Review Article

Plantar and Medial Heel Pain:

Diagnosis and Management

Abstract
Craig R. Lareau, MD Heel pain is commonly encountered in orthopaedic practice.
Gregory A. Sawyer, MD Establishing an accurate diagnosis is critical, but it can be challenging
due to the complex regional anatomy. Subacute and chronic plantar
Joanne H. Wang, BA
and medial heel pain are most frequently the result of repetitive
Christopher W. DiGiovanni, MD microtrauma or compression of neurologic structures, such as plantar
fasciitis, heel pad atrophy, Baxter nerve entrapment, calcaneal stress
fracture, and tarsal tunnel syndrome. Most causes of inferior heel pain
From the Alpert Medical School, Brown
University, Providence, RI (Dr. Lareau,
can be successfully managed nonsurgically. Surgical intervention is
Dr. Sawyer, and Ms. Wang), the Rhode reserved for patients who do not respond to nonsurgical measures.
Island Hospital, Providence (Dr. Lareau Although corticosteroid injections have a role in the management of
and Dr. Sawyer), and Harvard Medical
School and the Massachusetts General select diagnoses, they should be used with caution.
Hospital, Boston, MA (Dr. DiGiovanni).
Dr. Sawyer or an immediate family
member serves as a paid consultant to
Mitek. Dr. DiGiovanni or an immediate
family member has received royalties
from Extremity Medical; is a member of
H eel pain is a common complaint
among orthopaedic patients.
Establishing an accurate diagnosis can
ing exercises, physical therapy, pre-
fabricated shoe inserts, and custom
orthoses. Such measures are effective in
a speakers’ bureau or has made paid be challenging due to the complex most patients, especially when both the
presentations on behalf of BioMimetic
Therapeutics, Extremity Medical, and
regional anatomy and the close prox- patient and physician allow adequate
Wright Medical Technology; serves as imity of potential pain generators. The time for them to work. Corticosteroid
a paid consultant to BESPA, BioMimetic differential diagnosis should include injections should be used sparingly.
Therapeutics, Extremity Medical, and vascular, infectious, oncologic, and Although these are considered by many
Wright Medical Technology; has stock
or stock options held in Extremity
systemic causes. Subacute and chronic to be capable of accelerating recovery,
Medical and Wright Medical heel pain are most commonly due to the current literature demonstrates only
Technology; has received research or repetitive microtrauma or compres- short-term benefit and indicates a con-
institutional support from BioMimetic sion of neurologic structures. stellation of notable potential side
Therapeutics and Wright Medical
Technology; and has received
Typically, diagnosis can be made effects.1-6 Surgical intervention is indi-
nonincome support (such as equipment based on a detailed history and physical cated for carefully selected patients
or services), commercially derived examination that allow the clinician to with recalcitrant pain whose symptoms
honoraria, or other non–research- pinpoint the location of maximal ten- have persisted despite an appropriate
related funding (such as paid travel)
from CuraMedix and Performance
derness (Figure 1). Weight-bearing course of nonsurgical measures. Further
Orthotics. Neither of the following plain radiographs should be obtained study is needed to determine the efficacy
authors nor any immediate family to assess alignment and degenerative of the relatively new treatment modal-
member has received anything of value changes and to exclude fracture and ities, including platelet-rich plasma
from or has stock or stock options held
in a commercial company or institution
other skeletal abnormalities. Advanced (PRP) injection and extracorporeal
related directly or indirectly to the subject imaging studies and electromyography shock wave therapy (ESWT).
of this article: Dr. Lareau and Ms. Wang. (EMG) can be used to confirm or
J Am Acad Orthop rule out certain diagnoses and to
provide additional information when
Plantar Fasciitis
Surg 2014;22:372-380
http://dx.doi.org/10.5435/
the diagnosis is uncertain.
In general, initial management should Epidemiology, Anatomy, and
JAAOS-22-06-372
consist of one or more nonsurgical Pathophysiology
Copyright 2014 by the American
Academy of Orthopaedic Surgeons. modalities, including rest, shoe wear Plantar fasciitis (PF) represents the
modification, NSAIDs, home stretch- most common cause of heel pain in

