and make an informed diagnosis. Getting the right diagnosis then allows effective treatment and makes the best use of resources.
Barry Rose FRCS Tr & Orth, Consultant Orthopaedic Surgeon, Eastbourne Hospital NHS Trust, UK. Conflicts of interest: none declared. Dishan Singh FRCS Tr & Orth, Consultant Orthopaedic Surgeon, Royal National Orthopaedic Hospital NHS Trust, Stanmore, UK. Conflicts of interest: none declared.
ORTHOPAEDICS AND TRAUMA xxx:xxx
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Ó 2019 Published by Elsevier Ltd.
Please cite this article as: Rose B, Singh D, Inferior heel pain, Orthopaedics and Trauma, https://doi.org/10.1016/j.mporth.2019.11.002
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Figure 1 The differential diagnosis of inferior heel pain.
injected deep to the fascia, and may be guided by ultrasound to ensure accurate placement There is a small risk of plantar fascia rupture, fat pad atrophy or infection, especially with repeated injections.16 As a result of this, many clinicians do not use injections as first-line therapy. The risks may be reduced with the use of ultrasound. Extracorporeal shockwave therapy (ESWT) may produce improvement in some patients, by converting a chronic condition to an acute condition with the renewed presence of pro-inflammatory factors facilitating healing. The energy used may be high or low. High energy typically involves one treatment under general anaesthesia. Low-energy treatment is tolerable awake, usually over several weeks. The evidence is conflicting, with some studies showing a benefit, and others not so.17e19 Other techniques have been tried, with little supporting evidence: protein rich plasma, dry needling, prolotherapy, low-dose radiotherapy, Botox injections, whole blood injections.20 More than 90% of cases of plantar fascia pathology will heal with non-operative measures. One paper quotes a surgical rate of 3%.5 Surgery should be delayed until at least 12e18 months following onset of symptoms, and should only be considered if all non-operative measures have failed. In overweight individuals, weight loss should be achieved prior to considering surgery. Surgery generally involves a medial approach, although arthroscopic release is increasing in popularity.21 Most would advocate releasing only the medial half of the fascia to prevent arch collapse or lateral column overload.5,22 Other potential complications include nerve injury, persistent pain and chronic regional pain syndrome. Releasing the first branch of the lateral plantar nerve may be undertaken concurrently, with evidence that this combined approach achieves acceptable results. One study reports a good improvement in pain scores, but approximately half of patients still had ongoing symptoms.23 There is no good evidence that resecting a heel spur improves the results. Postoperatively patients may mobilize as tolerated to prevent stiffness.
diagnostics such as MRI, conditions related to the plantar fascia may be more definitively diagnosed including plantar fasciosis (thickening of the fascia is seen from a mean of 3 mm to a mean of 7 mm), peri-fascial oedema, calcaneal bone marrow oedema and a plantar fascia tear. There is strong evidence that conditions of the plantar fascia are self-limiting, resolving over a period of up to 18 months in 95% of individuals.4,5 Patents treated early will tend to be improved by 6 weeks.6 Patients should receive an information sheet describing the condition, and offering simple advice regarding obesity, footwear and analgesia. Treatment may consist of several different modalities depending on the underlying diagnosis. The optimal treatment algorithm however is still unknown. Ice and oral antiinflammatory medication may provide some symptomatic relief, but no good evidence exists to quantify the benefit. Gastro-soleus stretching exercises (Figure 2) are critical, with a success rate of 72%, and should be the first-line treatment in almost all cases.7,8 Different regimes are described, which are mostly equally successful.9 The addition of plantar fascia stretching exercises improves outcomes in the first 8 weeks, but by 2 years the outcomes are the same.10 Heel cushions may reduce the stretch on the Achilles tendon, and support the foot, as will the use of cushioned shoes. Prefabricated or custom orthoses are occasionally used as there is an unproven commonly-held belief that there is a relationship between plantar fascia pathology and over-pronation. The evidence is equivocal, especially in the longer-term. Night splints are used to prevent the ankle adopting an equinus position overnight, thus preventing tightness of the plantar fascia upon waking and pain with the first step. When added to standard multi-modal treatment, greater improvement may occur.11 This may lead to 80% improvement in chronic cases at 4 months.12 However there are studies suggesting the contrary. Patients prefer an anterior rather than posterior splint.13,14 Splints are generally however poorly tolerated. Steroid injections give 95% improvement initially, but less than half retain a long-term benefit.15 The steroid should be
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Figure 2 Gastro-soleus stretching exercises.
