Chapter 30: Heel Conditions

Anatomy of the Heel

Radiological Evaluation of the Calcaneus
The Heel in Systemic Disease
Seronegative Arthritis and Heel Pain
Heel Spurs and Heel Spur Syndrome
Tumors of the Heel
Tarsal Coalitions
Sever's Disease
Haglund's Deformity
Causes 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 toe
h. 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 metatarsals
i. 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 tarsi
j. Other ligaments include: the lateral, medial, and posterior talocalcaneal
ligaments, and the calcaneotibial and calcaneofibular portions of the
collateral ligaments of the ankle joint
k. 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 Disease
Many 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, plantar
myofasciitis, inferior and posterior calcaneal bursitis), or the presence of
rheumatoid nodules
b. 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 fascia
c. Bony changes involve bony proliferation or spurring, erosive changes,
sclerosis, and osteoporotic changes

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

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 radiographically
b. 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
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 bone
b. The calcaneus has been seen to be involved, with the chief symptom of
pain in the heel
c. 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 organs
b. Increased observance of HLA B8 antigen
c. 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

NOTE* HLA B27 is thought to be linked to genes that regulate new bone
formation
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 well
b. Methotrexate may be used in severe cases of Reiter's syndrome and
psoriatic arthritis
c. Physical therapy
d. Orthoses
Heel Spurs (Heel Spur Syndrome)
1. Etiology:
a. Disease processes
b. 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
 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.

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

3. Treatment: Heel spurs should only be treated if symptomatic

a. Orthoses
b. Oral anti-inflammatory medications and steroid injections
c. 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 avoid
transection of the lateral plantar nerve
iii. Other complications
• Wound dehiscence
• Hematoma
• Phlebitis
• Infection
• Fracture
 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.

Tumors of the Heel

As 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. Also
the 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 tissues
b. Traumatic neuromas: in the soft tissues
c. Ganglionic cysts: in the soft tissue or bone
d. Keloids: in soft tissues
e. Foreign body granulomas: in soft tissues
f. Piezogenic papules (protrusions of adipose tissue surrounding the heel)
g. Rheumatoid nodules: in soft tissues

2. Skin and soft tissue tumors:

a. Verrucae
b. Molluscum contagiosum
c. Keratoacanthoma
d. Squamous cell carcinoma
e. Plantar fibromatosis (Ledderhose's or Dupuytren's disease)
f. Lipomas
g. Eccrine poroma
h. Leiomyoma
i. Glomus tumor
j. Malignant melanoma
k. Kaposi's sarcoma
l. 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
c. Osteoid osteoma
d. Intraosseous lipoma
e. Giant cell tumor of bone

f. Multiple myeloma: the most common primary bone malignancy

g. Aneurysmal bone cyst
h. Chondroblastoma
i. Osteoblastoma
j. Chondromyxoid fibroma
k. Hemangioma
l. Osteogenic sarcoma

Tarsal Coalitions
It 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 osseous
c. Developmental pattern
d. 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. Talonavicular
d. Calcaneocuboid (rare)

3. Pathognomonic Signs and Symptoms:

a. Peroneal Spasticity (peroneal spastic flatfoot) b. Talonavicular beaking
c. 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 activity
g. Children begin to complain between the ages of 12-15 (with T-C bars) h.
Sinus tarsi syndrome
i. 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: Surgery
a. Calcaneonavicular coalition:
i. A modified Oilier approach
ii. Origin of the extensor digitorum brevis muscle belly is detached
proximally and reflected distally (bar now exposed)
iii. An osteotome or saw is used to resect the osseous segment (at least 1
cm 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 fixation
v. 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
• Orthoses
ii. 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 hemimelia
ii. Nievergelt-Pearlman syndrome
iii. Arthrogryposis multiplex congenita

Sever's Disease
Sever'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 ossified
1. 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 apophysis
c. 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 trauma
c. Infection
d. Embolism
e. Stress fracture
f. Obesity
g. Congenital and hereditary factors
h. Endocrine disturbances
i. Diet disturbances

3. Symptoms:
a. Increased pain with activity especially sports
b. 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 lifts
c. BK cast in resistant cases
d. Follow-up with an orthoses
e. Stretching excercises
 (NOTE* The symptoms will resolve when the apophysis fuses

Haglund's Deformity
Haglund'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)

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)

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 bursa
ii. Wedge (osteotomy with the base dorsally) is removed from the
proximal 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 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 RA
b. Rheumatoid arthritis
c. Ankylosing spondylitis
d. Reiter's syndrome
e. Gout

2. Metabolic:
a. Migratory osteoporosis
b. Osteomalacia

3. Degenerative:
a. Osteoarthritis
b. Atrophy of fat pad

4. Nerve entrapment:
a. Tarsal tunnel syndrome
b. Entrapment of the medial calcaneal branch of the PT nerve
c. Entrapment of the nerve to the abductor digiti quinti

5. Traumatic:
a. Calcaneal fractures
b. Calcaneal malunions
c. Traumatic arthritis
d. Rupture of the fibrous septae of the fat pad
e. Puncture of the fat pad

6. Overuse syndromes:
a. Plantar fasciitis
b. Stenosing tenosynovitis of the FDL and FHL
c. Calcaneal apophysitis
d. Subcalcaneal bursitis
e. Periostitis
f. Calcaneal stress fractures
g. Achilles tendonitis
h. Haglund's deformity

7. Infectious:
a. Osteomyelitis

8. Other:
a. Tumors