Help with heel pain

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I have a male patient, 50 years old, with heel pain of 4 months duration:

Pain started 1 week after a stomping activity (farmer)
Has not got better or worse since it started to hurt
Very sore to press on (patient jumps) - very defined / localised spot
Sorest when on feet alot and when pressing on it
Can be sore when not on feet
Not sore on rising from periods of nonweightbearing

Location is about 10mm proximal and medial compared to the plantar medial calcaneal tubercle.

Xrays report 'no meaningful spur or bony abnormality' in the region though to me there appears to be two spurs in the traditional medial tubercle area. There doesn't seem to be anything significant on the plantar calcaneus.

There is no pain on palpation of the plantarfascia, ankle joint dorsiflexion is adequate, fatty padding is good and percussion of the medial calcaneus and around the painful area is negative.

I have issued 6mm bilateral heel raises with a 12mm hole cut out at the appropriate spot on the right foot (The aperture is so medial as to be right on the medial border of the heel raise). This has helped somewhat at this early stage, but he hasn't been on his feet much this week.

So I feel I have ruled out plantarfasciitis and medial calcaneal nerve entrapment. I thought a bursitis would be more in the middle of the plantar calcaneus.

Any ideas?

Regards

Rebecca

 

G'day Rebecca,

Is there any throbbing discomfort at night? if so there may be a calcaneal fracture that teh radiographer has missed (as they quite often miss thinsg on foot X-rays). Can you post the X-rays? Alternatively you may be considering a rupture of the loculated fat pads?
Good luck!

 

I would start with the simplest..shoes. Check the interior of the shoe, there may be some point of irritation in there.
Are you palpating Abductor Hallucis? If in doubt check your anatomy book. There may be a tear at its attatchment.
I would trial strapping the foot with a rigid tape.

 

Hi Adrian. I have attached x-ray. What do you think about the two heel spurs, I'm not sure I've seen this before.

I had ruled out abductor hallucis trigger but you're quite right, it could be a small tear near its origin - I will muscle test to confirm / rule out.

Mark, the pain occurs with several types of shoes so I doubt this will be a problem, but thanks for your suggestion!

Rebecca

 

Sorry, about the image!

 

G'Day Rebecca,

Obviously wtihout being 100% I agree with Adrian - a fracture that has not been picked up (which is very, very common) would be my guess.

Also agree with Mark - look at shoes - but ultimately rest is best. Long term, get them out of slippers at home and barefeet, elastic Safety Boots or unsupportive work shoes.

Personally if it is that acute I would immobilize with strapping and an inflattable Royce Air - Walker (minimum 4 weeks) - or if preferred to approach more conservatviely strap the foot very heavily (every 4-5 days) and minimum weightbearing and leave good walking shoes on all day other than when going to bed and anti-infalmmatories therapy.

Intersted to see how you go!

Good luck!

TJ

 

Cheers Asher!
Any chance you can repost the image and have it lightened up? Really do need to see the calacaneal growth plate?

 

Thanks you guys. I'll try to sort out the x-ray image and repost.

Pressure deflection in the form of a heel raise with an appropriately positioned aperture has failed to provide significant relief. I am strapping him tomorrow to see if that helps. Have referred him to a podiatric surgeon (appt about 4 weeks from now) and will report back here on his fate.

Regards

Rebecca

 

Rebecca

Any follow up on this case? I realise this is six months on but would be interested to hear the result

Nick

 

Hi Nick,

From memory a cortisone injection (on referring to GP for more imaging) helped in the initial weeks at least. I don't know how he has faired longer-term.

Rebecca