372 Journal of the American Academy of Orthopaedic Surgeons

Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Craig R. Lareau, MD, et al

adults, affecting 2 million persons Figure 1

annually in the United States.7 The
peak incidence occurs between ages 40
and 60 years, although it has
been known to occur in runners who
are younger.8 Bilateral involvement,
which occurs in approximately one
third of patients, should prompt con-
sideration of inflammatory disease.8
The plantar fascia is a fibrous
aponeurosis that originates from
the plantar medial aspect of the
calcaneal tuberosity and divides
into five slips that insert distally on each
of the proximal phalanges. These fibers
also merge with the surrounding der-
mis, transverse metatarsal ligaments,
and flexor tendon sheaths. Especially at
the first metatarsophalangeal joint,
dorsiflexion activates the windlass
mechanism, which increases plantar
fascial tension and elevates the medial Clinical photographs of the medial (A) and plantar (B) aspects of a left foot
longitudinal arch.9 The plantar fascia demonstrating locations of tenderness for five diagnoses of heel pain: heel pad
lacks elasticity, exhibiting a maximal atrophy (1), plantar fasciitis (2), Baxter nerve entrapment (3), calcaneal stress
elongation of only 4% of its length in fracture (4), and tarsal tunnel syndrome (5).
cadaver specimens.10
PF is believed to result primarily from that culminates either with their first dorsiflexion can be obtained during
repetitive microtrauma and excessive steps in the morning or subsequent to knee flexion compared with knee
strain.11 Although it is considered to be prolonged periods of rest. This pain is extension, this test indicates the
an inflammatory condition based on typically sharp and does not radiate. presence of a primary gastrocnemius
historic descriptions, recent studies Physical examination reveals tender- muscle contracture. In the event that
suggest that it is a noninflammatory, ness at the site of the plantar fascial no such substantive difference exists
degenerative process that may be more insertion on the medial calcaneal between these two testing conditions
appropriately termed plantar fas- tuberosity. Tenderness may extend but there is still significant dorsi-
ciosis.11,12 Histologically, PF involves along the plantar fascia, and it in- flexion restriction, the patient is likely
myxoid degeneration with disorienta- creases with maneuvers that stretch to have an Achilles contracture (spe-
tion of collagen fibers, angiofibro- the plantar fascia, including passive cifically, combined gastrocnemius
blastic hyperplasia, and calcification.11 toe dorsiflexion. Restricted ankle and soleus muscle tightness).
Reduced ankle dorsiflexion due to dorsiflexion may be identified due to
tightness of either the Achilles tendon contracture of the Achilles tendon or
or the gastrocnemius muscle may be the gastrocnemius muscle itself. The Diagnosis
associated with the development of PF; Silfverskiöld test can be performed Typically, advanced imaging is not
obesity and weight-bearing professions to differentiate between primary con- necessary to confirm the diagnosis of
are other independent risk factors.13-15 tracture of the gastrocnemius muscle PF. However, weight-bearing plain
Other risk factors include advanced itself and of the gastrocnemius-soleus radiographs usually are obtained to
age, poor footwear, overtraining, and complex.16 This specific maneuver rule out other skeletal causes of heel
reduced subtalar joint mobility.8 involves comparative manual stress pain. The radiographic finding of
assessment of resultant maximal ankle a heel spur, or plantar calcaneal
dorsiflexion during neutral foot align- calcification, should be considered
Presentation and Physical ment when the knee is in full extension nonspecific because these are often
Examination and again when the knee is flexed present in asymptomatic patients.17
Patients usually experience start-up 90°. When a significant improvement Cadaver dissection has shown that
pain, that is, plantar medial heel pain (approximately 10° or more) in ankle these spurs are localized to the flexor

June 2014, Vol 22, No 6 373

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 Plantar and Medial Heel Pain: Diagnosis and Management

