Achilles spur syndrome Heel pain in the inferior region of the heel caused by pulling the plantar fascia over the periosteum, with or without the presence of spurs on X-ray. The spur is due to excessive pulling of the plantar fascia on the attachment of the heel bone to the periosteum. The excessive pull causes pain at the inner edge of the plantar fascia (plantar fasciitis). Lesions that cause tension in the plantar fascia include flatfoot and Achilles tendon contracture. Symptoms, signs and diagnosis Due to the pulling of the plantar fascia over the periosteum, the subacromial spur can cause pain in its early stages of formation, although the spur is small and cannot even be detected on X-ray. As the spur increases in size, the pain often disappears, perhaps due to adaptive changes in the foot. Thus, a typical bone spur visible on x-ray can be asymptomatic. Conversely, after an asymptomatic period, or as a result of local trauma (e.g., athletic injury-see section 62), the spur may become painful spontaneously. Occasionally, an exophytic bursa may form locally and cause inflammation (subacromial bursitis), causing a hot, throbbing pain at the base of the heel. The pain can be worsened by applying firm pressure to the center of the heel with the thumb during physical examination. In ankle dorsiflexion, firm finger pressure across the inner edge of the fascia with pressure pain is evidence of fasciitis. Although the presence of a bone spur on X-rays is diagnostic, early X-rays of heel spurs can be negative. Uncommonly, heel spurs are atypical on x-ray, showing a villi-like image of new bone formation. Seeing this change should consider the possibility of seronegative or HLA-B27 arthropathies (e.g., ankylosing spondylitis, Lyttle syndrome). Rheumatoid arthritis and gout are other causes of heel pain. These arthralgias often have moderate to severe fever and swelling, which can be distinguished from local causes of heel pain. Treatment Gastrocnemius elastic stretching exercises and night splints are often effective in removing pain and should be encouraged. Rubber plasters (similar to orthotics) can reduce plantar fascia tension and periosteal pulling pain, and oral nonsteroidal anti-inflammatory medications are preferred. Intraheel injections of local anesthetics are usually effective. When accompanied by signs and symptoms of inflammation, such as mild fever, swelling, and a history of subsequent throbbing pain (subacromial heel bursitis), an injection of a mixture of insoluble and soluble steroids can control symptoms, with the injection needle being inserted vertically from the medial aspect of the heel before moving to the painful point in the center of the heel. Achilles epiphysitis is a painful heel disorder that occurs in children. The heel bone develops from 2 ossification centers. One begins at birth and the other usually forms after 8 years of age. Before complete ossification occurs (usually by age 16), the fibers of the two parts of the bone or tendon attaching to the epiphysis are held together by cartilage. Strenuous activity can cause cartilage fracture. Diagnosis and treatment The diagnosis is based on the patient’s age, history of onset in sports and the typical site of pain, i.e., along the edge of the growth center. X-rays are not helpful in diagnosis. A heel pad is placed in the shoe. It may reduce the pull of the Achilles tendon on the heel. Plaster immobilization of the foot is sometimes effective. It is important to relieve the patient and his parents of any concerns, as symptoms can persist for months. Posterior bursitis of the Achilles tendon Inflammation of the bursa that occurs above the Achilles tendon is the result of abnormal heel position and function. Posterior Achilles bursitis is most commonly seen in young women, but can also occur in men. As the heel tends to move in an inversion position throughout the stride cycle, excessive pressure is placed on the soft tissue between the outer posterior aspect of the heel bone and the upper (forming a hard callus on the heel). This side of the heel bone becomes elevated and easily palpable and is often mistaken for an exophytic bone wart. Signs and Symptoms In the early stages, only a small, mild, hardened, painful erythema is seen over the posterior aspect of the heel, where patients often apply adhesive tape to relieve pressure from the shoe. When the inflamed bursa enlarges, a painful red lump appears on the Achilles tendon. Depending on the type of shoe the patient is wearing, the swelling sometimes extends to both sides of the Achilles tendon. In chronic cases, the bursa forms permanent fibrosis. Treatment The heel is elevated with a foam rubber pad or felt pad to remove the compression from the upper of the shoe. A shoe orthosis is required to control abnormal heel movement. In a small percentage of