heel pain

aetiology

Children

· Sever’s disease

Adolescents

· Haglund’s deformity

Young adults

· Achilles peritendinitis

· retrocalcaneal bursitis

Older adults

· plantar fasciitis

Other causes in children

· tarsal coalition

· juvenile rheumatoid arthritis

Other causes in adults

· tibialis posterior dysfunction

· peroneal tendon dysfunction

· tarsal tunnel syndrome

· rheumatoid arthritis

· ankylosing spondylitis

· Reiter’s diesease

· osteoarthritis

Generalised causes

· trauma

· calcaneal fracture

· stress fracture

· contusion/strain

· tumours

· osteoid osteoma

· osteochondroma

· bone cyst

· Ewing’s tumour

· metastasis

· infection

· soft tissue

· calcaneal osteomyelitis

Sever’s disease

definition

· calcaneal apophysitis

epidemiology

· young boys

· peak age 10

· bilateral in 60%

aetiology

· overuse injury of calcaneal apophysis

· repeated microtrauma

clinical features

History

· heel pain on actvity

· worse if barefoot

Examination

· no redness or swelling

· tenderness on sides of tendon insertion

· restricted ankle dorsiflexion

Radiology

· controversial whether normal

· increased fragmentation and density of apophysis

· may be the same on the other side

· primarily performed to exclude other conditions

treatment

· restriction of activities for 1-3 months

· heel cord stretching and dorsiflexion exercises

· heel cups and insoles

· short leg cast for 4 weeks if symptoms severe

· usually resolves by 10 weeks

Plantar fasciitis

definition

· pain at attachment of thickened central part of plantar aponeurosis and intrinsic muscles to medial calcaneal tuberosity

Epidemiology

· usually middle-aged male

· age 40-70

· M:F = 2:1

· usually unilateral

· predisposing factors

· obesity

· certain occupations (ie. policeman’s heel)

aetiology

· usually idiopathic

· may be associated with

· Reiter’s disease

· ankylosing spondylitis

· gout

Pathogenesis

Degenerative

· repetitive stress at attachment

· leads to microscopic tears and cystic degeneration

· may be periosteal reaction with spur formation

Entrapment

· nerve entrapment syndrome involving branch to AbDM

· branch of lateral plantar nerve

· compression occurs at

· sharp edge of AbH

· medial ridge of calcaneus

· beneath tuberosity where FDB originates

clinical

Symptoms

· pain at inferomedial aspect of heel

· worse when first rising from bed

· worse with prolonged standing

Signs

· local tenderness at inferomedial aspect of calcaneal tuberosity

X-ray

· may be calcaneal spur (50%)

treatment

Nonoperative

· moulded insole with arch support and heel cup

· ultrasound or laser therapy

· NSAIDs

· steroid injection

Operative

Indication

· failure of nonoperative treatment for 6 months

· occurs in 1 in 15-20 patients

Procedure

Release of plantar fascia

· 5 cm linear incision along origin of plantar fascia

· deep dissection plantar to AbH

· 2-3 cm plantar fascia released from origin medially

· heel spur removed

Neurolysis

· transverse incision across heel from medial edge

· lateral and medial plantar nerves identified and released

· plantar fascia released and heel spur removed

· FDB origin released

· branch of lateral plantar nerve to AbDM identified and released