digitorum brevis (FDB) origin and effective as more costly custom in the management of PF. Of eight
do not lie in the true substance of the orthoses.23 Following a dedicated double-blind placebo-controlled ran-
plantar fascia itself.18 trial of such treatment measures, 90% domized clinical studies, four con-
MRI is rarely required for the diag- to 95% of patients experience reso- cluded that ESWT significantly
nosis of PF. It is perhaps better used to lution of symptoms within 1 year.12 improved some short-term outcome
rule out alternative pathologies, such as For the small number of refractory measures.33-36 The remainder dem-
calcaneal stress fracture. In the patient patients, more invasive techniques, onstrated no significant differences in
with PF, MRI usually demonstrates such as injection and ESWT, may be any outcome measure.32,37-39 One
thickening of the plantar fascia—one considered. study demonstrated that plantar fas-
study showed it to be twice the In level I trials, corticosteroid in- cial stretching exercises were superior
thickness of healthy controls—and jections have resulted in significantly to ESWT.24
edema within the soft tissues.19 Edema improved pain relief in patients with Level I studies investigating pulsed
in the medial calcaneal tuberosity, PF at 4 weeks compared with pla- radiofrequency electromagnetic field
however, is only variably present on cebo.2,6 These same studies, however, therapy40 and botulinum toxin A
MRI. also suggest that corticosteroid in- injection41 for the management of PF
jections may only provide short-term have failed to demonstrate a significant
pain relief; injection did not provide difference compared with placebo.
Management significant pain relief compared with Neither has PRP injection demon-
In all cases, initial management should placebo at 3-month follow-up. strated comparative superiority over
be nonsurgical. Rest, structured phys- Corticosteroid injections are associ- corticosteroid injection in the man-
ical therapy, home stretching exercises, ated with a risk of plantar fascia rup- agement of PF.42
heel cushions, orthoses, ice, NSAIDs, ture.28 This finding was observed in Surgery for recalcitrant disease most
and weight loss all have been linked to 2.4% of patients who received corti- often entails partial plantar fasciotomy
the successful nonsurgical manage- costeroid injections.29 In a survey of without heel spur resection. In the past
ment of PF.20-26 Barefoot activities and members of the American Orthopae- two decades, endoscopic techniques
wearing shoes with inadequate cush- dic Foot and Ankle Society, this have gained in popularity due to
ioning and support should be avoid- complication was found to occur an the purported advantage of a more
ed.12 Shoe wear modifications, such average of 1.5 times per provider over rapid postoperative recovery.43 Open
as use of a rocker sole, have been the course of their careers.4 Plantar plantar fasciotomy, the traditional
shown to reduce dorsiflexion of the fascia rupture itself is not believed to be mainstay of surgical management,
first metatarsophalangeal joint and a common sequela of injection. Long- has been shown to provide pain relief
thereby decrease the peak tensile strain term consequences of rupture include in 76% of patients.18 In a recent level
of the plantar fascia.27 Stretching longitudinal arch strain, lateral and IV study, endoscopic plantar fas-
specific to the plantar fascia has dorsal midfoot strain, lateral plantar ciotomy completely relieved symp-
recently been shown to provide supe- nerve dysfunction, stress fracture, and toms in 76% of patients and was
rior pain relief when compared with hammer toe deformity.28,30 Other associated with a low complication
Achilles tendon stretching at 8 weeks; potential side effects of corticosteroid rate.44
however, no significant difference was injection include skin and fat atrophy Gastrocnemius recession may be
seen at 2-year follow-up.21 In a level I at the injection site, postinjection considered for the patient with PF
study, celecoxib was shown to provide flare, inadvertent intraneural/intra- and a concomitant gastrocnemius
short-term pain reduction compared vascular injection, hyperglycemia in contracture. In a retrospective series,
with placebo.22 patients with diabetes, tendon rup- 25 patients with PF and isolated
Other management options include ture, infection, and facial flushing.31 gastrocnemius contracture experi-
night splinting, prescription orthoses, Of these, postinjection flare, facial enced significant pain relief after
and a period of immobilization.12 flushing, and skin and fat atrophy are gastrocnemius recession, with the
Night splints are designed to prevent the most common. Systemic compli- average visual analog scale score
and correct passive contracture of cations are rare.31 decreasing from 8.1 to 1.9.14 In
the plantar fascia and gastrocnemius- ESWT uses acoustic waves that elicit 2012, Abbassian et al45 reported
soleus complex. In one study, foot an inflammatory response; in theory, that proximal gastrocnemius release
orthoses were found to improve pain this leads to neovascularization and resulted in complete or significant
and function at 3 months but not healing.32 Level I and II evidence, pain relief for 81% of patients; 58%
at 12 months.23 Prefabricated shoe however, have not convincingly dem- of patients experienced relief within
inserts have been shown to be as onstrated it to be superior to placebo 2 weeks of surgery.