A further surgical approach addresses the tight gastro-soleus complex (Figure 3). This may be lengthened at various levels within the musculo-tendinous unit. Most proximally, the medial head of the gastrocnemius may be released using a small transverse incision just distal to the popliteal fossa.23 This may provide a better outcome than the traditional plantar fascia release.24 The gastro-soleus complex may also be lengthened in the midcalf, using a Strayer or Vulpius release. Good results have been reported for the former.25 Distally, surgery at the level of the Achilles tendon may be utilised, either percutaneously (Hoke triple cut procedure) or open, but this comes with the attendant risk of reducing the power of the musculo-tendinous unit.
Enthesopathy Certain medical conditions may predispose to enthesopathy, such as ankylosing spondylitis, psoriatic arthritis, reactive arthritis and Reiter’s syndrome. A careful history will aid in the diagnosis. Patients may exhibit symptoms or signs of other inflamed joints or tendinosis. Enthesopathy should certainly be considered in bilateral cases. A careful systemic review may identify ophthalmic, dermatological or genitourinary symptoms. Blood tests for inflammatory markers and a rheumatology screen may prove helpful. Management is best undertaken by a rheumatologist and onward referral should be made.
Tarsal tunnel and other nerve conditions Plantar fasciosis This is best treated with a multi-modal approach, employing gastro-soleus stretching, plantar fascia stretching, oral analgesia, a heel cushion and a night splint. Custom orthoses may be useful in over-pronators to attain a neutral position. Steroid injections may be considered if these measures fail, but some would suggest that they are best avoided for simple fasciosis without evidence of inflammation. In recalcitrant cases, ESWT may be used. Rarely is surgery necessary.
Heel pain described as tingling, electric shocks or rest pain should alert the clinician to a potential neurological cause. Typically the nerve supply to the heel originates from terminal branches of the tibial nerve. Examination may reveal a positive Tinel’s test or altered sensation. Tarsal tunnel syndrome The tibial nerve passes posterior to the medial malleolus under the flexor retinaculum, which forms the roof of the tarsal tunnel. The tunnel also contains the tendons of tibialis posterior, flexor digitorum longus and flexor hallucis longus, as well as the posterior tibial artery. The nerve divides into the medial and lateral plantar nerves within the tunnel in the majority of cases, which enter the foot deep to abductor hallucis. Within the tunnel the nerve may become entrapped, producing symptoms related to it’s sensory distribution. The syndrome may be secondary to systemic conditions such as diabetes or other causes of neuropathy. Alternatively, local factors may be causative, with space-occupying lesions such as a ganglion, most commonly compressing the nerve. Other local predisposing factors may include trauma (e.g. calcaneal fractures) or hindfoot deformity (e.g. extreme hindfoot valgus). Classically patients may describe a burning pain or numbness in the sole of the foot or inferior heel. The symptoms may be specifically located within the distribution of the whole nerve or either of its medial or lateral plantar divisions. There may be a history of non-specific or vague pain on the sole of the foot or heel. A positive Tinel’s test directly over the nerve is present in many cases. Objective sensory deficit may be identified. However, the history and examination is notoriously variable and
Plantar fascia tear This is normally an acute event, with sudden onset of pain, often following sporting activity. There may be associated bruising and swelling, and an inability to toe-off, run or possibly even stand. Tears (Figure 4) may be secondary to injection. Radiographs may show a reduced calcaneal pitch. The diagnosis can be confirmed on ultrasound or MRI. The treatment for a plantar fascia tear is different to that of fasciosis, whereby patents are best rested by immobilization in a plaster cast until symptoms subside, followed by a period of time in a stiff-soled boot or shoe. This may take up to 6 weeks. Ice, elevation and anti-inflammatory medication should be utilised. There is no role for steroid injection. Peri-fascial oedema In the majority of cases, fascial thickening is seen on MRI but no significant oedema. When an MRI reveals florid peri-fascial oedema, the inflammatory process may be reduced by means of oral non-steroidal anti-inflammatory medication and/or an ultrasound-guided steroid injection above the fascia. This should be followed by a period of rest.
