The American College of Foot and Ankle Surgeons has developed a clinical practice guideline on heel pain. The guideline, which contains pathways (algorithms) for the treatment of heel pain based on underlying cause, was published in the September/October 2001 issue of The Journal of Foot and Ankle Surgery.

Mechanical Heel Pain

Mechanical factors are responsible for the majority of cases of heel pain. The plantar fascia is the most common location of mechanically induced symptoms, and the posterior heel is the next most common location.

PLANTAR HEEL PAIN

Plantar heel pain (insertional heel pain of the plantar fascia with or without a heel spur) usually occurs because of pathologic stress to plantar soft tissues as a result of biomechanical abnormalities. Localized nerve entrapment may be contributory.

The usual presentation is isolated plantar heel pain when weight is placed on the foot on arising in the morning or after sitting for a period of time. The pain generally decreases after a few minutes of weight-bearing but returns over the course of the day. Other findings may include pain on palpation of the inferior heel, a high body mass index, and a tight Achilles tendon. The diagnosis is based on the history, physical examination, and, when appropriate, radiographs.

Initial treatment options may include patient-directed measures such as regular calf-muscle stretching, cryotherapy, over-the-counter heel cushions and arch supports, weight loss (if indicated), activity limitation, and avoidance of flat shoes and barefoot walking. Treatment may also involve nonsteroidal anti-inflammatory drugs (NSAIDs), padding and strapping of the foot, and, in appropriate patients, corticosteroid injections. If improvement occurs, treatments are continued until symptoms resolve.

If no improvement occurs after six weeks, referral to a podiatric foot and ankle surgeon is appropriate. Initial treatment measures are continued, and additional treatments may include a customized orthotic device, night splinting, a limited number of corticosteroid injections, casting, or use of a fixed-ankle walker-type device during activity. If improvement occurs, treatments are continued until symptoms resolve.

If no improvement occurs after two to three months, initial treatment measures are continued. If not previously used, cast immobilization may be added. Further options include surgery (plantar fasciotomy) and extracorporeal shock wave therapy. Other diagnoses may need to be explored.

POSTERIOR HEEL PAIN

Insertional Achilles Tendonitis

Onset is usually insidious, and patients often have chronic posterior heel pain and swelling. Increased activity and pressure from shoes aggravate the pain. Relief of pain occurs when patients walk barefoot.

On physical examination, a prominence may be appreciated medially and laterally to the Achilles tendon insertion. Central or more global tenderness can be present. Radiographs often show spurring or erosion at the insertion of the Achilles tendon.

Initial treatment options may include open-backed shoes (to reduce pressure on the area), heel lifts or orthoses, NSAIDs, decreased activity, stretching exercises, and weight loss (if indicated). Local injections of corticosteroids are not recommended. In particularly acute or refractory cases, immobilization may be considered. If improvement occurs within six to eight weeks, treatments are continued until symptoms resolve.

If no improvement occurs, referral to a podiatric foot and ankle surgeon is appropriate. Initial treatments are continued, and an immobilization cast or fixed-ankle walker-type devise may be added. If symptoms do not improve after four to six weeks, resection of posterior spur and pathologic soft tissue may be indicated; to ensure complete resection, detachment and reattachment of the Achilles tendon may be required.

Bursitis Associated with Haglund's Deformity

This condition is most common in women 20 to 30 years of age, although it can occur in both sexes and at any age. Symptoms of acute pain and inflammation are aggravated by pressure from shoes. Pain is relieved when patients walk barefoot.

Tenderness is present lateral to the Achilles tendon, usually in association with a posterior lateral prominence. This prominence is commonly seen on radiographs.

Initial treatment options may include open-backed shoes, orthoses, accommodative padding, NSAID therapy, corticosteroid injections (avoiding the Achilles tendon), weight loss (if indicated), and physical therapy. If symptoms improve, initial treatments are continued.

If symptoms do not improve within six to eight weeks, other diagnoses may need to be considered, and patients should be referred to a podiatric foot and ankle surgeon. Initial treatments are continued, and an immobilization cast or fixed-ankle walker-type devise may be added. Bursa injection may be considered. The indicated surgical procedure is resection of the prominent posterior superior aspect of the calcaneus and inflamed bursa. Some patients may require calcaneal osteotomy to correct calcaneal alignment.

Neurologic Heel Pain

Neurologic heel pain can occur because of irritation or entrapment of one or more nerves innervating the heel. More proximal nerve impingement syndromes can also cause pain in the heel or absence of sensation in the heel and/or foot.

If neurologic heel pain is suspected, subspecialist referral for evaluation and diagnostic testing should be considered. Diagnostic studies may include electromyography, nerve conduction velocity studies, magnetic resonance imaging, and others. The podiatric foot and ankle surgeon may manage local conditions. Referral is required for problems originating in the lumbar area.

Heel Pain in Arthritides

Because heel pain can be caused by systemic arthritides (e.g., rheumatoid arthritis, psoriatic arthritis, Reiter's syndrome, fibromyalgia, gout), patients should be questioned about other joint pain and swelling. When an arthritis is suspected, proper diagnostic studies and consultation or appropriate referral are essential.

Traumatic Heel Pain

The most common osseous cause of heel pain is acute trauma to the calcaneus, almost always because of a fall onto the heel from a height. Diffuse pain in the rearfoot (poorly localized to the heel) occurs with intra-articular fractures involving the subtalar joint. In less severe injuries, more focal symptoms are present in the anatomic area of the fracture.

The diagnosis is based on a history of trauma and focal pain on palpation and is confirmed with radiographic studies. Surgery is the usual treatment. Simple immobilization is appropriate when fracture fragments are small, nonarticular, or minimally displaced.

Repetitive load to the heel can lead to stress fracture of the calcaneus, most commonly just posterior and inferior to the posterior facet of the subtalar joint. Many patients report increased walking activity just before the onset of symptoms.

Pain on compression of the calcaneus is highly suspicious for stress fracture. Tenderness occurs at the lateral wall of the calcaneus, slightly posterior to the facet. Swelling and warmth may be present. Symptoms often occur before the fracture can be seen on radiographs. In this situation, technetium bone scanning can be helpful. Treatment involves protecting and immobilizing the foot.

Soft tissue trauma, such as acute rupture of the plantar fascia, can cause heel pain. Radiographs and bone scans may be negative.

Other Causes

Rarely, tumors (malignant and benign), infections (soft tissue and bone), and vascular compromise can result in heel pain. If one of these conditions is suspected, proper diagnostic testing, as well as consultation and appropriate referral, are essential.

Calcaneal apophysitis is probably the most common cause of heel pain in adolescents. Palliative treatment is almost always successful.