Heel Pain: Why Achilles is the Least Favorite Greek Hero

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Heel Pain Why Achilles is the Least Favorite
Greek Hero

• Eden Wheeler, M.D.
• Rockhill Orthopaedics, P.C.

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Achilles

• In Greek mythology, Achilles was considered to be
  the bravest, handsomest, and swiftest in the army
  of Agamemnon. It is written thathis mother
  dipped the child in theRiver Styx, rendering him
  invulnerable except for the part of his heel by
  which she held himThe Aethiopis tells how
  Achilles wasslain by Paris, whose arrow was
  guided to Achilles heel by Apollo. Homer
  , Iliad

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I. Anatomy
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A. Bony Anatomy of the Foot and Ankle
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B. Common Painful Structures
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C. Plantar Fascia and Components
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II. Generalized Conditions
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A. Rheumatic Arthritis

• Can affect the tarsal and ankle joints as well as
  peritendinous sheaths
• More commonly involves small joints of
  extremities
• Must rule out in young females with
• Bilateral pain
• Morning stiffness
• Primary pain in MTPs
• Lab Rheumatoid factor and ESR
• Usually bilateral

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B. Seronegative Arthropathies

• Clinically will see synovial swelling and
  tendinitis
• More commonly involves Achilles tendon
• Includes
• Ankylosing Spondylitis
• Reiters Syndrome
• Psoriatic Arthritis
• Gout
• Lab HLA-B 27 and Uric acid
• Usually bilateral

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Osteoarthritis
C. Osteoarthritis

• Usually involves subtalar and midfoot joints
• Heel pain is referred
• Mostly seen with trauma
• Chronic / repetitive
• Sequellae of fracture
• Not normally responsive to conservative
  treatments--may result in surgical fusion

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Symptoms

• Clinical
• Painful ROM at subtalar joint with crepitus
• Tenderness over sinus tarsi, anterior to lateral
  malleolus
• Muscle spasm of peroneals
• Pain with weight-bearing
• Relief at rest

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• D. Osteoporosis
• Traumatic fractures of calcaneus
• E. Infection
• Appropriate History of
• Trauma
• Burns
• Puncture wounds
• Diabetes

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Tumor / Malignancy

• F. Tumor / Malignancy
• Suspect with any history of night pain
• Includes
• Multiple Myeloma
• Giant Cell Tumor
• Pigmented Villonodular Synovitis

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III. Congenital Disorders
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A. Clubfoot

• Includes
• Calcaneovarus
• Cacaneovalgus
• Pes cavus
• Some pes planus disorders
• Stiffness common
• Pain associated with activity level
• Treatments
• Modify footwear
• Orthoses to reduce impact force
• Occasionally surgery

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B. Accessory Ossicles

• Os trigonum is present in 10 of the population
• Stiedas process is an elongated lateral wall of
  the FHL groove on the posterior talus
• Between 8 - 11 years, ossification centers occur
  and fuse with the medial lateral tubercles of the
  groove
• Os trigonum is the persistent lateral center
• Impingement occurs of the OT against the
  posterior tibia with extreme PF causing pain
• Can see fractures with longer OT
• Treatment
• Injections
• NSAIDS
• Surgical excision only rarely indicated

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IV. Traumatic and Overuse Syndromes
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A. Severs Disease

• AKA Calcaneal Apophysitis
• Most prevalent in adolescent boys, 8 to 13 years
• Etiology is felt due to acute or chronic strain
  of Achilles tendon on the unfused posterior
  apophysis of the calcaneus
• Cartilaginous apophysis is subject to shearing
  stress of the gastrocnemius due to vertical
  orientation
• Cartilage is weaker, more vulnerable structure
• Contusion can occur with fall or trauma

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symptoms

• Clinical
• Often bilateral
• Pain in posterior heel below Achilles insertion
• Walking can be pain-free with tenderness only to
  palpation
• Increased pain with running or walking on toes
• If swelling, shoewear may be painful
• X-rays
• Fragmentation of apophysis
• Bony condensation of epiphysis