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Figure 3 Gastro-soleus lengthening procedures. MHGC, medial head of gastrocnemius.
unpredictable and may only give partial symptomatic relief.26 Recurrence of symptoms is a significant concern.
often underwhelming, often making diagnosis difficult. Frequently, tarsal tunnel syndrome is considered a diagnosis of exclusion. Nerve conduction studies may provide assistance in confirming the diagnosis. MRI or ultrasound should be performed to identify any space-occupying lesion. Non-operative measures, including neuropathic analgesic agents, orthoses and injections may prove helpful, but there is no clear evidence to support this. Failure to improve is an indication for surgical intervention, particularly if a surgical target is identified, such as a space-occupying lesion that can be excised. In cases without a lesion, the nerve is decompressed within the tarsal tunnel, as are the two plantar nerves as they exit deep to abductor hallucis, where the fascia may be the cause of compression. Results of surgery are highly variable,
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Nerve to abductor digiti quinti neuropathy Baxter popularized the concept that inferior heel pain may be due to compression of the nerve to abductor digiti quinti, the first branch of the lateral plantar nerve, itself a division of the tibial nerve distal to the medal malleolus. The nerve may become entrapped between the two heads of the abductor digiti quinti muscle. Patients present clinically with infero-lateral heel pain. Nerve conduction studies may be unrewarding. It is often a diagnosis of exclusion and may be over-diagnosed. Non-operative measures such as orthotics and injections should be tried initially. Failure of conservative measures may sometimes
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or changing activity to a lower impact exercise. If relevant, new softer shoe-wear may be needed. Any underlying cause identified should be addressed. A return to normal activities and increasing exercise regime should then be gradually undertaken. Calcaneal bone marrow oedema Oedema at the site of insertion of the plantar aponeurosis may be seen in the absence of fracture or enthesopathy. The cause may be unclear, or may relate to minor repetitive trauma. This is often characterized by night pain and is identified on MRI. Management is rest and cushioning orthotics although there is some limited evidence for the use of extracorporeal shockwave therapy in this situation.28 Bone tumour Tumours whilst rare in the calcaneus, must be included in the differential, especially in patients with red flag symptoms such as unremitting night pain, unexplained weight loss and general malaise. An MRI is critical if a bone tumour is being considered. Benign pathologies seen in the calcaneus include unicameral bone cyst, aneurysmal bone cyst, enchondroma, osteoid osteoma, osteoblastoma, fibrous dysplasia and intraosseous lipoma. Malignant pathologies include chondrosarcoma, Ewing’s sarcoma, osteosarcoma and secondary metastases. If identified, onward referral to a specialist bone tumour unit is recommended.
Figure 4 MRI of plantar fascia tear.
indicate the need for surgical decompression. Good results for this have been reported, especially in combination with partial release of the medial plantar fascia.22 Medial calcaneal neuropathy The medial calcaneal branch has variable anatomy, but generally originates within the tarsal tunnel. Rarely, entrapment may result in altered sensation on the medial side of the heel. One study has shown a high association between medial calcaneal neuropathy and plantar fasciosis.27 Treatment should be expectant initially. Intractable cases can be explored surgically to either release the nerve, or perform neurotomy, burying the proximal stump.
Osteomyelitis Infection should be included in the differential diagnosis of all pain potentially originating in bone. Patients may have risk factors, both systemic (e.g. diabetes) or local (e.g. trauma). A careful history may give clues. Investigations include blood inflammatory markers, plain radiographs, bone scan and MRI. It is critical to obtain a tissue diagnosis to institute appropriate focused antibiotic therapy. This may take the form of an imageguided biopsy or open surgical debridement prior to the commencement of antibiotics. Multiple samples (at least five) should be sent to improve the accuracy of diagnosis and treatment. Microbiological advice should be sought on the basis of the cultures and sensitivities to plan an antibiotic regime. This may involve intravenous medication for many weeks, necessitating the placement of central venous access. Failed conservative management of chronic calcaneal osteomyelitis can be addressed surgically by sub-total or total calcanectomy, which have a variable outcome, or below knee amputation.
