Dr. Ebraheim’s educational animated video describes different causes of heel pain.
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Heel pain is an extremely common complaint with several common causes.
1. Plantar fasciitis (the most common cause)
2. Baxters nerve compression (a rare cause)
3. Fat pad atrophy
4. Achilles tendonitis
5. Haglund’s deformity
6. Stress fractures of the calcaneus
7. Tarsal tunnel syndrome
8. Lumbosacral spine radiculopathy
So it is difficult to determine the source of the pain and this makes diagnosis difficult or confusing. The most common cause is plantar fasciitis. Plantar fasciitis is irritation and swelling of the thick tissue on the bottom of the foot. This fascia can become inflamed and painful, making walking more difficult. Plantar fasciitis is most severe in the morning. The start up pain symptoms is more severe for the first out and persist with activity through the day. Pain symptoms will intensify with prolonged exercise or standing. There will be tenderness over the plantar medial heel with negative Tinel’s sign. X-ray may show a plantar heel spur. Plantar fasciitis is usually associated with a tight heel cord.
The Baxters nerve. It is the first branch of the lateral plantar nerve. The Baxters nerve contributes to 20% of all heel pain cases in this nerve provides motor innervation to the abductor digiti minimi muscle. The nerve courses vertically between the abductor hallucis and the quadratus plantae muscles, then makes a 90 degree horizontal turn, coursing laterally beneath the calcaneus to innervate the abductor digiti minimi muscle. Involvement of the Baxters nerve may affect running athletes causing pain on the medial plantar aspect of the foot. Entrapment of the Baxters nerve is usually overlooked or misdiagnosed.
Fat pad atrophy. The fat pad cushions the calcaneus and in the condition of fat pad atrophy, the fact that cushions the calcaneus is thinned so the calcaneus loses its cushion. This condition is common in elderly people and can cause significant pain while walking. There is always a history of steroid injections. The injections are commonly used to treat plantar fasciitis and they can cause this heel pad atrophy. Patient will have pain when walking. The pain is deep, central, nonradiating plantar heel pain that is worsened when the patient is barefoot and resolves when the patient walks on her toes, with tenderness at the central aspect of the heel pad.
Achilles tendonitis
The patient will have ankle pain for several months (chronic condition).
The patient will complain of pain and swelling because the tendon is thickened with tenderness to palpation about the top of the calcaneus.
Haglund’s deformity
The Haglund’s deformity is an insertional calcification and exostosis at the insertion of the Achilles tendon. The patient is usually treated by physical therapy and noninflammatory medication. Do not injection through the tendon, rather inject around the tendon. If the symptoms persist beyond 6 months, then surgery may be needed with excision of the Haglund’s exostosis and insertional calcification. If more than 50% of the Achilles tendon is detached to remove the posterosuperior calcaneus prominence, and the tendon becomes weak and should be secured to the bone of the calcaneus with suture anchors or tendon transfer to bridge the gap. The operation will be an Achilles tendon debridement, calcaneal exostectomy and FHL tendon transfer, especially if the tendon degeneration is greater than 50% of the width.
Stress fracture of the calcaneus
The stress fractures of the calcaneus can occur due to overuse injuries. The patient will complain of heel pain, severe weightbearing pain in the patient increases with walking and running. The pain associated with the calcaneal stress fracture does not improve throughout the day and each step is painful. The pain is more with medial to lateral compression of the calcaneal tuberosity.
Compression tests or squeeze test
X-ray can be normal. We may need to get an MRI to diagnose the stress fracture of the calcaneus.
Tarsal tunnel syndrome
Paresthesia and numbness in the plantar foot. Symptoms are worse with activity and the paresthesia may wake the patient up at night.
Ganglion cyst of the ankle (tarsal tunnel syndrome). – Known cause of tarsal tunnel syndrome. Check the MRI.
The patient will respond well and have a favorable outcome to excision of the ganglia and the patient may have resolution of the tarsal tunnel syndrome symptoms.
Lumbosacral spine radiculopathy
Pain on the lateral side of the foot can result from L5-S1 herniated disc (will cause radiculopathy). The S1 nerve root supplies the lateral aspect of the foot. Pain on the lateral side of the foot can result from L5-S1 herniated disc. The S1 nerve root involvement causes decreased sensation and pain on the lateral aspect of the foot.
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