patients, lengthening the upper or removing the heel suture of the shoe may reduce inflammation, and placing a pad around the bursa may reduce compression. Oral nonsteroidal anti-inflammatory drugs may temporarily reduce symptoms. Infiltrative injections of soluble corticosteroids with local anesthetics may reduce inflammation. If conservative treatment is not effective, surgical resection of the posterior lateral talus may be required. Posterior external talar tuberosity fracture This fracture is the result of a plantarflexion injury where pressure is applied to the talar tuberosity from the posterior lower tibial labrum. This cartilage joint fracture usually occurs as a consequence of sudden metatarsal or toe jumps during basketball and tennis. Similarly, it can occur when a chair is stepped backwards with force. Ballerinas are more susceptible to this injury with elongation of the lateral talar node (Stieda process). Symptoms, signs and diagnosis There is often pain and swelling at the back of the ankle and difficulty walking down hills or stairs. There may also be persistent swelling without a significant history of trauma. The surface may be warm, but to a lesser degree. The patient’s pain worsens when the foot is plantarflexed toward the calf. It is said that this is sometimes done with dorsiflexion [of the toes. However, the latter maneuver is still suspicious. Lateral radiographs of the ankle are necessary to confirm the diagnosis. Bilateral X-rays should be performed to rule out triangular bone. Treatment Plaster immobilization is required for 4-6 weeks. If pain persists and soft tissue inflammation is present, a combination of corticosteroid and local anesthetic infiltration injections may be effective. Surgical removal of the lateral talar tuberosity may be required. Anterior Achilles tendon bursitis Inflammation of the bursa beneath the Achilles tendon where it attaches to the heel bone. Associated with trauma and inflammatory arthritis (e.g., rheumatoid arthritis). Any condition that increases strain on the Achilles tendon can be a cause of the disease, as can hard or high shoe tops. Symptoms, signs, and diagnosis Bursitis is rapid in trauma-induced bursitis and usually gradual in systemic disease. Common symptoms are pain in the posterior heel space, swelling, fever, difficulty walking, and difficulty putting on shoes. The swelling is initially limited to the anterior aspect of the Achilles tendon, but soon extends medially and laterally. The swelling, heat and pain near the Achilles tendon originate in the soft tissue, both of which can be differentiated from a posterior talar tuberosity fracture. X-rays should be performed to rule out fractures or rheumatoid erosive heel changes. Treatment Soluble corticosteroids and anesthetics are injected into the bursa, and care must be taken to avoid direct injection of the medication into the Achilles tendon. Warm compresses and rest may also reduce pain. Posterior tibial neuralgia Refers to the extension of pain along the distribution of the posterior tibial nerve (neuralgia). The posterior tibial nerve crosses the fibrocartilaginous canal in the plane of the ankle within the umbilical ligament and divides at the exit between the medial and lateral plantar nerves. Tarsal canal syndrome refers to compression of the nerve within this fibro-osseous canal, but this diagnosis has been used less strictly for different causes of posterior tibial neuralgia. Synovitis of the flexor tendons of the ankle due to abnormal foot function or inflammatory arthritis can sometimes cause secondary compression neuralgia of the posterior tibial nerve. Occasionally, venous stasis and edema can also cause posterior tibial neuralgia. Symptoms, signs, and diagnosis Burning or pins-and-needles pain within the ankle and around the ankle (often extending to the toes). The pain increases with activity and decreases with rest. Pain appears when standing, walking or wearing shoes. Tapping or palpation of the posterior tibial nerve on the lower aspect of the medial ankle that has been compressed or traumatized often produces a distal tingling sensation (Tinel’s sign). Electrophysiologic examination helps to clarify the diagnosis and should be performed on all patients preparing for foot surgery. When there is swelling in the nerve area, the cause should be sought (e.g., rheumatism, phlebitis, or fracture). Treatment The foot is held in its natural position or mildly pronated with adhesive tape, or an orthotic is fitted to the shoe to keep the foot in the pronated position to reduce tension on the posterior tibial nerve. Local infiltration with insoluble corticosteroids and local anesthetics may be effective when there is no real compression of the posterior tibial nerve in the fibular canal. Surgery is used only in those cases where conservative treatment has failed.