Lumbar radiculopathy S1 radiculopathy may present with inferior heel pain. Upon formal neurological examination, patients may also show reduced sensation in the heel, reduced power in plantar flexion and hyporeflexia at the heel (although the latter two are supplied by S1 and S2, and this may appear unaffected clinically). A Sciatic stretch test may also be positive. If the diagnosis is suspected, a lumbar spine MRI should be arranged.
Bony calcaneal pathologies Stress fractures Stress fractures of the calcaneus present with pain whilst walking or running as opposed to the typical pain associated with the first step in the morning classically attributed to pain originating from the plantar fascia. The pain diminishes at rest. Risk factors include osteopenia, osteoporosis and vitamin D deficiency. They are typically the result of a repetitive activity or overuse. Patients may have recently increased their activity levels, or changed their exercise shoe-wear. The onset of pain is acute. On examination, the pain is reproducible by medio-lateral compression of the calcaneus (squeeze test, Figure 5). Plain radiographs may show a line perpendicular to the trabeculae (Figure 6). The diagnosis can be confirmed on MRI if plain radiographs are unremarkable. If indicated blood tests should be taken to exclude pathological fracture. Treatment involves rest for 6e8 weeks with possible immobilisation depending on symptoms. It is important to adapt the individual’s regular activity, such as by running on softer ground
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Miscellaneous conditions Heel bruise and atrophy The heel fat pad is a highly specialized structure that is tightly bound to the calcaneus by mooring ligaments. Loss of the cushioning will cause the fat pad to spread. The pain is usually centrally located, and may not be characterized by morning pain. Treatment is usually with heel cups that will contain the fat pad in situ. The usual regime of stretching exercises may not be helpful in this situation. Repeated steroid injections into the fat pad may lead to fat pad atrophy, and are therefore contraindicated.
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the other potential sources of pathology for which treatments may be markedly different, the clinician may easily unwittingly discount these. It is therefore incumbent to be clinically prudent, having a logical approach to assessment and diagnosis, prior to embarking on an appropriate course of treatment. A REFERENCES 1 DeMaio M, Paine R, Manguine RE, et al. Plantar fasciitis. Orthopaedics 1993; 16: 1153e63. 2 Riddle DL, Pulisic M, Pidcoe P, Johnson RE. Risk factors for Plantar fasciitis: a matched case-control study. J Bone Joint Surg Am 2003; 85-A: 872e7. 3 Patel A, DiGiovanni B. Association between plantar fasciitis and isolated contracture of the gastrocnemius. Foot Ankle Int 2011; 32: 5e8. 4 Wolgin M, Cook C, Graham C, Mauldin D. Conservative treatment of plantar heel pain: long-term followup. Foot Ankle Int 1994; 15: 97e102. 5 Sammarco GJ, Helfrey RB. Surgical treatment of recalcitrant plantar fasciitis. Foot Ankle Int 1996; 17: 520e6. 6 Singh D, Angel J, Bentley G, Trevino SG. Plantar fasciitis. Br Med J 1997; 315: 172e5. 7 Snook GA, Chrisman OD. The management of subcalcaneal pain. Clin Orthop Relat Res 1972; 82: 163e8. 8 Radford JA, Burns J, Buchbinder R, Landorf KB, Cook C. Does stretching increase ankle dorsiflexion range of motion? A systematic review. Br J Sports Med 2006; 40: 870e5. 9 Porter D, Barrill E, Oneacre K, May BD. The effects of duration and frequency of Achilles tendon stretching on dorsiflexion and outcome in painful heel syndrome: a randomised, blinded, control study. Foot Ankle Int 2002; 23: 619e24. 