09/10/2024
Common Causes of Heel Pain: Analysis by Physio Meets Science
๐ฆถBaxter neuropathy, aka distal tarsal tunnel syndrome, or entrapment of the inferior calcaneal nerve (Baxter's nerve), presents at a distinct location (medial heel) from plantar fasciopathy as well as with a different constellation of symptoms (neuropathic) and may be considered in any patient with plantar heel pain (https://journals.lww.com/jaaos/abstract/2014/06000/plantar_and_medial_heel_pain__diagnosis_and.5.aspx). Patients complain of severe pain along the medial arch into the heel, which is often unrelenting. Unlike plantar fasciopathy, pain from Baxter's nerve entrapment is not usually worse in the morning.
๐ฆถ The heel pad, which is located beneath the calcaneus, consists of adipose tissue within a highly organized and specialized confluence of fibrous septae that extend from the skin to the calcaneal periosteum. These septae are arranged into a stiff superficial microchamber and a deep macrochamber that undergoes substantial deformation with loading (https://pubmed.ncbi.nlm.nih.gov/17272407/). The heel pad serves as a shock absorber, allowing the heel to tolerate high loads and repetitive load bearing. Heel pad atrophy typically begins in the fifth decade of life and likely is the result of loss of water, collagen, and elastic tissue (https://books.google.de/books/about/Surgery_of_the_Foot_and_Ankle.html?id=9VVRPgAACAAJ&redir_esc=y). The heel pad becomes less elastic in both the elderly and in persons with diabetes, and these patients are particularly prone to heel pad atrophy. (https://pubmed.ncbi.nlm.nih.gov/24860133/)
๐ฆถ Plantar fasciopathy, former plantar fasciitis, is a common cause of inferior heel pain in athletes (https://pubmed.ncbi.nlm.nih.gov/28717618/). In runners, the incidence of plantar fasciopathy ranges from 4.5% to 10.6% and is the third most common cause of running-related musculoskeletal injuries (https://pubmed.ncbi.nlm.nih.gov/22827721/, https://pubmed.ncbi.nlm.nih.gov/24416176/).Histological analysis of the plantar fascia in patients diagnosed with plantar fasciopathy demonstrate collagen degeneration, angiofibroblastic hyperplasia, and myxoid degeneration without inflammation suggesting that this condition is more consistent with a fasciosis (https://pubmed.ncbi.nlm.nih.gov/12756315/, https://pubmed.ncbi.nlm.nih.gov/6614290/).
Patients usually experience start-up pain, that is, plantar medial heel pain that culminates either with their first steps in the morning or subsequent to prolonged periods of rest. This pain is typically sharp and does not radiate (https://pubmed.ncbi.nlm.nih.gov/24860133/).
๐ฆถ Calcaneal stress fractures occur most frequently in athletes, military trainees, and elderly patients with osteopenia. These injuries are caused by repetitive overload and the inability of bone formation to match resorption. A thorough history often elicits changes in exercise or activity, typically involving recent adoption of a more rigorous exercise regimen. Patients with calcaneal stress fracture typically report intense, diffuse heelpain along the medial and lateral aspects of the posterior tuberosity. Pain is exacerbated by activity and weight bearing, and it may progress to become persistent even at rest (https://pubmed.ncbi.nlm.nih.gov/1978717/). Patients often experience tenderness along the lateral wall of the calcaneal tuberosity. A positive calcaneal squeeze test, or pain on direct compression of both the medial and lateral walls of the calcaneus, is pathognomonic.
๐ท Figure: Different tender locations for the various etiologies that cause heel pain, https://link.springer.com/book/10.1007/978-3-642-54493-4