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Treatment / Outcome

• Treatment
• Purely symptom dependent as usually
  self-limiting--dont treat X-ray changes if no
  pain
• Usually have to curtail exacerbating activities
  until symptoms improve
• Shoe lifts (1/4 inch) can lessen stress at tendon
• Can unload unilateral involvement with crutches
• Long-leg casts with KF and equinus foot placement
  can be used in severe cases
• Outcome
• Excellent prognosis without residual disability

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B. Bursitis andRelated Conditions

• Inflammation of the bursas can occur with or
  without bony changes
• Usually affect retrocalcaneal or subcutaneous
  bursae, but any of the following disorders can
  develop new bursae
• Must rule out other conditions
• Achilles tendinits
• Tumor
• Infection

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B. Bursitis andRelated Conditions (2)

• X-ray is helpful to determine bony versus soft
  tissue component
• Very common in women wearing high-heeled shoes
• Treatments
• Modify shoewear to limit heel cup pressure
• Padding at prominence for protection and pressure
  reduction
• Therapy
• Injection
• NSAIDS
• Surgical excision--rare

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Haglunds Deformity

• Haglunds deformity
• Congenital prominence of posterosuperior lateral
  border of calcaneus
• May be acquired bursitis via trauma, however
• Runners
• Figure skaters
• Clinically, large, painful masses are seen at
  site
• AKA Pump Bump or Runners Bump

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Exostosis

• Exostosis
• Bursitis with underlying bony component, usually
  spur
• Spur develops from microtrauma / microavulsions
  at Achilles tendon attachment
• If involving the tendon itself, classified as
• Enthesiopathy
• Can be seen commonly with systemic diseases
• Seronegative spondyloarthropathies
• RA
• Gout
• Osteomalacia

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Osteochondritis dissecans

• Osteochondritis dissecans
• Seen with bone fragment between Achilles tendon
  and calcaneus, usually middle 1/3 of posterior
  border
• Etiology is uncertain
• Can be confused for osteoid osteoma

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C. Fat Pad Syndrome

• Elastic adipose tissue covering the plantar
  calcaneus acts as a shock absorber
• With age, the elasticity is reduced as
  collagenous structures degenerate, leaving an
  unpadded calcaneus bearing whole body weight with
  subsequent pain
• Clinical
• Central heel pad pain increasing with activity
• Barefoot walking very painful, especially first
  weight-bearing upon awakening

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C. Fat Pad Syndrome (2)

• Predisposing factors
• Age
• Obesity
• Poorly cushioned or worn running / walking shoes
• Sudden increase in activity level
• Hard/ uneven terrain
• Recurrent heel trauma
• Running
• Gymnastics
• Single significant contusion with hematoma

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C. Fat Pad Syndrome (3)

• Treatment
• Modify training or activity to decrease trauma
• Appropriate shoewear
• Heel cup for protection and lift effect
• Basket-weaving taping program to maintain heel
  pad height
• NSAIDS
• Therapy with modalities
• Injection with anaesthetic only--steroid use may
  cause further atrophy
• Surgery will most likely result in scarring and
  therefore even less elasticity

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D. Calcaneal Fractures

• Stress fractures
• Seen in more active individuals
• Runners
• Dancers
• Jumpers
• Most common sites upper posterior margin of os
  calcis, followed by area adjacent to medial
  tuberosity
• Hard to identity by mere X-rays, therefore bone
  scan may help with diagnosis
• Treatment
• Cast
• Therapy
• Orthosis

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D. Calcaneal Fractures(2)

• Traumatic fractures
• Usually associated with osteoporotic changes in
  older adults
• Can be seen in excessive heel trauma
• Sky-diving
• Motor sports
• Associated with high morbidity and long-term
  disability from secondary complications
• Impingement of fibula
• Subtalar degenerative changes
• Heel widening
• Heel pad damage
• Clinically, pain at rest with throbbing
• Treatment Difficult

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V. Plantar Fasciitis
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A. Definition

• Inflammation of the plantar fascia and
  perifascial structures, a multilayered fibrous
  aponeurosis
• Can occur when the fascia assumes a greater share
  of force than it can physiologically accommodate