10 Digiovanni BF, Nawoczenski DA, Malay DP, et al. Plantar fasciaspecific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up. J Bone Joint Surg Am 2006; 88: 1775e81. 11 Sheridan L, Lopez A, Perez A, John MM, Willis FB, Shanmugam R. Plantar fasciopathy treated with dynamic splinting: a randomized controlled trial. J Am Podiatr Med Assoc 2010; 100: 161e5. 12 Powell M, Post WR, Keener J, Wearden S. Effective treatment of chronic plantar fasciitis with dorsiflexion night splints: a crossover prospective randomized outcome study. Foot Ankle Int 1998; 19: 10e8. 13 Attard J, Singh D. A comparison of two night ankle-foot orthoses used in the treatment of inferior heel pain: a preliminary investigation. Foot Ankle Surg 2012; 18: 108e10. 14 Bordelon RL. Subcalcaneal pain. A method of evaluation and plan for treatment. Clin Orthop Relat Res 1983; 177: 49e53. 15 Crawford F, Atkins D, Young P. Steroid injection for heel pain: evidence of short-term effectiveness. A randomized controlled trial. Rheumatology 1999; 38: 974e7. 16 Acevedo JI, Beskin JL. Complications of plantar fascia rupture associated with corticosteroid injection. Foot Ankle Int 1998; 19: 91e7. 17 Ogden JA, Alvarez RG, Marlow M. Shockwave therapy for chronic proximal plantar fasciitis: a meta-analysis. Foot Ankle Int 2012; 23: 301e8. 18 Buchbinder R, Ptasznik R, Gordon J, et al. Ultrasound-guided extracorporeal shock wave therapy for plantar fasciitis: a randomized controlled trial. J Am Med Assoc 2002; 288: 1364e72.
Figure 5 The heel squeeze test.
Figure 6 Stress fracture of the os calcis.
Soft tissue tumours As with bone, soft tissue tumours, both benign and malignant, should be considered. They may be diagnosed on ultrasound or MRI. Any suspicious lesions should be referred on to a specialist tumour unit for ongoing investigation and treatment.
Conclusion The management of inferior heel pain involves a careful history and clinical examination. Not all heel pain is simply related to the plantar fascia, and even that which is may not simply be ‘fasciitis’, which in itself is an erroneous term. Without considering
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19 Rompe JD, Schoellner C, Nafe B. Evaluation of low-energy extracorporeal shock-wave application for treatment of chronic plantar fasciitis. J Bone Joint Surg 2002; 84: 335e41. 20 Lee TG, Ahmad TS. Intralesional autologous blood injection compared to corticosteroid injection for treatment of chronic plantar fasciitis. A prospective, randomized, controlled trial. Foot Ankle Int 2007; 28: 984e90. 21 Bazaz R, Ferkel RD. Results of endoscopic plantar fascia release. Foot Ankle Int 2007; 28: 549e56. 22 Davies MS, Weiss GA, Saxby TS. Plantar fasciitis: how successful is surgical intervention. Foot Ankle Int 1999; 20: 803e7. 23 Abbassian A, Kohls-Gatzoulis J, Solan MC. Proximal medial gastrocnemius release in the treatment of recalcitrant plantar fasciitis. Foot Ankle Int 2012; 33: 14e9.
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24 Monteagudo M, Maceira E, Garcia-Virto V, Canosa R. Chronic plantar fasciitis: plantar fasciotomy versus gastrocnemius recession. Int Orthop 2013; 37: 1845e50. 25 Maskill JD, Bohay DR, Anderson JG. Gastrocnemius recession to treat isolated foot pain. Foot Ankle Int 2010; 31: 19e23. 26 Pfeiffer W, Cracchiolo 3rd A. Clinical Results after tarsal tunnel decompression. J Bone Joint Surg Am 1994; 76: 1222e30. 27 Chang CW, Wang YC, Hou WH, Lee XX, Chang KF. Medial calcaneal neuropathy is associated with plantar fasciitis. Clin Neurophysiol 2007; 118: 119e23. 28 Maier M, Steinborn M, Schmitz C, et al. Extracorporeal shock wave application for chronic plantar fasciitis associated with heel spurs: prediction of outcome by magnetic resonance imaging. J Rheumatol 2000; 27: 2455e62.
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