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Patient with Plantar calcaneal pain and palpable 'lump'

Discussion in 'Biomechanics, Sports and Foot orthoses' started by connor909090, Jul 19, 2014.

  1. connor909090

    connor909090 Welcome New Poster

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    Hi, was wondering if anyone could offer me some help!

    Patient is a 30 year old female, high level athlete (Age group Olympic distance triathlon world champion) in training for an iron man.

    Patient presented with plantar calcaneal pain, after being told by 2 separate physio's it was plantar fasciitis, to rest and wear flat shoes (she was wearing dolly shoes and flip flops) she was wondering why the pain was getting worse despite the rest from running and stretching plantar fascia, icing etc as she was told to do.

    Symptoms came on fairly insidiously, aching/bruised pain after a 10 mile run. There is no recollection of trauma, drastic change in mileage, uneven terrain.

    Upon examination patient has tight gastrocnemius and soleus, moderate overpronation, rear foot varus, hypermobile forefoot. Most interesting (to me) was a palpable 'lump' to the plantar aspect of the calcaneus, which was fairly painful when pressure was applied to it. It feels firm/hard, doesn't appear to be mobile. Pain is unilateral and there is no pain upon palpation of medial tubercle of calcaneus or plantar fascia more distally.

    Using Felt I applied a heel raise to an insole, with a cut out where the palpable lump was (total 10mm) , also added a d-filler (10mm) Patient reported this has helped alleviate the pain in trainers but still feels very sore barefoot. Patient still gets some dull aching in trainers with felt additions. In addition to this I have advised to carry on ice treatment and have used stirrup and low dye taping which again has helped with symptoms.

    She has her ironman in 2 weeks time, im finding it difficult to diagnose (especially without further imaging) will running the ironman be a very bad idea?

    Any ideas on potential diagnosis/ further treatments? She is getting an MRI after the ironman.
  2. An Ironman consists of a full marathon 26.2 miles of running, so probably not a good idea if even possible with the amount of pain she will endure. Sounds like a tear in her plantar fascia (or neurofibroma). Sounds like she needs urgently to have orthotics to control elongation and rear foot pronation? You could add the padding to offload the area of pain. It is unlikely she will complete a full marathon in two weeks time and participate in a event which for first timers on average will take 12 hours plus, which will include 5 hours of marathon running. She might manage the swim 3.8km and possibly the bike 180km and could withdraw at the point of running. I've watched enough Ironman events & treated enough Triathletes to know that you can't complete a marathon while exhausted with the addition of pain and of course struggling through pain will indeed make things worse!!!! "Going Long" from Olympic/Standard distance is a normal progression and considering most Ironman events costs around £300/$500 she will be reluctant to give up at this stage but I am sure pain will be her final determinant in the eventual outcome. Welcome to the world of helping athletes get to the finish line!
  3. Lab Guy

    Lab Guy Well-Known Member

    I would place a large bet without seeing the patient that she developed an epidermal inclusion cyst from the constant and high GRF being exerted on her heel. These cysts take time to become larger which is why her symptoms came on gradually. She would have remembered if she tore her plantar fascia as she would be in a world of pain. Plantar fibromas emanate from connective tissue and these occur along the middle of the plantar arch of the foot most commonly.

    I think your making the right treatment choices by off-loading the painful area and reducing the high ground reactive forces. Use a high quality viscoelastic material to absorb shock for both heels (to keep pelvis level).

    Ultimate treatment will be surgical excision.


  4. Good call, Steven. This definitely isn't a plantar fibroma since these only occur within the midsubstance of the plantar fascia, not at the plantar calcaneus. A plantar fascial tear will cause a lot of pain and a very small lump and, again, not at the plantar calcaneus.

    Is the lesion warm, hard and attached more to the skin or to the calcaneus? Doe is hurt more with direct compression or with side to side squeezing of the plantar calcaneal skin? Clinical photos would helpful.
  5. connor909090

    connor909090 Welcome New Poster

    Hi Guys,

    Thanks for the responses, greatly appreciated.

