Heel Pain : Mnemonic

Mnemonic: HEEL PAINS

1. Heel pad syndrome

2. Enthesopathy

3. Entrapment

4. Ligaments

5. Plantar fasciitis

6. Posterior tibial tendinopathy/tenosynovitis

7. Peroneal tendinopathy/tenosynovitis

8. Arthritis

9. Impingement

10. Neuroma

11. Spurs

12. Stress fracture

13. Sinus tarsi syndrome

14. Sever’s disease

15. S1 radiculopathy

heel pain causes
ConditionDescriptionSite of heel painSymptomsSignsManagement
Heel pad syndromeInflammation or atrophy of heel fat padPlantarWalking after rest or barefoot painful, pain increases with activity; patient often overweightTender to palpation of heel pad; tiptoe standing/walking may cause pain reliefRest, ice, taping, anti-inflammatory/analgesic medicines, heel cups, proper foot wear
Enthesopathy – AchillesAchilles insertional tendinopathyPosteriorChange to weight bearing load (foot wear or running); middle aged; worsens with activity; fluoroquinolone useTenderness +/- palpable prominence on both sides of achilles tendon insertion; passive dorsiflexion increases painTier 1: Heel-lifts, open back shoes, cryotherapy/topical anlagesics, limit activities, oral anti-inflammatories, orthoses, physical therapy, weight loss

Tier 2: + Immobilization (cast or CAM walker)

Tier 3: Surgery (resection of insertional spurring; tendon debridement)
a. Posterior tibial nerve (Tarsal tunnel syndrome)Can be caused by trauma, space occupying lesions, poor biomechanics or systemic diseasesMedialNeuropathic pain in posteromedial ankle/heel (sometimes into distal sole and toes); worsening with standing, walking, running; relieved with rest, elevation, loose footwear; pain radiating to medial aspect of leg (Valleix phenomenon)Tinel sign positive; Provocative maneuver (dorsiflexion-eversion or plantar flexion-inversion); often hyperpronated or flat feetActivity modification, corticosteroid injection, oral or topical NSAIDs, orthotic devices, neuromodulator drugs (TCAs, antiepileptics)
b. Baxter’s nerve entrapment (between abductor hallucis/AH and Quadratus plantae/QP)Baxter nerve is the 1st branch of lateral plantar nerve (motor to Abductor digiti minimi; sensory to plantar heel)MedialNeuropathic pain; common in running atletesTenderness over the medial aspect of the heel in line with the
posterior border of the medial malleolus; no sensory deficit
Like tarsal tunnel syndrome

Surgical release of abductor hallucis fascia
c. Jogger’s foot (medial plantar nerve entrapment)Compression at knot of henry (FDL and FHL); most common cause is foot orthotics; also in running athletesMedialPain and numbness at the medial heel and arch radiating towards the first and second toeMedial arch tenderness;
Abductor Hallucis tenderness at navicular tuberosity; Tinel sign; Provocative (forced passive heel eversion)
Discontinue/modify orthotics

Surgical release
LigamentsDeltoid and spring ligamentsMedial
Lateral ligaments of ankleLateral
Plantar fasciitis/fasciosisInflammation of the plantar fascia aponeurosis; baxter’s neuritis may co-existPlantarPain with first steps after prolonged rest (often morning)Tenderness of medial calcaneal tuberosity (insertional) or along plantar fascia; Provocative (passive toe dorsiflexion – tightens windlass mechanism)Tier 1 (trial of 6 weeks): Padding and strapping, stretching exercises, OTC arch support/heel cup, shoe recommendations, oral anti-inflammatories, corticosteroid injection

Tier 2 (trial of 6 months): Corticosteroid injection, custom orthotics, night splint, immobilization, physiotherapy

Tier 3: ESWT; Fascia release +/- Nerve release (nerve release cant be done endoscopically)
Posterior tibial tendinosis (PTT)/dysfunction (PTTD)PTTD – increased laxity of posterior tibial tendon resulting in flat foot and heel varus; overuse and obesity; arthropathiesMedialPain at posterior edge of medial malleolus that may extend toward arch of footSwelling or redness over painful area; progressive loss of arch of foot; Unable to perform single limb heel raiseEarly – weight loss, NSAIDs, icing, physical therapy, orthotics or bracing for arch and ankle support

Trial of short leg cast for 6 weeks

Surgery – tendon repair, tendon transfer, calcaneal osteotomy, tarsal bone fusion
Peroneal tendninopathyLateral
ArthritisSubtalar jointDeep, vague
ImpingementSoft tissues or os trigonumPosteriorRepetitive flexion activities; Pain in plantar flexed/en pointe positionPosterolateral ankle pain with passive ankle plantar flexionNSAIDs, rest, immobilization, restricted weight bearing

Surgical excision – open lateral approach or posterior ankle arthroscopy
NeuromaPlantarNeuropathic painPainful lump on palpationDecrease pressure over affected area
SpursHaglund deformity/runner’s bump/calcaneal exostosis/pump bump +/- retrocalcaneal bursitisPosteriorEnlarged posterosuperior calcaneal prominence; aggravated by shoe wear; relieved by barefoot/open shoesTenderness lateral to the Achilles tendon, usually associated with
a palpable posterior lateral prominence (but it is a radiographic diagnosis)
Tier 1: Open back shoes, cryotherapy/topical analgesics, orthoses, accommodative padding, oral anti-inflammatories, physiotherapy, weight loss

Tier 2: + immobilization( cast or CAM walker) +/- injection of bursa

Tier 3: Resection of Haglund’s/bursa; Calcaneal osteotomy
Plantar heel spurPlantarAssociations – plantar fasciitis, arthritides (osteoarthritis, ankylosing spondylitis, psoriatic arthritis)Decrease pressure to affected area
Stress fractureCalcaneumPlantarIncreased activity or change to harder walking surface; pain with activity progressively worsens to pain at restTenderness with compression of calcaneus (but it is a radiographic diagnosis)Activity modification with occasional non-weight bearing

Heel pads or walking boots
Sever diseaseCalcaneal apophysitisPosteriorAdolescents; Worsens with activity or during growth spurtTenderness at achilles insertion; Pain with passive dorsiflexion and mediolateral calcaneal compressionActivity modification; NSAIDs; Ice; Stretching/strengthening exercise; Orthotics/shoe modification
Sinus tarsi syndromeSinus tarsi, or talocalcaneal sulcus, is an anatomic space bound by the calcaneus, talus, talocalcaneonavicular joint, and posterior facet of the subtalar jointLateral (anterior and inferior to lateral malleolus)Pain in lateral calcaneus or ankle; feeling of foot/ankle instability; worse with exercise or uneven surface; history of repeated ankle sprainsSubtalar instability and increased ROMOrthotics, Icing, Anti-inflammatory/Analgesics, Physiotherapy, Corticosteroid injections

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