Help with Heel Pain

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I've not posted on the forum before so please be gentle with me!

An active, fit middle aged woman presented with heel pain that has been getting worse over several weeks.
There is no discomfort in the heel first thing in the morning or after rest.
The pain develops and intensifies with prolonged standing or walking. By the end of the day the heel is extremely painful. The pain is localised over the medial calcaneal tubercle where palpatation causes extreme discomfort and yes there is localised swelling.
At her first visit I referred her off for an X-ray and ultrasound and I did low dye strapping to attempt to offload the plantar fascia; this she found quite comfortable.
X-ray did not reveal the presence of a spur and/or fracture.
She didn't get an ultrasound as her GP advised against it as he thought it would only reveal inflammation (?)!
At her second visit I took a plaster cast in order to fabricate an orthotic to offload the plantar fascia. Structurally, she is hypermobile, she has a rearfoot varus and a very mobile plantarflexed 1st ray.
I'll be fitting the orthotics next week and I've also requested that she still get an ultrasound.

So what am I thinking?
Calcaneal nerve entrapment or a rupture of the attachment of abductor hallucis brevis.
I found that percussion of the Tibial nerve aggravates it a little, as does passively working the abductor hallucis.
Can anyone assist me with this?

 

have you tried resting it an icing it? so rolling a frozen bottle underneath her foot? pain is present after long periods of standing/walking, what is her heel strike like? bony bruise or fat pad contusion? Depending on foot type, orthotics may help to change force on the heel. is the pain at both heels? shoewear?

 

She has found heat to be a better option to ice. Her heel strike is not heavy and as far as she can recall there was no episode of injury. Its only in one heel and her footwear is not a contributing factor. As far as resting it ......... she is a busy mum and its not an option at this point in time.

 

Hi,
It sounds like plantar fasciitis, although the classic "morning pain" is not present. The mere fact that she felt better from the strapping is encouraging. I am sure the orthosis that you will make for her will help even more. Good Luck. Regards, Vernon Lever:dizzy:

 

Thanks Vernon,
problem is that the plantar fascia is not tender to palpate. It is possible that this is an atypical case but I'm still leaning toward nerve entrapment. It is possible I guess that she has a tear in the plantar fascia but I would expect that palpating the fascia would aggravate it.

 

It does have the Nerve entrapment feel to it with what you have written. Have you done a full nerve mobilisation testing program on both legs?

Also you did not state anything about length of gast. sol and hamstrings. Also have you checked for a forefoot equinus ?

 

Hi Syndactyl,

When you said fit middle age female, what are her activity levels? whats her footwear like?
Is she doing aerobics? Running? or just chasing kids?
Are her shoes supporting? Does she wear shoes at all at home? Does she have slate/tiles at home?
These would all be relevant questions that you may have asked her but not posted.

My thinking at the moment is bruised heel/contusion? this may be due to poor shock absoption from any of the above factors along with the rearfoot varus.

Taping may have helped by not only offloading, but the support and by 'holding' the fat pad under the calc to provide better cushioning. This can be reproduced with a device with a deep heel cup.

I may be way off.......anyway, just my thoughts.

Hope it Helps,

Sally Belcher

 

Thanks Sally,

Her shoes are fine - good support and good cushioning. She does not run about barefoot (I did ask about that) i't's too cold here for that and her home has timber floor boards.
Out of the blue she started to develop heel pain.
You're right that the strapping may have increased the cushioning by containing the fat pad and a substantial heel cup should also replicate this.

 

Thanks
Tell me more of what you refer to as nerve mobilisation testing program.
Gastroc/Soleus is a little tight and I've requested she do some stretching just as a matter of course.

 

It tends to be from the physio world. So if you have not done much nerve mobilisation work find a good physio to test your patient. By irratating the nerves of the leg you can work out if there is reduced nerve mobility which can lead to many different symptoms one of which can be heel pain.

A slump stretch can be part of the program, but it´s much better to get hands on demonstration of the other positions to test different nerves of the legs.

 

Hi and Welcome to Podiatry Arena, you missed teh introduction forum :--)) so almost the welcoming committee.
If there is nerve irritation I would expect the symptoms to follow that, sharp/burning/pins/needles type thing?
Still sounds like P.F. to touch and help with strapping.
Depth of History is really important with busy mums. One of the things I go back over is, just how long have you had the pain, many have had it longer than thye realise. ask if it was there at school holidays? Long weekend? Kids Birthdays? this can then trigger memory that it has been there longer and often is associated with doing something out side the "norm". Eg different activities with the kids etc. Once started then does not get a rest to allow it to heal?
Look forward to further postings.

Again welcome and good luck

Cheers

 

Thanks ,

Symptoms have been there for a matter of weeks and the fact that it seemed to be getting worse or rather not going away all together is what brought her to see me. The pain she experiences as the day progresses is 'constant pain' but this is interrupted with non weight-bearing periods of tingling, shooting 'annoyance' into the heel. Nothing she describes is typical of plantar fasciitis as I usually see presented (and I see plenty of cases). I think I've covered all the bases as far as history is concerned as we have spoken at length concerning all that you have mentioned ie. holidays, new activities, etc. etc. It's either a very atypical case of pf or very likely a combination of pf with nerve involvement. As I mentioned in a previous posting - when the hallux is passively moved through dorsi/plantar flex and abduction several times the pain starts up in the heel. Sounding more and more like a tricky nerve. I'm fitting her orthotics this week as she is making do with strapping until then. I'll post the results as they present. As for 'rest' I don't think that's going to happen...........I'm trying to fix a 'moving cart'!

Thanks again for your interest and suggestions

 

There is a good article on the Podiatry today web site, go on their home page and search neurogenic etiologies of heel pain. Plenty of good advice there!

 

You did not indicate trauma nor did you comment on any back conditions or sciatic type symptoms. Your analysis point toward plantar fasciitis and / or tarsal tunnel. Along with orthotics you may want to add a steroidal or non-steroidal anti-inflammatory. Ultrasound is not essential but can help in diagnosis when comparing plantar fascial thickness to the contralateral limb. Yes it will show inflammation as well as bursal formation and give you a better feel where the majority of the pain is coming from. It is essential to have her perform calf stretching exercises three times a day. With tarsal tunnel, manipulating the abd hallucis will compress the nerve so that would explain that. An abd rupture would be highly unlikely. Do a cortisone injection if indicated and do sustained compression of the tibial nerve within the tarsal tunnel as well as popliteal fossa as a diagnostic. The pain will get worse the longer you compress it. With sciatica you will have a tender poplital area and may have pain on straight leg raise in the back. The orthotics and anti-inflammatories will help with that as well.
Good luck.

 

Thanks for that.
There was no history of trauma nor does she have sciatic type symptoms. I'm treating her for the combination of plantar fascia injury plus nerve involvement. She is doing calf stretches twice daily. I fitted her orthotics just 3 days ago and she was delighted with them ............. instant comfort! That is not often the response with plantar fasciitis. Anyway, its early days and I'll be interested to see how things have progressed when I review her.
Thanks again