Atypical heel pain

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G'day All,

I've got case which has got my stumped, hope someone's got some ideas!

Male patinet, 52 years old, works as a stock agent suffering heel pain bilaterally for approx 5 months now after a particurly big day on feet. Described as an aching stabbing pain, worse with prolongued activity and hard working surfaces. Nil history of other foot, knee or hip pathology. Patient wears elastic sided boots to work, and sandals and slippers when at home. Pain is minimal in all footwear, but excessive when not in any footwear. Pain elicted when patient inverts feet and occurs in medial distal calcaneal region. Discomfort reproducable with direct palpation of insertion of plantar fascia approx 1 inch from insertion, however not reproducable anywhere else.

Biomechanically, patient demonstrates a mild forefoot supinatus bilaterally, compensated with a slightly planatrflexed 1st ray. Gait demonstrates delayed resupination at midfoot consistent with saggittal plane block and windlass failure (functional hallux limitus). Slight abductory twist with propulsion consistent with saggittal plane block also. Otherwise biomechanically unremarkable.

Nil relief with modified low-dye taping with false fascia, increased discomfort with 9mm PPT heel pads, nil relief with physical therapies: rest, ice, massage, topical NSAIDs.

Patient has today been refered for ultrasound to both heels.

Not quite sure how to tackle it as the pain is pretty much without footwear, and additions in the shoes makes it worse?

Any ideas?? :bang:

 

Adrian:

This injury is most likely caused by long hours of walking/standing on hard surfaces and the resultant compression injury that often occurs to the insertion of the plantar fascia at the medial calcaneal tubercle from such prolonged forces on the plantar heel. I will first try a custom foot orthosis with a deep heel cup with a 3-6 mm neoprene cover on it and/or a heel bubble filled with PPT (or similar material) to help better unweight the plantar calcaneus. The orthosis must conform the medial and lateral arches well to further decrease the ground reaction force on the plantar heel. If this doesn't work, try cortisone injections and then get the patient off their feet for 2-4 weeks, or longer, by taking them off work and/or having them use crutches and/or having them use bilateral cam walker braces or some other similar off-weighting method to allow the plantar calcaneus to heal. Sometimes, rest is best.

Hope this helps.

 

Hi Adrian:

If Kevin's suggestion proves unrewarding...................

When I see a patient with "aching STABBING" pain worse with activity I normally think nerve etiology.

I would suggest evaluating this patient for tarsal tunnel and or porta pedis syndrome. A simple percussion to elicit a tinel's sign radiating to the symptomatic area might be all you need to make a dx.

As a side note, patient's with sensitive tarsal tunnel's will commonly be unable to tolerate therapeutic US over the tunnel.

Steve

 

Thanks Guys,

Where this has got me stumped is that the patient is fine in footwear, even in very unsupportive footwear, but is in pain without. there seems to be no obvious fat pad atrophy or pathology that I can ascertain. If it's purely a shock attenuation issue, the heel pading should have helped, however it made the symptoms worse.
As for tarsal tunnel, palpation/rolling of the posterior tibial nerve elicted nil symptoms aside from the usual shooting sensation noted with nerve palpation.
I'm beinning to think that a steroid injecting into the painful area of the plantar fascia might be next point of call, pending (diagnostic) ultrasound results, being that I can't really stick something under a foot that isn't in a shoe, and is unresponsive to taping and other physical therapies.

Thanks!

 

Adrian:

Have you ever experienced a "bone bruise" by having a hard object hit one of the bony prominences on your body? What you will find that it is relatively nonpainful when not being touched and that more pressure on the "bone bruise" causes more pain. The more you put pressure on it, the longer it takes to heal. If you reduce the pressure on it over time, it eventually heals.

I suspect that your patient has what amounts to a bone bruise in the plantar calcaneus. Your heel cushion may attenuate the ground reaction force vs. time curve but it likely does nothing to reduce the absolute magnitude of ground reaction force under the plantar heel. In fact, your heel cushion you gave to the patient could potentially increase the ground reaction force under the plantar heel, especially during standing, versus no heel cushion, simply due to it's heel lifting effect. The patient could potentially get more relief from his heel pain if you put the heel lift under the arch of this foot, rather than under his heel.

To treat this patient you may find that trying to redistribute the ground reaction force to other areas of the foot, and away from the plantar heel, gives the patient the most relief. Why not try the deep heel cupped, higher arched orthosis, cushioned custom foot orthosis I spoke of earlier?

 

Hi Adrian

Any findings of note on neural tension testing?

Ian

 

Hi Adrian:

Re: R/O Tarsal Tunnel......

I normally percuss the area from the proximal end of the TT to the opening of the Porta Pedis.
I have found that TT patients will always (almost!) have a tinel's sign and it usually radiates to the Painful area.
When it is unilateral there is usually no tinels sign or a diminished one with more pronounced percussion needed.

In addition, patients that have a History of "fasciitis" of over 6 -12 months that have not responded to fasciitis treatments and have no spur formation tend to fall into the Tarsal Tunnel category.

I would not discount this so quickly.

Steve

 

Thanks everyone,
Will keep you all posted when I review him

Thanks!

 

Just a question in regards to Kevin's suggestion of a cortisone injection. My concern at this stage ( being 5 months or more since the patient began getting pain) is that there is actually a lack of inflammation in the plantarfascia and that a cortisone injection is only going to prolong the healing process. Could maybe Prolotherapy be a better option as far as injection therapies go? This could then initiate a healing process as inflammation is the 1st stage of healing. Just a thought.

 

I'd use injection of Lidocaine, Celestone, Kenalog 10, rest, a custom foot orthosis with a deep heel cup-
Let us know how the patient is doing-
-John