Heel pain / Plantar / Achilles tendon issues

Question 1

Important causes of heel pain include:

Answer 1

Achilles tendon disorders:

–tendonopathy/peritendonitis

–bursitis

• postcalcaneal
• retrocalcaneal

–tendon tearing

• partial
• complete

Others:

• bruised heel
• tender heel pad—usually atrophy
• ‘pump bumps’
• plantar fasciitis
• calcaneal apophysitis
• peroneal tendon dislocation
• posterior tibialis tendonopathy
• tarsal tunnel syndrome
• neuropathies (e.g. diabetic, alcoholic)

Question 2

Investigation of choice:

Answer 2

US examination is useful to differentiate the causes of Achilles tendon disorders.

Question 3

Achilles tendon bursitis

Answer 3

Bursitis can occur at two sites:

• posterior and superficial—between skin and tendon
• deep (retrocalcaneal)—between calcaneus and tendon

Treatment

• Avoid shoe pressure (e.g. wear sandals)
• 1–2 cm heel raise inside the shoe
• Apply local heat and ultrasound
• NSAIDs (14-d trial)
• Inject corticosteroid into bursa with a 25 g needle

Question 4

Plantar fasciitis, features

Answer 4

This common condition (also known as ‘policeman’s heel’) is characterised by:

• pain on the plantar aspect of the heel,
• esp. on the medial side;
• it usually occurs about 5 cm from the posterior end of the heel.

History

• Pain:
• –under the heel
• –first steps out of bed
• –relieved after walking about
• –increasing towards the end of the day
• –worse after sitting
• May be bilateral—usually worse on one side
• Typically >40 yrs
• Both sexes

Signs

• Tenderness: deep and localised
• Heel pad may bulge or appear atrophic
• Crepitus may be felt
• No abnormality of gait, heel strike or foot alignment

Question 5

Treatment of Plantar fasciitis

Answer 5

Heals spontaneously in 12–24 mths

Consider trial NSAIDs—3 wks

Therapeutic foot massages

Exercise program to stretch Achilles tendon & plantar fascia (very effective)

US therapy

Hydrotherapy: place foot alternately 30 secs in hot & cold water for 15 mins

Protect heel with an orthotic pad to include heel and foot arch (e.g. Rose insole or thick pad of sponge or sorbo rubber)

Injection of LA and depot corticosteroid into tender site helps for at least 2–3 wks for very severe pain (otherwise avoid)

Question 6

Achilles tendonopathy/peritendonitis

Answer 6

Clinical features

• History of unaccustomed running or long walk
• Usually young to middle-aged males
• Aching pain on using tendon
• Tendon feels stiff, esp. on rising
• Tender thickened tendon
• Palpable crepitus on movement of tendon

Treatment

• Rest: ? crutches in acute phase, plaster cast if severe
• Cool with ice in acute stage, then heat
• NSAIDs (14-d trial)
• 1–2 cm heel raise under the shoe
• US and deep friction massage
• Mobilisation, then graduated stretching exercises

Avoid corticosteroid injection in acute stages

• and never give into tendon.
• Can be injected around the tendon if localised and tender.

Question 7

Partial rupture of Achilles tendon

Answer 7

Clinical features:

• A sudden sharp pain at the time of injury, radiates to knee
• Sharp pain when stepping off affected leg
• A tender swelling palpable about 2.5 cm above the insertion
• May be a very tender defect about size of tip of little finger

Treatment:

If palpable gap—early surgical exploration with repair.

If no gap, use conservative treatment:

• initial rest (with ice) and crutches
• 1–2 cm heel raise inside shoe
• US and deep friction massage
• graduated stretching exercises

Convalescence is usually 10–12 wks.

Question 8

Complete rupture of Achilles tendon

Answer 8

Clinical features:

• Sudden onset of intense pain
• Pt usually falls over
• Feels more comfortable when acute phase passes
• Development of swelling and bruising
• Some difficulty walking, esp. on tiptoe

Diagnosis:

• Palpation of gap (best to test in first 2–3 h as haematoma can fill gap)
• +ve Thompson’s test (calf squeeze test)

Treatment:

Early surgical repair (within 3 wks).