Chapter 30: Heel ConditionsAnatomy of the HeelRadiological Evaluation of the Calcaneus The Heel in Systemic DiseaseSeronegative Arthritis and Heel PainHeel Spurs and Heel Spur SyndromeTumors of the HeelTarsal CoalitionsSever's DiseaseHaglund's DeformityCauses of Heel Pain (a summary)

HEEL CONDITIONS

Anatomy of the Heel 1. Blood supply:

2. Attachments:a. The plantar calcaneal tuberosity consists of 2 smaller tubercles, the larger, the medial process, and the smaller the lateral process, separated by a sulcus.b. The plantar aponeurosis is made up of a medial, central, and lateral band (the central band being divided into a superficial and a deep plantar fascia).c. The central band is attached to the medial process of the plantar tuberosity, posterior and plantar to the origin of the flexor digitorum brevis.d. The band divides into 5 slips as it approaches the digits (the superficial stratum inserts into the skin of the transverse sulcus separating the digits from the sole, and the deeper stratum divides into two slips which embrace the sides if the flexor tendons and blend with the sheaths of these tendons).e. The abductor hallucis originates from the medal tubercle of the calcaneal tuberosity and plantar aponeurosis and extends along the medial side of the foot until it inserts into the medial side of the proximal phalanx of the hallux.f. The FDB attaches at the medial calcaneal tubercle just superior to the plantar aponeurosis, and extends along the aponeurosis where it sends tendon slips to the 4 lateral digits, with each tendon splitting into 2,allowing the FDL to pass between them on its way to the distal phalanx

(these medial and lateral slips insert into the base of the middle phalanx) g. The abductor digiti minimi originates at the medial and lateral tubercles of the calcaneal tuberosity and plantar aponeurosis and extends along the lateral aspect of the foot to insert into the lateral side of the base of the proximal phalanx of the 5th toeh. The long plantar ligament attaches at the medial and lateral tubercles of the calcaneal tuberosity and extends across the plantar aspect of the calcaneus where it branches into 4 ligamentous slips to the bases of the 4 lesser metatarsalsi. Dorsally interconnecting the talus and calcaneus and in reinforcing the functional subtalar joint are the interosseous talocalcaneal ligament (located in the sinus tarsi) and the cervical ligament (located lateral to the sinus tarsij. Other ligaments include: the lateral, medial, and posterior talocalcaneal ligaments, and the calcaneotibial and calcaneofibular portions of the collateral ligaments of the ankle jointk. The calcaneal dorsal surface has 3 facets, anterior, middle and posterior. The posterior is the largest, separated from the middle by the sulcus calcanel (or sinus tarsi when including the sulcus tali of the talus)

3. Innervation:a. The tibial nerve gives off the medial calcaneal branches that innervates the heel while continuing through the tarsal tunnel, and as it exits the tunnel it divides into the medial and lateral plantar nerves b. The lateral plantar nerve runs along the medial side of the lateral plantar artery where it innervates the quadratus plantae and abductor digiti minimi ms., and then divides into superficial and deep branches. The lateral plantar nerve travels deep to the plantar aponeurosis as it leaves the tibial nerve from the tarsal tunnel to travel distally and laterally and crosses the aponeurosis where it inserts into the calcaneal tuberosity c. The inferior calcaneal nerve branches from the lateral plantar nerve just distal to the bifurcation of the tibial nerve into medial and lateral plantar nerve, and courses between the abductor hallucis ms. and medial head of the quadratus plantae ms., and continues laterally remaining 5.5 cm anterior to the calcaneal tuberosity coursing between the FDB and long plantar ligament. It finally crosses over the lateral head of the quadratus plantae and terminates in the abductor digiti minimi ms.