374 Journal of the American Academy of Orthopaedic Surgeons

Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Craig R. Lareau, MD, et al

Diagnosis motor function to the QP, FDB, and

Heel Pad Atrophy abductor digiti quinti (ADQ) muscles,
Although radiographic studies are not
required to either make or confirm the as well as sensation to the lateral
Anatomy and plantar skin, calcaneal periosteum,
Pathophysiology diagnosis of heel pad atrophy, imaging
should be considered to rule out alter- and long plantar ligament.48 The two
The heel pad, which is located beneath native pathology. Heel pad thickness potential points of compression are
the calcaneus, consists of adipose tis- is typically greater in men than in the deep margin of the abductor
sue within a highly organized and women.17 This thickness is measured hallucis muscle and the point at
specialized confluence of fibrous sep- on the weight-bearing lateral view as which the nerve passes anterior to
tae that extend from the skin to the the distance between the ground and the medial calcaneal tuberosity49
calcaneal periosteum. These septae are the plantar aspect of the calcaneal (Figure 2). Pain is felt approximately
arranged into a stiff superficial micro- tuberosity. The relationship between 4 to 5 cm anterior to the posterior
chamber and a deep macrochamber this measurement and the presence of aspect of the heel or just distal to the
that undergoes substantial deforma- symptoms remains unclear because medial calcaneal tuberosity at the
tion with loading.46 The heel pad not all patients with heel pad atrophy junction of the glabrous and non-
serves as a shock absorber, allowing are symptomatic. MRI is usually glabrous skin.50 Nerve compression
the heel to tolerate high loads and unnecessary, but it may demonstrate causes burning pain that may radiate
repetitive load bearing. Heel pad edema and atrophy of the heel pad. distally toward the plantar lateral foot.
atrophy typically begins in the fifth The diagnosis commonly coexists
decade of life and likely is the result of with PF. In one study, PF occurred in
loss of water, collagen, and elastic
Management 52.5% of patients with an MRI finding
tissue.47 The heel pad becomes less Resolution of symptomatic heel pad of ADQ atrophy, a manifestation of
elastic in both the elderly and in per- atrophy can be challenging. Manage- chronic compression of the first branch
sons with diabetes, and these patients ment may include NSAIDs, properly of the lateral plantar nerve.51 In con-
are particularly prone to heel pad padded shoes, and customized ortho- trast, ADQ atrophy on MRI is seen in
atrophy. Prichasuk17 defined the heel ses or over-the-counter silicone heel only 6.3% of the general population.49
pad compressibility index as the ratio cups. Given that the inherent nature of Although Baxter and Pfeffer52 reported
of the heel pad thickness in loaded this pathology is mechanical, lower- that in some cases a small portion of
and unloaded positions. An increase impact and offloading activities can be the medial plantar fascia was removed
in the heel pad compressibility index very helpful. Corticosteroid injection to facilitate exposure, to our knowl-
indicates loss of elasticity. should be avoided because it can result edge there are no studies that specify
in further atrophy of the plantar fat.1 the percentage of patients with Baxter
Surgical management is not rec- nerve entrapment who required plan-
Presentation and Physical ommended. There are no proven tar fascia release.
Examination techniques capable of adequately
Heel pad atrophy results in deep, non- recreating or replacing the normal
radiating pain that typically involves heel pad architecture. Furthermore, Presentation and Physical
the central weight-bearing portion of the plantar skin is prone to problems Examination
the calcaneal tuberosity. It is com- with wound healing, and infection in Physical examination should include
monly misdiagnosed as PF. Symptoms this region can be difficult to manage. an evaluation of gastrocnemius-soleus
of heel pad atrophy are usually exac- contracture and hindfoot alignment.
erbated by walking barefoot or on Both hindfoot valgus due to posterior
hard surfaces and are relieved by
Baxter Nerve Entrapment tibial tendon insufficiency and ankle
the absence of heel pressure. Physical plantar flexion resulting from equinus
examination typically elicits centrally Anatomy and contracture can accentuate symp-
located tenderness over the plantar Pathophysiology toms. Pressure has been shown to be
aspect of the calcaneal tuberosity; The first branch of the lateral plantar highest in the lateral plantar tunnel
this tenderness can be associated with nerve, that is, the Baxter nerve, is the during plantar flexion and pro-
varying degrees of swelling. Usually, only nerve branch that lies deep to the nation.53 Percussion over the nerve
pain is not reproducible with passive abductor hallucis and FDB muscles. It should be performed to assess for
motion of the ankle or toes or travels superficial to the quadratus reproduction of symptoms. Dimin-
with side-to-side compression of the plantae (QP) muscle along the medial ished sensation in the plantar lateral
tuberosity. aspect of the calcaneus, providing foot may be seen in chronic cases.50

