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Unusual Heel Pain

Discussion in 'Biomechanics, Sports and Foot orthoses' started by MelbPod, Jan 16, 2010.

  1. MelbPod

    MelbPod Active Member

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    Hi all,

    Would like to hear others opinions on a patient I had this morning:

    - 24 year old female. No prior medical history. Fit and healthy, no meds. No current sporting activity. Works in an admin sitting role.

    - Previously worked in retail with long periods on standing on hard surface (when pain began)

    - Heel pain orignally dx as plantar fasciitis 2 years ago. Tried rest, gel heel pads, contrast bathing. Pain continued to progress.

    - Returned to GP, again Dx as p.fasciitis told to rest.

    - Now had xrays and US taken; results stating plantar fascia normal, traumatic bursa present sub R calcaneus 16x 7 x18 mm.

    - FOOTWEAR: mainly enclosed leather type shoes with small heel. heeled shoe more comfortable than flat. Can not tolerate hard soled shoes.

    - palpable firm lump can be felt over medial tubercle of calc. Feels superficial, just sub cutaneus. any pressure inflicts discomfort.
    - patients foot posture fairly normal - mildly inverted calc.
    - Patient reports consciously supinating foot to avoid pain from standing on the 'lump'

    - Pain is worst 1st step in morning, cushioned shoes makes it feel better. at times pain and inflammation is felt along MLA. Right foot only.

    - patient also reported 'the same feeling' at left sesamoid. Small palpable lump typical of sesamoiditis.

    I provided low dye taping to right foot to reduce the tension and pain felt through MLA, provided 8mm Poron heel pads with cut-out Right to accommodate 'lump'.

    Review next week.

    See attached x-rays showing right heel in two medial-lat , and both feet oblique.

    Thanks all, have a good weekend :)


    Attached Files:

  2. Hi Sally,


    Are the results of the ultra sound able to tell you if there is any truma in the surrounding muscles . It sounds like the smaller muscle are your problem not the fascia, but the low dye and Poron is what I would have done but I would have added ice and NSAIDS as well.

    Good luck
  3. MelbPod

    MelbPod Active Member

    Thanks Michael,

    The US results stated no abnormality of the plantar fascia or the surrounding musculature. It identified the 'traumatic bursa'.

    Since I have not had a patient with a bursa in this area before, I no comparison (hense post up here to see if anyone has experienced similar)

    The easily palpable 'lump' beneath the plantar heel feels very solid, almost too firm to be a bursa. I am ravaging through Ddx but either they are a soft tissue (haemorrhage of fat pad) or it should have shown on x-ray if a osseus injury....:wacko:

    The patient prefers not to take NSAID's due to previous GI problems when taken.
    Has been using anti-inflam gel and icing. (she has done this for extended periods through out the 2 year Hx with no real relief)

    Pain currently 7/10 every day.

    Thanks for you input :drinks
  4. Paul Bowles

    Paul Bowles Well-Known Member

    If it looks like a duck, quacks like a duck then chances are its probably a duck!

    Why are you rummaging through DDx's? The US and your clinical exam I would imagine proves beyond any doubt what it is. NSAID's will most likely do very little in the short/long term anyhow. Anti-inflammatory gel - we all know what the research says about penetration into tissue of that (my clinical pinion is you may as well use sorbolene). Ice - sure why not, can't hurt, but won't really solve the issue!

    If you trust your ultra-sonographer then go with the below (BTW can you post the US pictures, they would be much more helpful than the plain films):

    If you are not comfortable doing it, referral to Pod Surgeon/Radiologist for injection/drainage with lignocaine 1% and corticosteroid.

    Monitor for a period of weeks, if pain/bursae returns surgical excision.

    If you don't trust them (your sonographer that is), get a second U/S done for a second opinion or go all out and refer them to an orthopod for an MRI - at this point you will lose the patient forever though - is that such a bad thing? :)

    If symptoms appear consistent with traumatic bursitis, and there is no predisposing medical history - who cares what caused it she is is pain! Solve that issue first. Getting her out of pain in the immediate future is priority and should be easy to do in a 5 min consult.

    PS - also why the hell aren't those plain films weight bearing??????
  5. Every now and then, I will see an "inflamed nodule" on the plantar heel. These are very easily appreciated via manual palpation. Put a little bit of skin lubricant (e.g. K-Y Jelly) on the plantar heel, firmly use your index finger to feel the deep texture of the plantar heel fat pad and these odd little irregularities within the plantar heel fat pad are quite readily detected. Most are probably irregularities within the fibrous septa of the plantar heel, I have never seen a fluid-filled sac on the plantar heel either with MRI. Also, I believe there is a possibiliby of a neuroma in the plantar heel but this is rare.