Radiological Evaluation of the Calcaneus

The Heel in Systemic DiseaseMany diseases manifest themselves in the heel. These include the following:1. Rheumatoid arthritis:a. Sources of heel pain in RA have been attributed to plantar and posterior spurring, calcaneal erosions, valgus deformity of the STJ and heel, associated sites of soft tissue inflammation (Achilles tendonitis, plantarmyofasciitis, inferior and posterior calcaneal bursitis), or the presence of rheumatoid nodulesb. Most commonly affected sites in the heel are the posterior surface near

the insertion of the Achilles tendon and the inferior surface near the origin of the plantar fasciac. Bony changes involve bony proliferation or spurring, erosive changes, sclerosis, and osteoporotic changes

2. Gout:a. The calcaneus may be affected in gout by pressure erosion from adjacent tophaceous deposits penetrating bone, classically producing wellmarginated bony erosions with sclerotic margins and over-hanging edges b. Mineralization of the calcaneus in gout is unaffected

3. Calcium pyrophosphate dihydrate deposition (CPPD):a. This disorder mimics acute gouty attacks, and rarely affects the calcaneus, however, can affect the talocalcaneonavicular region producing an osteoarthritis profile demonstrating joint space narrowing, and subchondral cyst formation. This is sometimes called chondrocalcinosis.

4. Osteoporosis:a. It is estimated that 30% of bone must be lost before osteoporosis can be identified radiographicallyb. It has been suggested by numerous authors that the calcaneus be used in the evaluation of osteoporosis by grading changes (as bone mass diminished, there was a reproducible change in the trabecular appearance which was progressive as bone became more porotic)

5. Diffuse idiopathic skeletal hyperostosis (DISH):a. This is recognized as an ossifying diathesis, most commonly encountered in middle-aged males, characterized by areas of hyperostosis at points of attachment of tendon, ligament or fascia to bone (axial spinal symptoms predominate).b. Pedal conditions involve the talus (beaking), heel pain, and plantar and retrocalcaneal spurs. The spurs are large, irregularly shaped, with well defined margins, without reactive sclerosis, periosteal reaction, or erosions producing a noninflammatory appearance (calcification of the plantar fascia may be seen)

6. Diabetes mellitus:a. Periarticular calcifications of the calcaneus b. Calcifications of the long plantar ligament c. Osteophytosis of the calcaneus

NOTE* Rheumatoid arthritis according to a study by Resnick et al, produces erosive bony changes at the posterior/superior surface and the posterior surface of the calcaneus immediately above the site of attachment of the Achilles tendon. It also produces well-developed posterior and plantar spurs at the posterior surface at the site of insertion of the Achilles, and the plantar surface anterior to the site of attachment of the plantar aponeurosis

d. Diabetic osteoarthropathy e. Pathologic fractures

7. Hypertrophic osteoarthropathy:a. Involves the clinical triad of clubbing of the nails, periostitis with new bone formation, and arthritis. Often seen secondary to pulmonary neoplasms or pulmonary suppurative conditions, bowel disorders, heart disorders, thyroid disorders, and other conditions (some genetic) b. It has been reported that the calcaneus has been involved with this disease, manifesting itself with a band of increased density elevated from the lateral aspect of the tuberosity, in the region of the calcaneo-cuboid joint (acute periostitis with subperiosteal new bone formation)

8. Paget's disease of bone (osteitis deformans):a. This condition involves accelerated bone resorption and destruction followed by disorganized repair, leaving an irregular mosaic pattern of well defined mature and immature boneb. The calcaneus has been seen to be involved, with the chief symptom of pain in the heelc. Radiographic demonstration of areas of decreased density with widening, destruction, and disorganization of the calcaneal trabecular pattern amid irregular, patchy, sclerotic areas creating the typical irregular mosaic type pattern

9. Sarcoidosis:a. Is a multisystem, multiorgan disorder of a autoimmune etiology and with associated immunologic abnormalities, typified by the development of noncaseating granulomas in various organsb. Increased observance of HLA B8 antigenc. Sarcoid arthropathy occurs 3-15%, and presents as an acute polyarthritis d. This disease can affect the calcaneus with the symptom of heel pain. Radiographically there can be cortical defects or cyst formation

10. Sickle cell anemia:a. An autosomal dominant disorder characterized by an abnormality in hemoglobin, producing hemolytic crises and a variety of clinical complications related to vascular occlusive phenomena. b. Calcaneal involvement has been reported manifested by aseptic necrosis documented by Tc-99m bone scans (decreased uptake), and an erosive process on the superior surface of the calcaneus (may be pathognomonic for sickle-cell)

