Monday, May 1, 2017

Plantar Heel Pain

Plantar heel pain is a commonly encountered orthopedic problem that can cause significant discomfort and a limp because of the difficulty in bearing weight. The etiologies of this condition are multiple; therefore, a careful clinical evaluation is necessary for its appropriate management. Nonsurgical or conservative care is successful in most cases.

The specialized soft tissue at the heel functions as a shock absorber. The subcutaneous structure consists of fibrous lamellae arranged in a complex whorl containing adipose tissues that attach with vertical fibers to the dermis and the plantar aponeurosis.

An inflammatory response and reparative process can double the thickness of the plantar fascia, which is normally approximately 3 mm. Biopsy specimens reveal collagen necrosis, angiofibroblastic hyperplasia, chondroid metaplasia, and calcification.

The heel pain can also have a neurologic basis. The tibial nerve, with nerve roots from L4-5 and S2-4, courses in the medial aspect of the hindfoot, through the tarsal tunnel, under the flexor retinaculum, and over the medial surface of the calcaneus. The calcaneal branch, arising directly from the tibial nerve, carries sensation from the medial and plantar heel dermis. The tibial nerve and its branches in the hindfoot can be involved with compressive neuropathies. A valgus heel can stretch in the tibial nerve.

Clinical Presentation
A careful history and physical examination is valuable in identifying the etiology of heel pain. Taking a comprehensive medical and general history is important in order to distinguish between various causes.
The most common cause of plantar heel pain in both athletic and nonathletic populations is proximal plantar fasciitis.
  • The discomfort commonly manifests spontaneously and insidiously without an antecedent trauma or fever. Occasionally, some patients state they might have stepped on a small object such as a pebble or they may have recently started an exercise regimen involving walking or running.
  • The pain is localized to the plantar and medial aspects of the heel. It is worse typically with the first few steps in the morning. The pain causes patients to limp for approximately half an hour. It is also worse after a period of rest, such as after standing up from a chair or getting out of a car.
  • An acute onset of pain, especially after a vigorous or sudden athletic activity, can be indicative of traumatic rupture of the plantar fascia.
  • Fat pad atrophy in elderly patients and in persons who have received multiple steroid injections manifests with pain under the heel that is more diffuse, involving most of the weight-bearing surface.
  • Pain radiating from the heel distally or proximally and associated with numbness, paresthesia, or a burning sensation after activity and continuing even after rest is likely to be neurologic in origin.
  • Significant loss of appetite and weight or pain at night can be indicative of a neoplasm.
ExaminationA general examination is necessary to rule out systemic causes of heel pain. A spine examination is required if the pain radiates.
In the local examination, inspect the foot and the heel for any abnormalities such as swelling, lumps, scars, bruising, or foot deformities such as pes planus or pes cavus.
Palpation is performed to elicit the site of maximum tenderness. Check the condition of the fad pad, feel for defects or lumps in the plantar fascia, and identify any bony deformity due to previous fractures.
Percussion over the tibial nerve in the tarsal tunnel and its distal branches is performed to check for hypersensitivity or tingling. Percussion over any previous scars in the region can be performed to detect a neuroma in the scar.

Generally, plantar fasciitis is a clinical diagnosis; laboratory and imaging studies are rarely indicated. However, heel pain, especially bilaterally, can be a rare primary presenting sign of systemic inflammatory disorders. If a patient presents with bilateral heel pain in association with systemic symptoms, then screen the blood for inflammatory markers, such as the erythrocyte sedimentation rate (ESR), human leukocyte antigen (HLA)-B27, rheumatoid factor (RF), and antinuclear antibodies (ANA).
Proximal plantar fasciitis is successfully managed with conservative care in approximately 90% of cases. In general, the longer the duration of symptoms, the longer it takes for the patient to obtain complete pain relief. Various modalities of treatment are available, and patient education is important to improve the understanding of the condition and to obtain compliance with various treatment regimens.
  • Reducing impact
  • Reducing inflammation
  • Stretching and strengthening
  • Fat pad atrophy is managed conservatively with the use of heel cups, soft insoles, and soft-soled footwear.

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