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Painful conditions – at the heel

1)    Plantar fasciitis :-

Clinical Features

Pain at the inner aspect of the sole; during warking or standing. The 1st step taken after sitting or lying is specially painful.

Pathology:-

Lesion is usually mechanical in origin; and causes when too much strain falls on plantar fascia. This is likely happen in patients who have to stand for a prolonged period of time.

The normal shape of longitudinal arch of the foot is maintained by the muscles of foot but because of prolonged weight bearing, these muscles may become tired. Strain then falls on to the plantar fascia.

The condition seems to be more common in people with vaigus deformity, because this flattens the foot and put more strain on fascia.

Short calf muscles also causes overstrain on fascia in this condition achillis tendon tends to pull the heel upwards during standing; which stress the longitudinal arch and plantar fascia.

Examination;-

·       Functional examination of foot and ankle – Negative

·       Only positive sign is the deep tenderness of the anteromedial portion of the calcaneus; i.e. the origin of plantar fascia.

·       Calcanial spurs, coming forward at the anterior border of calcaneus are commonly seen in x-rays. Casually it has been implicated as the cause of Plantar Fasciitis, but mere is no relationship between the pain and the spur. The cause for pain is tendinitis of the fascia due to over strain.

Treatment:-

·       As there is no relationship between spur and pain surgical removal of spur is not advisable.

·       Raise the heel horizontally 5-10mm which will drop the fro foot when the pt stands. It has double effects.

a)     Shortens the distance between metartarsals and calcaneus directly relives the fascia from strain.

b)     It removes the tension on achillis tendon.

·       A high heel affords immediate release of pain. Relive of pain. (Upper surface is horizontal and not wedge)

·       If there is valgus deformity small inner wedge should be placed.

·       If those methods fail infiltration of steroids can be used accompanied with raised heel

·       Strengthening of short plantar flexor muscles as active protection against further overstretched.

·       Deep friction may also be helped to relive the pain.

 

2)     Plantar fascial tear:-

Mostly occurs in middle aged athletes.

Clinical Features

·       Sudden pain in mid foot during a sprint or jump.

·       Area of ecchymosis at the sole.

·       On palpation – tenderness at medical plantar aspect of foot

 

Treatment:-

 

·       Reduction of formation of haematoma and swelling by ‘RICE’.

·       Strengthening exs for foot, deep friction for tender area should be used in latter stage.

·       Within 3-4 wks fully recover.

 

3)     Heel pad syndrome :- (Superficial plantar fasciitis)

 

Tenderness of the heel pad between the calcaneus and the skin of the heel.

 

The heel pad consists of fatty tissues, elastic fibrous tissues enclosed in a fibrous septa. It connects the skin of the heel with the periosteum of the calcaneus and act as a shock absorber.

It can inflame after a direct blow or continuous strain on it pain is felt at posterior part of heel on examination.

 

Treatment:-

 

·        Raising of the heel and infiltration of steroid – useless

·       Injection of 10ml of local anesthetics into the pad between the superficial fascia and periosteum of calcaneus is effective.

·       The condition improves after a few days. The pt should have another injection a week later (If necessary).

 

4)      Subcutaneous bursitis:-

 

There is no an anatomical bursa between the posterior aspect of the calcaneus and the skin. But in some circumstances bursa may form; particularly when narrow and ill filling shoes are warm. Specially when they are carved in at the upper posterior edge.

Friction between hard borders against the calcaneus may form a bursa. Chronic irritation may thicken the wall of the bursa and skin overlaying.

 

In palpation very tender area at the posterior and upper end of the calcaneus; or at the lower end of the achillis tendon.

The bursa is usually visible inflamed and may contain fluid.

 

Treatment:-

 

·       Alter the back of the shoe.

·       Keep a rubber pad at the posterior end of the calcaneus to keep the calcaneus away from the compressing edge of the shoe.

·       Aspiration of the fluid and infiltration of steroid.

·       If above methods fails – surgical intervension.

 

 

 

 

AMAL GUNARATHNE

                  NTC, NATIONAL HOSPITAL

                  COLOMBO, SRI LANKA

 

Painful conditions – at the heel