11. Acromegaly:a. Occurs secondary to an excessive amount of growth hormone present after epiphyseal closure which results in excessive growth of various body parts, (hands, feet, jaw, internal organs, etc.)b. Clinical there is thickening of the skin (increased heel pad thickness)

Seronegative Arthritis and Heel Pain

Patients who do not respond to conservative treatment or present with an atypical picture might cause the clinician to consider some of the less common causes of heel pain as these.1. General features of the seronegatives:a. Unlike RA, these disorders have a greater affinity for the spinal and sacroiliac areas, and involve the insertions of tendons and ligaments on bone which produce painful enthesopathies (these are thought to produce the heel pain associated with the seronegatives)b. Increased incidence of HLA B27

2. Ankylosing spondylitis (Marie Strumpell disease): Peripheral arthritis may be the initial presentation and the heel may be involved.

3. Reiter's Syndrome: Involvement of the enthesis of the calcaneus, presenting with mild, moderate swelling without redness.

4. Psoriatic arthritis

5. Treatment:a. NSAIDs usually work wellb. Methotrexate may be used in severe cases of Reiter's syndrome and psoriatic arthritisc. Physical therapyd. Orthoses

NOTE* HLA B27 is thought to be linked to genes that regulate new bone formation

Heel Spurs (Heel Spur Syndrome)1. Etiology:a. Disease processesb. Biomechanical abnormalities (physiologic reaction to constant stress forming new connective tissue which eventually converts to bone) includes all types of feet with an abnormal pronation component and even supinated foot types

2. Diagnosis:a. Radiographicallyb. Palpation with execution of the Hubscher maneuver over the medial band of the plantar fascia

3. Treatment: Heel spurs should only be treated if symptomatica. Orthosesb. Oral anti-inflammatory medications and steroid injectionsc. Shoe accomodations d. Strappings e. Physical therapy f. Surgery:i. Surgical approaches: Medial horizontal incision (DuVries) Posterior horizontal "U" incision (Griffith) Transverse plantar incision (Michetti) Longitudinal plantar incision Lateral horizontal incision Minimal incision approach (Mercado) Endoscopic Plantar Fasciotomy (Barrett and Day)ii. Whatever the approach, careful dissection is mandatory to avoidtransection of the lateral plantar nerveiii. Other complications Wound dehiscence Hematoma Phlebitis Infection Fracture

NOTE* A heel spur (exostosis) need not be painful; it is only significant that the patient has pain at the anatomic site and that we determine the pain is caused by a mechanical abnormality and not to any other sources of heel pain (heel spur syndrome). Abnormal pull of the plantar calcaneal periosteum at the tuberosity causes separation of periosteum from bone and an inflammatory reaction (hence pain). The pulled periosteum fills in forming the spur. Hence, it is an adaptive response. No pull=no separation=no inflammation=no pain. Once a spur forms and there is no new pull, etc., there is no pain despite the presence of a spur (barring fractures, etc.). Pronation and supination place a twisting pull on the calcaneal periosteum at the tubercles, hence spurs form.

Tumors of the HeelAs the largest bone in the foot, the calcaneus has many anatomic features which make it unique and potentially more prone to develop tumors and tumor-like conditions. Internally, it has an abundant vascular supply, which may explain the increased incidence of metastatic malignant lesions. Alsothe large cancellous component may sequester these tumors for long periods of time before they become symptomatic. Externally, the extensive surface area of the calcaneus and the numerous points of attachment of intrinsic and extrinsic muscles, tendons, and ligaments lend themselves to a vast array of tumors. Pain has been shown to be the primary complaint of patients presenting with tumors. 1. Pseudotumors:a. Inclusion cysts: in the soft tissuesb. Traumatic neuromas: in the soft tissuesc. Ganglionic cysts: in the soft tissue or boned. Keloids: in soft tissuese. Foreign body granulomas: in soft tissuesf. Piezogenic papules (protrusions of adipose tissue surrounding the heel) g. Rheumatoid nodules: in soft tissues

2. Skin and soft tissue tumors:a. Verrucaeb. Molluscum contagiosumc. Keratoacanthomad. Squamous cell carcinomae. Plantar fibromatosis (Ledderhose's or Dupuytren's disease) f. Lipomasg. Eccrine poromah. Leiomyomai. Glomus tumorj. Malignant melanomak. Kaposi's sarcomal. Many others