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B. Functionally

• In heel strike, the fascia relaxes with the toes
  in neutral position, allowing the arch to
  collapse
• In toe off, toe extension causes the fascia to
  shorten, reforming the arch and resulting in the
  windlass effect---a more rigid foot for
  powerful propulsion

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C. Clinical

• Insidious onset
• Pain and tenderness in anterior heel (distal to
  medial calcaneal tubercle)
• Unilateral with first AM weight-bearing pain, or
  recurrence following prolonged sitting
• Can progress and radiate to arch as well as more
  persistence, occurring at rest
• Decreased ROM of 1st MTP may be seen

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C. Clinical(2)

• If limping occurs, will have pain involving other
  areas of leg
• Increased pain with
• PROM of DF
• Hopping on toes

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D. Diagnostic Studies

• Must rule out systemic diseases
• ESR
• Rheumatoid factor
• HLA B-27
• Uric acid
• Electrodiagnostics to rule out
• Tarsal tunnel syndrome
• Lumbar radiculopathy

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E. X-rays

• Spurs may be present in up to 75 of symptomatic
  patients on involved limb with 63 in
  uninvolved side
• However, also have been reported at incidence of
  10 to 30 in asymptomatic population
• Bone scans will have increased uptake in the
  aponeurosis or calcaneus in up to 60
• Bone spurs can contribute to but usually not the
  cause of pain
• Soft tissue swelling

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F. Predisposing Factors

• Possible
• Leg length discrepancy
• Subtalar pronation
• Congenital pes planus with hypermobility
• High arch in foot
• Cavus foot
• External rotation of the lower extremity

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F. Predisposing Factors(2)

• Probable
• Age over 40 years
• Poorly constructed and excessively worn shoewear
• Tight Achilles tendon
• Decreased ROM of great toe
• Degree of PF in running cadence
• Training duration/type
• Over 30 miles per week running more susceptible

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G. Treatments

• Acute Rupture / Fasciitis
• Protected weight-bearing via short-leg walking
  cast to allow healing
• Therapy and modalities for pain control, maintain
  ROM of fascia and MTP of great toe
• NSAIDS
• Cortisone injections cautiously
• Taping via modified low dye method to be
  completed with foot in neutral
• Activity modification to nonweight-bearing
• Supported Achilles stretches

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Achilles Stretching Principles

• Achilles Stretching Principles
• Warm up part to be stretched
• Provide support to foot and arch (via slant
  board) to isolate stretch
• Hold stretch 1 minute, progressing to 3 to 5
  minutes
• Use active rest periods--PF and DF while tendon
  is at rest
• Build up to 3 sets per session with last stretch
  incorporating cool down
• Perform 2 times daily

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Chronic Fasciitis

• Chronic Fasciitis
• Casting can still be quite beneficial for pain
  reduction via rest and continuous stretch
• NSAIDS in combination with mechanical
  interventions
• Injections at area of maximal tenderness
• Therapy modalities and exercise/stretch
• Night splints
• Activity modification
• Limit running/walking distances by 25-75
• Substitute water jogging or cycling
• Surgery in recalcitrant cases over 1 year
• Release of medial half of aponeurosis

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Customized Orthotics

• Customized Orthotics
• Provide support for longitudinal arch
• Broaden area of plantar contact and
  weight-bearing
• Pressure relief at areas of pain
• Contain the heel pad to increase shock absorption
• Maintains subtalar joint in neutral position

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VI. Tendinopathies
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A. Achilles Tendon Rupture

• Most often seen in men aged 40 to 50 years with
  sedentary habits with sudden increased activity
  level or minor trauma
• Mechanics
• Tendon can function normally with only 25 of
  fibers intact
• Biopsies reveal pre-existing microtrauma or
  microtears 2 to 6 cm above insertion site
• Can see with
• Uncontrolled ankle DF with stable subtalar joint
• Extra stretch to already fully stretched tendon
• Direct trauma with tendon stretched

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A. Achilles Tendon Rupture(2)