    I have since seen her again and we seem to be getting somewhere by offloading and raising the heel. I have swapped the felt for TTP and a softer pink Poron, under both heels. Happy to be getting results treating symptoms but irritating me that I cant give an accurate diagnosis to formulate a long term treatment plan for her.

    She also has seen another clinician who had used ultrasound on the area, which the patient reports was painful during and increased soreness the next day, but when she came back to me (2 days after the ultrasound) she reported an overall improvement in symptoms, but symptoms were still present.

    Kevin, the lesion doesn't appear warm when compared to the asymptomatic heel, there are no visible signs of the lesion either. If im honest, if it wasn't for the patient highlighting to me that she thought she could feel a lump (after some investigative prodding/poking herself) I might have missed it.

    It seems quite deep to me, requiring a bit of palpation and force to locate (deep to the fibrofatty pad?) I would also say it is fairly hard, seems more attached to the calcaneus (but I will admit my experience is limited with this type of lesion, not something I have come across before, my career is still relatively in its infancy-2years) and it is definitely more painful with direct compression. I could 'flick' across it with almost no discomfort, but applying pressure directly onto it was painful for the patient.

    She doesn't report any pain or discomfort anywhere else and is otherwise fit and healthy.

    Thanks Guys,

  6. Connor:

    Sometimes one of the fibrous septa in the plantar heel gets irritated and creates a "movable lump" within the plantar calcaneal fat pad. Take some skin lubricant (e.g. K-Y Jelly), rub it on the calcaneal plantar skin, then see if this allows you to better feel the dimensions and consistency of the mass. If that is the case, then a cortisone injection into the lump should diminish it. However, if you are having success with the padding, I would continue with that and daily icing therapy, 20 minutes, three times a day.

    Hope this helps.:drinks
  7. drdebrule

    drdebrule Active Member


    I would keep plantar fibromatosis in the differential, but agree with others that it sounds like something else. See abstract below.

    J Foot Ankle Surg. 2011 May-Jun;50(3):366.e1-5.

    Proximal plantar fibroma as an etiology of recalcitrant plantar heel pain.

    Hafner S1, Han N, Pressman MM, Wallace C.

    Author information


    Prompted by repeated pathology reports of fibromas at the origin of the plantar fascia after fasciectomy for chronic plantar heel pain, this study examines the incidence of proximal plantar fibroma. A retrospective study of 101 pathology specimens from 97 patients with the preoperative diagnosis of recalcitrant plantar fasciitis was performed. Patients ranged in age from 36 to 82, and included 30 males and 67 females. The specimens consisted of medial and central bands of the fascia obtained from transverse plantar fasciectomies. The fasciectomies were performed between July 1994 and March 2008. One quarter of the cases studied had a histological appearance of plantar fibroma. This new finding has not been reported in any literature in connection with recalcitrant heel pain. Histologic findings of the specimens were placed into 3 groups: neoplastic involvement (25%, 21 female and 6 male), inflammation without neoplastic involvement (21%, 13 female and 6 male), and other, which consisted of having no inflammatory or neoplastic response (54%, 32 female and 19 male). All of the patients failed a 3- to 6-month conservative treatment regimen, which included anti-inflammatory medication, modification of activities, injection of corticosteroids, night splints, custom molded orthotics, and physical therapy. Only 4 patients underwent bilateral plantar fasciectomies. No patient required a revisional procedure. The authors conclude that 25% of recalcitrant heel pain is neoplastic in origin, and that patients presenting with these lesions require excision and not fasciotomy.
  8. drdebrule

    drdebrule Active Member

    Also, it may be appropriate to not treat this patient (not apply padding) and insist on MRI test. By applying padding to the heel, it sounds like you are approving of the patient's plan to run ironman. However, there is a good possibility patient could become further injured. This is a tough situation. I think a lot of us have had patients who are running an upcoming race no matter what no matter what the diagnosis is. Thanks for sharing.

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