3. Bone tumors:a. Solitary bone cyst: Most frequently seen bone lesion other than the heel spur, found in the anteroinferior and lateral regions of the calcaneus. Can be found as a result of pathologic fracture of the thin wall (“Fallen Fragment” sign on x-ray)b. Ewing's sarcoma and other sarcomas

NOTE* Endoscopic Plantar Fasciotomy by Barrett and Day has been reported to give excellent results via the transection of a portion of the plantar fascia. The bony exostosis is left intact. This procedure utilizes two small incisions with a slotted canula passed just inferiorly to the fascia. Through one end of this canula a camera (scope) is passed and through the other end a small knife is passed.

c. Osteoid osteomad. Intraosseous lipomae. Giant cell tumor of bone

f. Multiple myeloma: the most common primary bone malignancyg. Aneurysmal bone cysth. Chondroblastomai. Osteoblastoma

j. Chondromyxoid fibromak. Hemangiomal. Osteogenic sarcoma

Tarsal CoalitionsIt is usually a congenital anomaly that represents a failure of differentiation and segmentation of primitive mesenchyme, which results in failure of joint formation. These coalitions cause a limitation or absence of motion of the involved joint and can affect the entire foot in gait 1. Classifications:a. Intra-articular vs. extra-articular (usually accessory bone fusion) b. Fibrous, cartilaginous, or osseousc. Developmental patternd. Congenital or acquired (acquired cases include trauma, previous surgery, infection, RA, and OA).

2. Types:a. Talocalcaneal (fuses between the ages of 12-16): Talar beaking; broadening lateral talar process; middle subtalar joint not visualized; asymmetric anterior subtalar joint; "ball and socket" ankle joint. Usually the middle facet.b. Calcaneonavicular (fuses between the ages of 8-12): Close approximation of the calcaneus and navicular; irregularity and indistinctness of cortical surfaces; hypoplastic head of the talus c. Talonaviculard. Calcaneocuboid (rare)

3. Pathognomonic Signs and Symptoms:a. Peroneal Spasticity (peroneal spastic flatfoot) b. Talonavicular beakingc. Halo sign (in cases of T-C coalition, occasionally this sign can be observed on the lateral projection, seen around the sinus tarsi) d. Broadening and flattening of the lateral process of the talus e. Decrease in ROM of the subtalar joint f. Sudden onset of pain after excessive activityg. Children begin to complain between the ages of 12-15 (with T-C bars) h. Sinus tarsi syndromei. If an osseous bar is present then there will be no motion at the STJ and no pain over the bar but pain can be present distally j. Adults may be asymptomatic but show degenerative changes

4. Radiological Diagnosis:a. Normal Harris Beath projections: the posterior and middle facets should be present and parallel to each other. With a subtalar coalition the facets are no longer parallel.b. CT scanning provides the best diagnostic tool (it is the gold standard) c. Calcaneonavicular coalitions can best be seen on the 45° medial oblique x-ray d. Talonavicular and calcaneocuboid coalitions can be seen on the lateral view

5. Treatment: Surgerya. Calcaneonavicular coalition:i. A modified Oilier approachii. Origin of the extensor digitorum brevis muscle belly is detachedproximally and reflected distally (bar now exposed)iii. An osteotome or saw is used to resect the osseous segment (at least 1cm of bone is removed)iv. The EDB belly is now placed Into the defect created and then sutured to the plantar medial aspect of the foot using Keith needles, nonabsorbable suture, and button fixationv. The wound is closed in layers

vi. A BK cast is applied for 4 weeks

NOTE* The calcaneonavicular bar resection is contraindicated in the presence of degenerative changes In the talonavicular joint with accompanying talar beaking, with complete ossification of the bar, and when there is a second coalition between the talus and calcaneus. If this procedure fails, a triple arthrodesis may be indicated to relieve the patient's symptoms

b.

