Heel pain is a painful syndrome in the heel caused by a range of disorders. Heel pain can be divided by location into heel-plantar pain and posterior heel pain. The former is often caused by metatarsal tendinitis, metatarsal tendon membrane rupture, heel fat pad inflammation, plantar lateral nerve first branch entrapment, heel spur, heel osteochondritis, and heel fracture. The latter is often caused by Achilles tendonitis, Achilles bursitis, etc. In turn, Achilles tendonitis can be divided into two categories: non-stop Achilles tendonitis and stop Achilles tendonitis. In children, posterior heel pain is most often seen in heel nodal epiphysitis. Some systemic diseases, such as rheumatoid arthritis, gouty arthritis, Reiter syndrome, and ankylosing spondylitis, can also cause pain in the heel. Intraheel hypertension is thought to be a cause of heel pain syndrome, but there are objections to it. Heel pain is now rarely treated with heel drill decompression. Proximal metatarsal tendonitis (a) Anatomical features The metatarsal tendon membrane is a superficial part of the plantar fascia, similar to the palmar tendon membrane, but more developed and tough, consisting of longitudinal white fibers. It can be divided into medial bundle, lateral bundle and medial bundle. The middle fascicle is the thickest, starting from the medial tuberosity of the heel bone and dividing into five fascicles, which end at the skin of the metatarsal side of each metatarsophalangeal joint, the flexor tendon and the tendon fiber sheath. The intrinsic muscles of the foot that originate from the medial tuberosity of the heel are the bunion, the lesser trochanter and the metatarsophalangeal muscle. The role of the metatarsal tendon membrane is to (1) protect the plantar tissues of the foot. (2) To provide attachment points for certain intrinsic muscles of the plantar aspect of the foot. (3) To assist in maintaining the arch of the foot. (B) Etiology and pathology The exact cause of proximal plantar tendinitis is not well understood. Possible causes of pain include: (1) dorsal extension of the metatarsophalangeal joint during walking, which pulls on the metatarsal tendon membrane and thus on the heel tuberosity. As the foot muscles and ligaments weaken with age, the force of the metatarsal tendon membrane pulling on the heel tuberosity increases, and the long-term, repeated pulling causes a small tear at the beginning of the metatarsal tendon membrane, followed by inflammation, causing pain. 2.Osteochondritis at the heel stop of the metatarsal tendon membrane and fatigue fracture of the medial heel tuberosity. 3, Inflammation and edema at the stop of the flexor digitorum teres and its proliferating bone spur lead to entrapment of the first branch of the lateral plantar nerve. Although proximal plantar tenosynovitis is used as a diagnosis, in practice, inflammation of the proximal stop of the plantar tenosynovium and entrapment of the first branch of the lateral plantar nerve may coexist and be clinically indistinguishable. Clinically, it has been found to occur more frequently in obese middle-aged women and in those who enjoy sports, such as professional athletes and dancers who run and jump for long periods of time and in the general population who need to walk long distances. In addition, wearing soft-soled shoes and excessive exercise may also be a cause of metatarsal tendonitis. Other conditions, such as tibial entropion, Achilles tendon contracture, heel exostosis, foot rotation front deformity, and changes in the arch of the foot after degeneration of the tendons and ligaments in middle-aged and elderly people, will subject the metatarsal tendon membrane to greater stress, and the long-term chronic strain can cause small tears in the local tendon membrane and local edema to produce inflammation. Berkowitz compared the thickness of the proximal metatarsal tendon membrane between normal subjects and patients with chronic heel pain by MRI and found that the latter had an increase of 4.4 mm compared to the former. Pathological examination of the proximal metatarsal tendon membrane also revealed collagen necrosis, fibrovascular hyperplasia, chondrogenesis and matrix calcification. This pathologic change is similar to that seen at the flexor hallucis brevis stop in patients with tennis elbow, which has been referred to as “tennis heel” in proximal plantar tenosynovitis. Many patients with proximal plantar tenosynovitis are found to have heel spurs, which were thought by DuVries to be the main cause of medial heel-plantar pain, and by Tanz in 1963, who compared lateral radiographs of heel pain with those of normal subjects and found a 50% rate of heel spurs in the former compared with 16% in the latter. In contrast, Rubin and Witton concluded that only 10% of heel spurs cause heel pain. Later studies also found that the heel spur was not located at the beginning of the heel of the metatarsal tendon membrane, but at the beginning of the heel of the flexor digitorum profundum. With the exception of a few patients, the vast majority of patients with proximal metatarsophalangeal tendinitis do not require removal of the bone spur. (iii) Clinical manifestations Pain on the metatarsal side of the heel bone. The onset is usually slow. The pain is worse in the morning when walking the first few steps and can be partially relieved by further activity. However, the symptoms can be aggravated after prolonged activity. On examination, swelling of the anterior medial aspect of the heel is seen. There is significant pressure pain at the medial heel node and 2-3 cm from the beginning of the metatarsal tendon membrane. Pay attention to whether the patient has abnormal foot force lines, tibial inversion, inversion of the foot, as well as flat feet, high arched feet, etc. The Achilles tendon should also be checked for contracture. X-ray examination: about 50% of patients can see bone spurs on the metatarsal side of the heel node, and ultrasound and MRI examination can show thickening and edema of the metatarsal tendon membrane. The diagnosis is based