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Let’s talk heel pain, this is a common complaint I see in the clinic. There can be many causes of heel pain. It is important to accurately diagnose heel pain and distinguish the vast causes of heel pain for the appropriate management. Below, is an Algorithm of heel pain from a paper that highlights the complexity around heel pain (see photo underneath of complexity of heel pain).
However, for the purpose of this blog, I will concentrate on two of the most common causes of heel pain I see which is plantar fasciosopathy and nerve entrapments.
Plantar fasciopathy or plantar fasciitis as it is commonly referred to is the most common cause of heel pain in the adult population. The plantar fascia plays an important role in foot biomechanics.
How does the plantar fascia act during walking?
What is the windlass mechanism?
Tension is placed on the plantar fascia which causes compression of the midfoot, raising the arch which creates mid-foot stability for effective propulsion (see photo plantar fasciitis explained above)
It is generally an over use injury where micro tears develop in the plantar fascia, followed by secondary degeneration.
It usually multifactorial condition with interrelated risk factors associated in its development from one person to another.
Typically, pain is around the medial aspect of the plantar heel and is aggravated with first steps in the morning or after periods of rest, which routinely gets better during the day and then resurfaces again at rest (show photo of plantar fascia anatomy).
Arguably, the second most common cause of heel pain I see in the clinic would be nerve entrapments. I will briefly discuss a few nerve entrapment types I see in the clinic. (To the right have photo of nerves from cadaver)
Tarsal tunnel syndrome – is an entrapment of the tibial nerve under the flexor retinaculum on the medial side of the ankle. Generally due an anatomical variation, structural anomoly putting pressure on the nerve- eg ganglion cyst, varicosties, abductor hallucis muscle, fascia irritation. Patients generally have pain, tingling, numbness basically along the whole bottom of the foot.
Medial calcaneal neuropathy – Medial calcaneal nerve is a branch of the posterior tibial nerve which carries sensory information from the skin over the plantar surface of the calcaneus and subcutaneous fat and part of the forefoot. It’a entrapment is likely caused from a tight plantar fascia, or other structural variations – ganglion sacs, varicosities etc. Patients often complain of a burning pain, pins and needles around the skin of the calcaneus and into part of the forefoot. See nerve anatomy below, and the sensory mapping of individual nerves categorised by the coloured regions.
Baxter’s nerve – is the first branch of the lateral plantar nerve. It supplies motor innervation to the quadrates plantae, flexor digitorum brevis, and abductor digits minima muscles within the foot, in addition, it provides sensory information from the calcaneal periosteum and long plantar ligament. It primarily gets entrapped distally between the abductor hallucis and the quadrates plantae muscles or in the calcaneal tuberosity between flexor digitorum breves and quadrates plantae muscles. Patients often describe a sharp, radiating pain along the course of the lateral plantar nerve (Baxter’s nerve). Pain is often brought on by walking and at times night. (see below baxter’s nerve anatomy)
Moroni, S., Zwierzina, M., Starke, V. et al. Clinical-anatomic mapping of the tarsal tunnel with regard to Baxter’s neuropathy in recalcitrant heel pain syndrome: part I. Surg Radiol Anat 41, 29–41 (2019). https://doi.org/10.1007/s00276-018-2124-z