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Advice for (not quite) heel pain

Discussion in 'General Issues and Discussion Forum' started by Aidan Hobbs, Sep 4, 2008.

  1. Aidan Hobbs

    Aidan Hobbs Active Member

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    Hi! Hoping to get some advice for an elderly patient I am seeing (as a student)with which I am struggling for differentials
    She C/O pain in the left foot localised to a small (2cm^2), well defined, superficial area approx. 2cm distal to the medial tubercle of the calcaneous (I marked it spot on with a dot). Pain is elicited with mild pressure on palpation, however appears to be slightly diminished whilst the foot is completely dorsiflexed with soft tissue structures at stretch :confused:

    She notes that pain in both feet (L>R) had begun in Feb this year after a long walk with grandkids along the beach. She experienced difficulty walking on the sand but the sharp pain only began first thing the next morning.

    She has had Knee Sx which has left her with a secondary LLD L>R by roughly 2-3cm. I have made up some formies for her with a 1cm lift to the right which she wears with Asics 1130's. She has found the right is "perfect" and resolved the pain on that foot, however the L is still causing problems. We tried her with an "orthotix" off-the-shelf on the L for 2 weeks but still no better.
    She has casual flats with no support which she finds more comfortable.
    I have sent her for an ultrasound and ground a cavity to the area (at about the proximal, lateral 1/3 of the arch) which she said automatically reduced the pain.
    Im lost for ideas as to what this could be??

    Any suggestions?
  2. Donna

    Donna Active Member

    Hi Aidan,

    Sounds like bursitis to me... Can you palpate any lumpiness or thickening in the area? What degree of swelling is there compared to the "good" side? It might be worth referring to a musculoskeletal practitioner for treatment (remember back to the April QSPG meeting, I think you were there) ;) Did you include bursitis on your ultrasound referral request?

    We refer for injection therapy quite a bit, in combination with orthotics to correct the poor biomechanics... Often gets faster results compared with orthotic treatment alone...


    Donna :D
  3. LuckyLisfranc

    LuckyLisfranc Well-Known Member


    I was not aware of an anatomical bursa 2cm distal to the medial tubercle of the calcaneus. Can you tell me more?


    You would benefit from us by defining what it is you are palpating. Use your anatomy knowledge - look up a textbook if you need to. The most likely area of point tenderness 2cm distal to the medial tubercle of the calcaneus at a superfical level will be the medial slip of the plantar fascia, and more deeply the medial and lateral branches of the posterior tibial nerve. I assume the pain is more inferior than the porta pedis is located.

    You have not defined the nature of the pain, which will assist in determining the tissue that is affected (eg burning, lancinating - more likely to be neural in origin). In presenting a patient it is very helpful to present in typical grand rounds abridged SOAP format.

    That being siad, a history of beach walking is common in the history for plantar fasciitis. However, you will find that depending on comorbid orthopaedic issues with the foot - there are many times that prefabricated foot orthoses will fail to resolve this condition alone. However, in most experienced podiatrists hands, 90% resolution of this diagnosis is possible with standard non-invasive mechanical interventions, including casted devices.

  4. Donna

    Donna Active Member

    Hi Lucky,

    Sorry, I missed the "2cm distal" bit... my bad... :eek:

    I guess the point that made me think bursitis was
    , ie. pressure on bursa = pain... But rethinking the whole "2cm distal" location: you're right, it would be the plantar fascia that is the problem... ;) Aidan says she is wearing her casual flats with no support and therefore this is not actually allowing the orthotics and supportive shoes to do their job for 100% of her weightbearing time... and what about barefoot walking? This could also aggravating the problem!:eek:

    Is there equinus present in this patient? Maybe that's why the right foot only has resolved, regardless of the LLD, the heel raise maybe have been useful in decreasing tensile strain through the Achilles and therefore less tensile strain through the plantar fascia? :confused:

  5. Aidan Hobbs

    Aidan Hobbs Active Member

    Thanks Donna, NAD at the ankles but that does remind me her right knee is flexed slightly at full extension but the left I noted was in neutral to slight recurvatum. Perhaps a tear may have resulted from sagittal plane stress with the LLD. Ill give the heel lift a try.

    She described the pain as stabbing when palpated but sharp aching whilst on her feet.
    I would have said it's a tear to the central band of pl. fasc as the pain is centralised slightly more laterally to the medial band but pressing the area whilst the foot and toes were dorsiflexed produced less pain than under no tension. Does this contraindicate my Dx?

    I might just wait for the Ultrasound results
  6. Griff

    Griff Moderator


    Have you performed any neural tests? (SLR/Slump etc)

    Just a thought


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