on local swelling and pain, pressure points, and ultrasound and MRI findings of metatarsal tendon membrane thickening. (D) Treatment 1. Non-surgical treatment is effective in more than 90% of patients, but since it is not possible to determine which treatment has a definite effect when treating, it is often necessary to use a combination of several methods for comprehensive treatment. In some patients, even if they are not treated, the pain can eventually be relieved by itself. However, some patients have pain that can last for years. (1) Reduce activities that expose the heel to percussive impact. Reduce weight in obese patients. (2) Achilles tendon and metatarsal tendon membrane stretching exercises. Since contracture of the Achilles tendon is a common cause of metatarsal tendonitis, and moderate stretching of the metatarsal tendon membrane helps the inflammation to subside. Repeated daily Achilles and metatarsal tendon stretching exercises have become one of the most effective methods to reduce pain in patients with metatarsal tenosynovitis. The aim is reported: an efficiency of 83%. Exercises should be performed every day after waking up and before walking. Insist on exercising 4 to 5 times a day, 5 to 10 times each time, and obvious results can be achieved after 1 to 2 months. Metatarsal tendon pulling exercise method: ①Patient sit, bend knee, put the affected heel on the bed, ankle joint dorsal extension, push the 5 toes to the dorsal side with hand, maintain 30 seconds, repeat 5 times. ②Heel lift, sit with the hip on the heel,, maintain for 30 seconds, repeat 5 times. ③Patients sit with the affected heel raised, make the metatarsophalangeal joint extend dorsally as much as possible, push down on the posterior calf with the hand to further increase the metatarsal tendon pulling force, maintain for 30 seconds, repeat 5 times. ④ Place the front part of the affected foot below the wall and plantar flex the ankle joint with force, maintain for 30 seconds, repeat 5 times. Achilles tendon pulling exercise method: ① Flounder muscle pulling exercise, the patient stands toward the wall, the affected side is behind, slowly bend the knee joint to the flexed position, maintain 30 seconds, repeat 5 times. ② gastrocnemius muscle pulling exercise, the patient to the wall standing, the affected side in the back, keep the affected side of the lower limb straight, and the affected foot does not move, the heel can not lift, the upper body moved forward, so that the Achilles tendon is pulled. Maintain 30 seconds, repeat 5 times. (3) Achilles tendon pulling exercise, stand on the inclined plate, body upright, so that the Achilles tendon is pulled. (3) Physical therapy. Such as ultrasound, myoelectric stimulation, hot and cold therapy, etc. But the effect is generally not obvious. (4) Correction of poor force lines in the foot. Such as the use of foot pads, semi-hard adaptive foot pads for high arched feet, and slightly harder supportive foot pads for flat feet to reduce the tarsal tendon membrane pull. The use of heel pads can reduce the impact force on the heel, thus reducing pain. (5) Anti-inflammatory and pain-relieving drugs. Local closure. (6) If the pain is severe, use a night splint or plaster rest to fix the ankle joint 5° to 10° dorsiflexion to avoid contraction of the metatarsal tendon membrane at night, which will cause pain when moving in the morning. (6) Plaster fixation In patients with severe pain, if the above treatment fails, a short-legged cast can be used to fix the ankle joint in a neutral position for 1 month. (7) Extracorporeal shock wave therapy Extracorporeal shock wave therapy was first used to treat kidney stones. In the 1990s, extracorporeal shock wave has been widely used in the field of orthopedics. It is used to treat non-union and delayed healing of fractures and some chronic painful diseases such as tennis elbow, frozen shoulder, and plantar tendonitis. The mechanism of shock wave action on human tissues is not well understood, and Strash suggested that the mechanism of shock wave treatment for metatarsal tendonitis is that shock wave promotes the proliferation of new blood vessels at the junction of tendon and bone, which increases local blood flow and accelerates the regression of local inflammation. Ogden et al. analyzed 302 patients with metatarsal tenosynovitis treated by ESWT according to a randomized double-blind principle, and after 3 months of treatment were evaluated according to 4 criteria 1. subjective pain perception improved by at least 50%, and VAS pain score was below 4.0. 2. At least 50% improvement in pain at the start of walking in the early morning, with a VAS pain score of 4.0 or less. 3.The patient walked pain-free for the time and distance, basically pain-free or improved by more than 1 point out of 5 points. 4.No painkillers are needed after treatment. The percentage of patients who could meet all four criteria at the same time after ESWT treatment was 56%. The authors used extracorporeal shock wave to treat 98 patients with metatarsal tenosynovitis with an efficiency of 80%. However, the efficiency of 1 treatment was low, and the efficacy could be significantly improved after 3 treatments. 2.Surgical treatment Very few patients can be treated surgically when non-surgical treatment for more than 6 months is ineffective. Since the metatarsal tendon membrane plays an important role in maintaining the arch of the foot, completely severing the metatarsal tendon membrane may have adverse effects on the function of the foot. It has been shown that complete severance of the metatarsal tendon can cause weakness in walking on the surgical side of the foot and reduce arch stabilization by 25%. Currently, the recommended surgical approach is a partial cut of the metatarsal tendon membrane, i.e., a 35% to 50% cut medially from the metatarsal tendon membrane stop. This can be done with or without removal of the medial heel nodal spur. The procedure can be done incisionally or percutaneously, or arthroscopically, if available, with partial metatarsophotomy and spur removal.