Chinese name：跟痛症
English name: heel pain
Definition: A generic term for painful disorders around the heel.
Heel pain is a disease named after the pain in the heel of the foot. It is a disease caused by chronic strain around the heel nodes, mainly pain and difficulty in walking, often accompanied by the formation of bone spurs in the heel nodes. The disease is most common in middle-aged and elderly people aged 40 to 60 years old and obese people. Clinical heel pain is often accompanied by bone spur formation, but the degree of heel pain is not proportional to the size of the bone spur, but rather to the direction of the bone spur. If the spur is oblique to the bottom, there is often pain, but if the spur is parallel to the heel bone, there may be no symptoms. Although there are various causes of heel pain, the main etiology is chronic inflammation of the metatarsal tendon membrane or the attachment of the Achilles tendon.
1.Physiological structure
The heel bone, which is approximately rectangular in shape, is the main part of the body that carries weight. At least 50% of the body’s weight needs to be borne by the heel bone and talus when the body is standing. In order to walk and absorb shock, the foot forms two longitudinal arches and one transverse arch. The inner longitudinal arch is higher and consists of the heel bone, talus, navicular bone, cuneiform bone and one, two and three metatarsals, while the outer longitudinal arch is lower and consists of the heel bone, dice bone and four and five metatarsals. In the front of the foot, the three cuneiform bones and the five metatarsal bases are arranged in an arch-like arrangement with a wide back and a narrow back, forming the so-called transverse arch. The arch of the foot can act as a spring to cushion the shock produced by walking, jumping and running. The heel bone and the talus bone form the posterior arm of the longitudinal arch, which is mainly weight-bearing. The heel-talar joint allows the foot to be turned inward, outward or abducted and externally rotated to adapt to walking on uneven roads. The heel tuberosity is where the Achilles tendon attaches, and its upper edge forms a tuberosity joint angle of 30° to 45° with the heel-talar joint surface (Bere’s angle), which is an important symbol of the heel-talar relationship. This angle often decreases, disappears or becomes negative due to heel fracture, thus weakening the strength of the gastrocnemius muscle and the spring effect of the foot.
The sole of the foot is a three-point weight-bearing, with the heel bearing about 50% of the weight and the bunion and ball of the little toe jointly bearing about 50% of the weight. Because the first metatarsal is generally longer than the other metatarsals, and there are two sub-bones cushioned under its head, thus the weight-bearing thumb ball than the ball of the little toe for more.
The back of the heel body is oval in shape and is divided into three parts: upper, middle and lower. The upper part is smooth; the middle part is the starting and ending part of the Achilles tendon, and there are small bursae in front of and behind the Achilles tendon stop; the lower part migrates to the heel tuberosity, and there are bunions, toe flexors and talonavicular membrane attachments, which play a role in maintaining the arch of the foot. There are also bursae below the heel tuberosity. The skin of the heel is the thickest part of the body, and its subcutaneous tissue is composed of elastic fibers and dense and well-developed fat, also known as fat pad.
The metatarsal fascia is triangular in shape, narrow at the posterior end and about 2 mm thick. It starts from the front of the medial process of the heel node, its deep surface is closely combined with the short toe flexors, and gradually widens and thins forward, dividing into five bundles at the head of the metatarsal bones, extending to the 1-5 toes respectively, ending at the skin of the front of the sole and migrating to the tendon sheaths of the toes. The plantar tendon membrane has the role of protecting the plantar muscles, muscle legs, and supporting the arch of the foot.
2.Etiology and pathogenesis
(1) Achilles tendon stop bursitis: mainly due to shoe friction, especially women often wear high-heeled shoes, repeated friction between the back of the shoe and the heel nodes, resulting in chronic aseptic inflammation of the bursa at the heel nodes, so that the bursa increases, the wall of the bursa thickens, and the disease occurs.
(2) Inferior heel fat pad inflammation: generally patients have a history of trauma, mostly due to careless walking, the heel was injured by uneven pavement or small stone road, causing damage to the fatty tissue below the negative focus of the heel bone, local congestion, edema, hyperplasia.
(3) Heel epiphysitis: This disease occurs only during the period from the appearance of the heel epiphysis to its closure. The second ossification center of the heel bone appears from the age of 6 to 7 and gradually closes at the age of 13 to 14, so this disease occurs mostly during the growth period of adolescents.
(4) Metatarsal fasciitis: this disease is due to long-term occupational relationship standing on hard ground work, or because of flat feet, so that the talar tendon membrane in a long-term tension, at its starting point due to repeated strains of congestion, exudation, over time, the bone hyperplasia, the formation of bone spurs.