June 2014, Vol 22, No 6 375

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 Plantar and Medial Heel Pain: Diagnosis and Management

Figure 2 Calcaneal Stress Fracture

Anatomy and
Pathophysiology
The calcaneus is the largest tarsal bone
and is subject to considerable weight-
bearing stresses on a routine basis.
Despite these chronic loads, however,
the bone remains predominantly can-
cellous in nature. As a result, stress
fractures of the calcaneus are not
uncommon; typically, they occur
immediately posterior and inferior to
the posterior facet12 (Figure 3). The
calcaneus is one of the most common
locations of stress fracture in the foot,
second only to the metatarsals.19
Calcaneal stress fractures occur
most frequently in athletes, military
trainees, and elderly patients with
osteopenia. These injuries are caused
by repetitive overload and the
inability of bone formation to match
Illustration of a left heel showing the potential sites of compression of the Baxter resorption. A thorough history often
nerve: the deep margin of the abductor hallucis muscle (1) and the point at which
the nerve passes anterior to the medial calcaneal tuberosity (2). elicits changes in exercise or activity,
typically involving recent adoption of
a more rigorous exercise regimen.

Diagnosis gical decompression consisting pri- Presentation and Physical

marily of release of the superficial and Examination
Similar to other etiologies of chronic
heel pain, entrapment of the first branch deep fascia of the abductor hallucis Patients with calcaneal stress fracture
of the lateral plantar nerve is primarily overlying the nerve is warranted and typically report intense, diffuse heel
a clinical diagnosis. Imaging modalities usually effective.52 Although Baxter pain along the medial and lateral
are of limited usefulness because ADQ and Pfeffer52 also mentioned resection aspects of the posterior tuberosity. Pain
atrophy is seen in 6.3% of all patients of small spurs that might be encoun- is exacerbated by activity and weight
who undergo MRI of the foot.49 Elec- tered in some patients, the experience bearing, and it may progress to become
trodiagnostic studies in conjunction of the senior author (C.W.D.) indicates persistent even at rest.55 Patients often
with clinical evaluation can help that this is rarely necessary. In our experience tenderness along the lateral
delineate whether compression exists practice, however, we have on occa- wall of the calcaneal tuberosity. A
in the lateral plantar tunnel or more sion felt the need to provide additional positive calcaneal squeeze test, or pain
proximally in the tarsal tunnel.50 decompression via release of the FDB on direct compression of both the
and even the QP depending on their medial and lateral walls of the calca-
relative size, proximity, and perceived neus, is pathognomonic. This maneu-
Management direct effect on the course of the lateral ver helps to differentiate a calcaneal
Initial management may include rest, plantar nerve branch as assessed stress fracture from other causes of
ice, NSAIDs, orthoses for hindfoot visually.54 However, although our heel pain.56 The amount of ecchymosis
malalignment, and physical therapy experience in finding and treating this and swelling depends on the acuity of
with local modalities. There is no evi- latter presentation is positive, it is quite the injury.
dence to support one nonsurgical limited and lacks formal study. Baxter
method over another. If nonsurgical and Pfeffer52 described excellent or Diagnosis
measures have been exhausted and good results in 89% of heels managed Radiographs, specifically the lateral
symptoms persist for .3 months, sur- with open surgical release. foot view, may reveal disruption of