    Most of these nodules are asymptomatic, but some can be quite painful, like in your patient's example. I would inject the bursa with a healthy dose of cortisone (i.e 10-20 mg of depemedrol) to see how it responded since intralesional cortisone can work quite well in shrinking the tissues and reducing the inflammation. Foot orthoses with deep heel cups and plantar heel bubbles also work extremely well at relieving the pain from these, whereas "horshoe pads and heel cushions" only work well for slight ones. If the nodule is huge, and doesn't respond well to cortisone injections or to well-designed foot orthoses, it may require surgical excision. NSAIDS, creams, etc will probably help this very little.

    Hope this helps.
  6. MelbPod

    MelbPod Active Member

    Paul, I appreciate your reply and advice. However, it would come off much better if you weren so arrogant about it.

    Obviously it didn't look, sound and quack like a duck (in my opinion) as it didn't clinically feel like bursa I have treated before.

    I have had patients been diagnosed with pathologies by radiologists, that I have not completely agreed with and as a health professional I like understand and confidently diagnose the pathology.
    In this case I was unable to do that.
    To many practitioners I know make a dx from refering for imaging and then reading the report alone, I think this is poor professionalism.
    Yes I trust the radiologist (not my usual one as this was from GP referral), but I like to use this information in conjunction with what I see clinically to come to a dx.

    As the x-rays were done prior to this patient presenting for treatment, I don't know why they weren't WB.

    I had tried to put US up, but the clarity was terrible so it wasnt worth it.
  7. MelbPod

    MelbPod Active Member

    Thanks for you advice Kevin. I will look at cortisone injection.

  8. Paul Bowles

    Paul Bowles Well-Known Member

    Apologies didn't mean to sound arrogant (didnt realize it was!) must have been the fact it was 1am and I was dead tired. Apologies!

    Fair enough - but you did put it all in your first post. You had it all there from the start, so it looked like a duck most definitely. I think you were right all along, you just needed some advice on management.

    See above - I reckon you had it from the start - you had just never seen it before. I am not saying to 100% trust your ultrasonographer or radiologist for the diagnosis, but your clinical description above fit the bill perfectly and with the data provided from the plain films and US you were spot on the money.

    Diagnoses are formed from good clinical examination, extrinsic tests and experience. What did the great Phil Pearlman used to say "treat the patient not the films!"

    Spot on!

    It wasn't a jab at you - I was having a crack at the GP - I would never expect any Podiatrist to order anything but non-WB films.

    Cheers - was just a thought as they would have showed much more!

    Do what Kevin says above - your patient will be bringing you a bunch of flowers within 48 hours because of all the pain relief you have brought them! Good luck!
  9. Adrian Misseri

    Adrian Misseri Active Member

    Hey Sally,

    I had a similar patient only a few months ago who I diagnosed with deep traumatic bursae under both of her 1st MTPJs after my patinet (who has the same histery as yours, except she was 23) had tried getting into running and had 4 nights in a row of running. The bursae were quite large but were obviously fluid. On X-ray (using diacom images) I was able to even 'just ' see them in the soft tissues plantar the 1st MTPJs bilaterally, they were that large. I used tight, agressive taping to the area to put compression on the area to force them to re-absorb, as well as daily icing (especially after work as she worked in a cafe). Settled down in about a fortnight. At that point I got her into orthoses for other biomechanical issues, but certainly had to settle down the pain first.

    Interesting cases!!

  10. jane.e.benson

    jane.e.benson Active Member

    Has she been tested for RA?(more pain early morning)
    I have Ra with variuos bursa of different consistancies (but am serum negative)
    simplest treatment that seems to work is padding round bursa!
  11. Itchyfeet

    Itchyfeet Member

    HI There

    This sounds like a problem I have come across before.

    Please check out the Abductor Hallucis; it is possible this could have trigger points in, especially with the patient's past history of PF. The trigger points are found in the body of the muscle on the plantar aspect and similarly medially (2 points each). The pain is usually referred along the MLA and superiorly to above the ankle.
    Pain may aslo be felt under the 1st met.

    Treatment is by using well supported thumbs over the trigger points (the most painful areas) press in and move the thumbs about one inch lift thumbs off and go back to where you started. Do this about 6-10 times, the pain level for the patient should be 7/10. The points on the plantar aspect can be treated by using a small very firm rubber ball in a sock on the floor, ptnt standing and putting their weight on the ball till they reach that 7/10 and moving the foot over the ball.

    This needs to be carried out about 6 times a day and may take some time to clear, so the patient needs to know how to self treat.

    Trigger points in the Quad. plant. can also produce pain in the heel, the trigger point for this is found on the plantar aspect, distally about 4 cm from posterior of calc; press here and if it causes the ptnt pain there's the trigger point.

    A trigger point in the soleus (found at the junction with the Achilles tendon slightly medially to the midline of the lower leg.)

    If you are interested in trigger points check out The Trigger Point Therapy Workbook by Clair Davies - not only can you help your patients but also rid yourself of those shoulder, neck and back pains ( If you have a feeling of stiffness in the back of your neck this coould be TPs in the Sterno Cl Mast.

    All the best


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