Atypical Lateral Heel Pain

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I recently picked up this pleasant gentleman who is quite desparate for help with his heel pain. I cannot immediately think of a working diagnosis and will be interested in the collective wisdom of the forum.

Male, Caucasian, 67, 5.10, 189lbs, Health Service NE Director
Part time sports masseur Ex-dance teacher

C/O: Atypical Heel Pain: sharp, knifelike, localized, intermittent, causes a limp when severe.

HPC: 30 year Hx of pain, lateral calcaneus, initially sudden onset, settled but occurs intermittently every 2-3 months, probably activity related but no specific association - aware of pain at heel lift.
Was seen by two Orthopaedic Surgeons 15 years ago: no specific diagnosis
NSAID’s (oral & topical): no effect, Physiotherapy: no improvement

Previous Investigations: XRF: NAD, Bone Scan: “Hot Spot” lateral calcaneus


Previous Treatments:

Anti-pronatory insoles : various designs over the years, not very helpful e.g. Langer Casted Orthoses / Scholls Metal Arch supports etc
Cortisone injection: 2-3 from orthopaedic consultant over the years helps but only temporararily.

Shoe wear: Pronator (sole and upper showing signs)

Clinical Findings: no overt signs other than discreet tenderness on direct firm palpation on the lateral border of the calcaneus about 2cm below the lateral malleolous, without swelling or inflammation (see photo)

Musculo-skeletal Findings:

General Findings: all pedal articulations can be mobilised passively, actively and against resistance without reproducing the pain.

Gait : increased mild foot pronation / medial column sag is evident. With forefoot loading the foot is inclined to swing in (in-toe). ? Metatarsus Adductus. Confirms tenderness on heel lift

Hips: Evidence of some internal hip rotation of bony origin
Knees: NAD
Ankles: No evidence of Achilles tendon tightness or other restriction
STJ: on the stiff side but WNL . MTJ: NAD 1st MTPJ : NAD
1st ray: mild reduction in 1st metatarsal stiffness
Alignment rearfoot:forefoot acceptable.

No evidence of peroneal tendon dysfunction: all other tendon complexes challenged and tested: NAD

Impression: possible soft tissue culprits include lateral collateral ankle ligaments (not tender on forced STJ inversion), and peroneal retinacula(mobiisation of tendons does not evoke pain). Bone pathology cannot be ruled out yet. Sural nerve pathology is possible but lacks neurogenic XS.

Plan: Request ultrasound studies & ?CT scan (is this the most appropriate options)
Treatment Options Subject to investigations: further cortisone/ cryoanalgesia ?biomechanical therapy, accupuncture

 

I would guess, from its anatomical location, that the pain is originating from either the peroneus longus tendon or the sural nerve. How often does the pain occur.....only every 2-3 months??? How long does it stay around for once it recurs? What helps the pain? What makes it worse? Related to any physical activities or special shoegear?? Does it hurt during tiptoe standing?

From the foot type you describe, I would add a 3-5 mm forefoot valgus (2-5) wedge to the shoe insole as a clinical test to decrease the tensile force within the peroneus longus tendon since peroneal tendinopathy will occur in patients with metatarsus adductus every now and then. Metatarsus adductus deformity will cause the metatarsal heads to be relatively more medial to the STJ axis than normal which will increase the STJ supination moments in late midstance and propulsion from ground reaction force (Kirby KA: Subtalar joint axis location and rotational equilibrium theory of foot function. JAPMA, 91:465-488, 2001).

To specifically test for the peroneus longus, have the patient plantarflex their first metatarsal head and ankle into the palm of your hand while you are actively trying to dorsiflex the ankle and invert their forefoot with the same hand. There is no extrinsic muscle that can plantarflex the ankle and plantarflex the first metatarsal other than the peroneus longus.

Traumatic sural neuropathy may occur as a result of irritation from some types of shoes or sitting positions (such as sitting on ones foot). However, a sural neuropathy will not light up on a bone scan, unless it is caused by blunt trauma that also injures the periosteum of the calceneus. However, I tend to doubt it is sural neuropathy.

If I was to do another test, I would do an MRI scan, which would best show either bone pathology or soft tissue pathology.

Good luck.

 

Kevin .....

Kevin - thank you for your thoughts. I will try out the FLW

 

The pain at heel lift sounds like peroneal tendinitis to me. The forefoot valgus wedge or, better yet, a foot orthosis with a forefoot valgus wedge should help. Make sure also that his shoes are not inverted due to shoe wear.

 

Informative history.

Don't forget that a 30 year Hx of heel pain (at HL) would have altered much. So maybe what you are seeing (met stiffness, medial arch collapse etc) is happening as a long-term sequale rather than the other way around.

If you suspect lateral ligament pathology, just tape it. Lateral ligament pathology 'loves' the typical ankle strapping.

But I think you will get more out of another testing procedure. I will message you.

 

I h ave a patient with pain at the soft tissue posterior rim of his calcaneus. This is obviously not plantar fascitis however he does pronate minimally and has a mild proximal pain on palpation of the plantar ligament. He wears boots for work as a stone mason, is on his feet all day and takes his dogs for walks twice a day for miles and miles. He is from Edinburgh. (this is significant)
I have tood him to rest,use ice and massage. If no improvement I will inject LA to see if it is a nerve impingement. any suggestions welcome. (before friday please)
Kate Patty