(5) Kidney deficiency heel pain: old age and weakness or prolonged illness in bed, kidney deficiency, then bone atrophy and tendon relaxation, modern medicine believes that prolonged illness in bed, the heel because of infrequent weight-bearing and degenerative changes, thinning of the skin, partial atrophy of the fat pad under the heel, bone decalcification changes caused by.
3.Clinical manifestations
(1) Achilles tendon stop bursitis: swelling and pressure pain at the Achilles tendon attachment. The pain can be caused by the friction of shoes when walking more. It is more serious in winter than in summer, and the pain is related to weather changes.
Examination: There is a cartilage-like elevation above the posterior aspect of the heel bone. The skin on the surface is thickened and slightly red, and the mass is cystic to touch and painful to pressure.
(2) Inferior heel fat pad inflammation: pain below the heel bone when standing or walking, with stiffness and swelling and pressure pain, but no cystic sensation.
(3) Staghorn epiphysitis: Most commonly seen in children aged 6 to 14 years. Radiographs show that the heel bone is flattened, the density is unevenly increased, the shape is irregular, wavy or worm-like, and the posterior line of the epiphysis is widened.
(4) Metatarsal fasciitis: pain under the heel bone when standing or walking, pain can extend forward along the medial side of the heel bone to the bottom of the foot, especially in the morning after waking up or after resting when just starting to walk, but the pain is reduced after walking for a period of time.
(5) Kidney deficiency heel pain: bilateral heel pain and weakness when standing or walking, but no obvious local pressure pain. X-ray film shows that there is no obvious abnormality outside the heel bone itself slightly decalcified.
4.Diagnosis and differential diagnosis
This disease can be diagnosed according to the medical history, symptoms and related examination. However, attention should be paid to differentiate it from the following diseases.
(1) Heel osteomyelitis: Although heel osteomyelitis has symptoms of heel pain, there may be obvious signs of acute infection such as localized redness, swelling, heat and pain, and in severe cases, systemic symptoms such as high fever. Laboratory tests and radiographs can establish the diagnosis.
(2) Tuberculosis of the heel bone: This disease occurs mostly in adolescents, with obvious local symptoms, a large range of swelling and pain, poor general condition, and low fever and night sweats, fatigue and weakness, loss of appetite, etc. Laboratory tests and X-ray examinations can distinguish it.
5.Treatment
(1) Treatment principle: relaxing tendons and channels, activating blood circulation and relieving pain.
(2) Points and areas: Sanyinjiao, Yinlingquan, Taixi, Zhaohai, Rangu, Kunlun, Servant Ginseng and around the affected area.
(3) Main techniques: pointing, pressing, pressing, kneading, stroking, side striking and other techniques.
(4) Operation methods
a, heel stop bursitis: patients lying prone on the bed, the affected limb knee flexion 60 °, the doctor held the affected foot with one hand for dorsiflexion fixed, so that the Achilles tendon tension, the other hand with a small fish interval, aimed at the bursa force side strike. The function of the manual method is: to promote local blood circulation, reduce swelling and pain, or make the bursa rupture and fluid absorption. (The principle of small needle knife treatment is the same).
b. Plantar fasciitis: the patient lies on his back with the lower limbs straight. The doctor first presses the acupuncture point with the point press method, then presses and kneads the painful point with one thumb or “dingzhi”, then pushes and rubs and smooths along the direction of Yang’s fascia with the rubbing and smoothing method, and makes the bottom of the foot hot.
c. Western medicine treatment: local painful point closure treatment.
6.Caution
(1) Patients with plantar fasciitis should pay attention to proper rest, reduce weight-bearing and control strenuous exercise during the acute period. After the symptoms are relieved, gradually carry out contraction exercises of the plantar muscles to enhance the muscle strength of the plantar muscles.
(2) Pay attention to local warmth and avoid cold stimulation.
The mechanism of massage treatment for this disease is mainly to stimulate the soft tissues of the bone spurs to promote the dissipation of the inflammation caused by their proliferation, rather than to make the bone spurs disappear. In patients who are clinically cured, the heel pain disappears completely, but the bone spur still exists. For patients with metatarsal fasciitis, orthopedic insoles can be used to cushion the proximal end of the metatarsal head so that the metatarsal head holds less weight and to make plantarflexion and dorsiflexion movements of the metatarsophalangeal joint.
A final reminder: heel pain is a “self-limiting disease” in clinical practice, and no one will go a lifetime without relief.