• Clinical
• Visible defect in tendon
• Inability to perform single leg heel raises
• Swelling and contusion around malleoli
• Positive Thompson test
• Failure of PF with passive compression of gastroc
• Excessive passive DF
• Distortion of Kagers triangle
• Seen on lateral view on X-ray
• Composed of
• Posterior surfaces of tibia and long flexors
• Achilles tendon
• Superior border of calcaneus
• Extreme pain in calf interfering with walking

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A. Achilles Tendon Rupture(3)

• Treatment
• Conservative cast
• Minimum of 6 weeks
• Complications
• Recurrent rupture in 10 to 25 , but decreases
  with longer period of immobilization (up to 12
  weeks )
• Overelongation of the tendon
• Surgical
• Consider in the more active person or athlete
• Complications
• Deep infection 1
• Superficial infection 2
• Skin necrosis 2
• Recurrent rupture 2
• Followed by casting 6 weeks
• Either will require therapy program after cast

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B. Achilles Tendinitis

• Inflammation of the tendon and its sheath may
  occur with athletic injuries as well as everyday
  activities
• Clinical
• Insidious onset of progression of pain and
  stiffness
• May start as stiffness only following running
• Painful resisted single toe raises
• Gastroc and soleus tightness on exam
• May have tendon defects if partial rupture
• Tenderness localized to tendon only

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B. Achilles Tendinitis(2)

• Diagnostic testing
• X-rays to evaluate soft tissue versus bony
  components or changes
• MRI or CT more helpful in recalcitrant cases for
  partial tears, cystic changes or early
  calcification
• US also helpful for ruptures, necrosis or thinning

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B. Achilles Tendinitis(3)

• Predisposing factors
• Stiff-soled shoe / inappropriate shoewear
• Sudden change in activity / exercise
• Intensity
• Duration
• Incline
• Impact
• Chronic Achilles tendon contracture
• Pronated foot

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B. Achilles Tendinitis(4)

• Treatment
• Activity modification during acute (up to 3
  weeks) with progression on symptom resolution
• Casting
• Taping of calf / foot into equinus position
• Modalities /stretches
• NSAIDS
• Progression to eccentric loading with recovery
• Heel lift more helpful in acute over chronic
• Orthosis for hindfoot control/ limit pronation
• Appropriate shoewear
• Injections with anaesthetic
• Surgery in recalcitrant cases only

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C. Flexor HallucisLongus Tendinitis

• FHL lies medial to Achilles tendon in groove
  between talar tubercles
• Flexes the great toe for smooth toe-off
• Tenderness and pain will be in medial tendon on
  resisted toe flexion
• Most common in
• Ballet dancers
• Runners
• High jumpers

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D. Tibialis Posterior Tendinitis

• TP lies posterior to medial malleolus and is
  palpable at its insertion site onto to navicular
  tuberosity
• Primary function of inversion and adduction of
  foot
• Difficult to isolate, but tendon is more
  prominent with PF and inversion
• Commonly seen with joggers

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E. Peroneal Tendinitis

• Includes peroneus longus and brevis
• These are the first 2 tendons posterior to
  lateral malleolus
• Primary functions are foot eversion with lesser
  abduction
• Usually associated with recurrent inversion
  strains/sprains
• Less common diagnosis, but can be seen in figure
  skaters

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VII. Nerve Entrapment Disorders
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A. Abductor Digiti Quinti Compression

• Originates from calcaneus, passes through the
  plantar fascia and inserts onto the lateral
  proximal phalanx of the small toe
• Function is abduction of the small toe
• Chronic compression can cause plantar pain
• Treatment and diagnosis is local injection with
  small toe abduction paralysis and pain resolution

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B. Tarsal Tunnel Syndrome

• Involves compression of the posterior tibial
  nerve as it passes posterior to the medial
  malleolus through the tarsal tunnel
• Tarsal tunnel
• FDL and FHL
• Posterior artery and veins
• Flexor retinaculum
• Tibia
• Pain radiates from posterior medial malleolus to
  medial heel

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B. Tarsal Tunnel Syndrome(2)

• Diagnosis
• Clinical history of pain in nerve distribution
• EMG changes
• Positive Tinnels
• Treatment
• NSAIDS
• Activity modification in active persons
• Modalities and therapy
• Injection
• Surgical release of the retinaculum