Talocalcaneal coalition:i. Conservative therapy 1 st since most of these are asymptomatic and when symptomatic respond to conservative care. BK walking casts for 3-6 weeks Injection into the sinus tarsi with steroids Orthosesii. Surgery (resection of the bar vs. triple arthrodesis)•Medial Incision for resection of middle facet coalition, with the incision starting just behind the medial malleolus and following the top of the calcaneocuboid joint

The posterior tibial and FDL are retracted superiorly; the FHL and neurovascular bundle are retracted inferiorly K-wires are used to locate the joint A rotary drill with a burr is used to resect the coalition If successful there will be an immediate increase in motion

c. Associated Conditions: (Tarsal coalitions have been reported to be associated with the following)i. Phocomelia and hemimeliaii. Nievergelt-Pearlman syndromeiii. Arthrogryposis multiplex congenita

Sever's DiseaseSever's disease was first described by Haglund who noted irregularities of the calcaneal apophysitis, similar to those observed in osteochondrosis of the tibial tuberosity. It is the only bone in the body whose epiphysis assumes the entire weight before it is ossified1. Secondary ossification:a. First appears in females (ages 4-6) and later in males (ages 7-8)b. It can be divided into a bipartite or tripartite apophysisc. Fusion takes place as early a 12 years old in females and 15 years old in males

2. Etiology:a. Tension from the Achilles tendon and plantar fascia (equinus) b. Acute and chronic traumac. Infectiond. Embolisme. Stress fracturef. Obesityg. Congenital and hereditary factorsh. Endocrine disturbancesi. Diet disturbances

3. Symptoms:a. Increased pain with activity especially sportsb. Demonstrable pain when the posterior aspect of the heel is squeezed from side to side when direct pressure is exerted on the lower one-third of the posterior calcaneus

4. Treatment: Always conservative a. Rest and cessation of sports b. Heel liftsc. BK cast in resistant casesd. Follow-up with an orthosese. Stretching excercises

Haglund's DeformityHaglund's syndrome, a common cause of pain in the posterior heel, consists of a painful swelling of the local soft tissues with or without the prominence of the calcaneal. bursal projection. 1. Clinical presentation: It is a chronic, sometimes painful condition, characterized clinically by a tender swelling in the region of the Achilles tendon near its insertion and radiographically by an osseous proturberance at the superio-posterior aspect of the calcaneus

2. Radiographic analysis:a. Fowler-Phillip angle: 44°-69° is normal (>75° is pathologic)

b. Using the following diagram is more accurate to represent this disorder

3. Treatment:a. Conservative: Removing pressure either with a heel lift or orthoses

b. Surgical:i. Resection of the posteriosuperior border of the calcaneus and bursaii. Wedge (osteotomy with the base dorsally) is removed from theproximal half of the calcaneus posteriorly to the posterior articular facet (the vertical cuts to be two-thirds the height of the calcaneus, but through and through from medial to lateral)

(NOTE* The symptoms will resolve when the apophysis fuses

NOTE* Since the calcaneal inclination angle can influence the usefulness of the Fowler-Phillip angle, the C-I angle should, therefore, be taken into account (see the following diagram)

NOTE* The incision most commonly employed for both procedures is a lateral para-Achilles tendon approach with the incision being linear, lazy "L", or reversed "J" shaped

Causes of Heel Pain (a summary)1. Inflammatory:a. Juvenile RAb. Rheumatoid arthritis c. Ankylosing spondylitis d. Reiter's syndrome e. Gout

2. Metabolic:a. Migratory osteoporosis b. Osteomalacia

3. Degenerative:a. Osteoarthritisb. Atrophy of fat pad

4. Nerve entrapment:a. Tarsal tunnel syndromeb. Entrapment of the medial calcaneal branch of the PT nerve

c. Entrapment of the nerve to the abductor digiti quinti

5. Traumatic:a. Calcaneal fracturesb. Calcaneal malunionsc. Traumatic arthritisd. Rupture of the fibrous septae of the fat pad e. Puncture of the fat pad

6. Overuse syndromes:a. Plantar fasciitisb. Stenosing tenosynovitis of the FDL and FHL c. Calcaneal apophysitisd. Subcalcaneal bursitise. Periostitisf. Calcaneal stress fractures g. Achilles tendonitish. Haglund's deformity

7. Infectious:a. Osteomyelitis

8. Other: a. Tumors