376 Journal of the American Academy of Orthopaedic Surgeons

Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Craig R. Lareau, MD, et al

the trabecular pattern of the calcaneus tunnel. The tarsal tunnel is a fibro- Figure 3
2 to 8 weeks after symptom onset,56 osseous space located posterior and
although these images are frequently distal to the medial malleolus. Its roof
interpreted as normal during the early is formed by the flexor retinaculum,
course of this disease process (Figure 3). and the medial wall of the calcaneus
The rare finding of a linear sclerotic serves as its floor. The posterior tibial
line in the tuberosity perpendicular to neurovascular bundle passes through
the natural trabecular pattern indicates this tunnel, along with the tendons of
the presence of a healing stress frac- the tibialis posterior, flexor digitorum
ture.19,57 During the early stages of longus, and flexor hallucis longus
fracture, radiographic sensitivity can muscles. The tibial nerve divides into
be as low as 10%, but follow-up the medial and lateral plantar nerves
radiography reveals diagnostic fea- as well as the medial calcaneal branch.
tures in 50% of patients.19,56 When TTS is a relatively uncommon clinical
pain persists but radiographs appear entity that may be overdiagnosed. Lateral foot radiograph
normal, MRI or bone scanning may be Pes planus is one of the more com- demonstrating a calcaneal stress
fracture (arrow). (Reproduced with
helpful to establish the diagnosis. monly purported causes of TTS because
permission from Spitz DJ, Newberg
Technetium bone scans typically detect hindfoot valgus and forefoot abduction AH: Imaging of stress fractures in the
a stress fracture 1 to 2 weeks before place the nerve under tension.58 Other athlete. Radiol Clin North Am
changes become apparent radio- reported causes include fracture, space- 2002;40[2]:313-331.)
graphically.57 MRI demonstrates high occupying lesions, tenosynovitis, and
signal intensity due to marrow edema an accessory abductor hallucis mus- such as the dorsiflexion-eversion test,
and hemorrhage on T2-weighted im- cle.19,58,59 Systemic inflammatory which stretches the tibial nerve, may
ages.19 MRI is superior to bone scan- arthropathy, diabetes, and rheumatoid also elicit reproducible discomfort in
ning because it enables concomitant arthritis may also play a role in the this anatomic region.
evaluation of soft-tissue structures.57 development of TTS.60 This syndrome
is not typically bilateral, so systemic
and spinal pathology should be Diagnosis
Management
excluded first in patients who present MRI is the modality of choice for eval-
Treatment consists of activity modi- with neurologic findings in both feet. uating the anatomy of the tarsal tunnel
fication and protected weight bearing and detecting space-occupying lesions
in a fracture boot or short leg cast for responsible for tibial nerve compression
4 to 8 weeks. The treating clinician Presentation and Physical (Figure 4). Nerve conduction velocity
also should consider a metabolic Examination (NCV) studies and EMG can be per-
workup, including vitamin D levels and Identification of TTS can be chal- formed to confirm the diagnosis;
bone density testing, especially for the lenging. Patient complaints may be however, an overview of four pro-
patient with a previous history of frac- vague and difficult to localize. Never- spective level III studies indicates that
ture. Normal activities can be resumed theless, pain and paresthesia are clas- false-negative rates are high with these
after this period of immobilization, sically localized to the posteromedial modalities.61 Negative NCV findings
once tenderness resolves. The prog- ankle and heel, often radiating distally do not exclude the diagnosis. Sensi-
nosis is excellent, and surgery is rarely into the plantar foot. Symptoms are tivity of sensory NCV abnormalities
required. Significant displacement often exacerbated by stance and ranged from 90.5% to 96% (false-
and malalignment are uncommon, exercise. Dysesthesia can disrupt the negative rate [range], 4% to 9.5%),
and nonunion is rare. patient’s sleep. Severe compression and sensitivity of prolonged distal
may cause weakness; this finding is motor latency ranged from 21.5% to
among the latest, presenting first 52.4% (false-negative rate [range],
Tarsal Tunnel Syndrome in the toe abductors and subsequently 47.6% to 78.5%).
in the short toe flexors.60 Impaired The usefulness of NCV and EMG in
Anatomy and sensation along the tibial nerve dis- diagnosis and prediction of outcomes
Pathophysiology tribution associated with a Tinel sign in TTS remains questionable. These
Tarsal tunnel syndrome (TTS) is an along the tarsal canal is considered techniques also vary greatly between
entrapment neuropathy of the tibial to be the most pathognomonic find- studies, and few high-quality reports
nerve as it courses through the tarsal ing.59 Other provocative maneuvers, either correlate NCV and EMG with

June 2014, Vol 22, No 6 377

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 Plantar and Medial Heel Pain: Diagnosis and Management

Figure 4

Axial proton density-weighted magnetic resonance images without (A) and with (B) fat saturation, and sagittal short tau
inversion recovery (C) sequence image, demonstrating a tarsal tunnel ganglion (*) compressing the medial (red arrow) and
lateral (blue arrow) plantar nerves. (Courtesy of Peter T. Evangelista, MD, Providence, RI.)

outcome or provide supportive evi- tunnel release involves careful division tes, decompression has been reported
dence for significant diagnostic util- of the flexor retinaculum overlying the to significantly improve one-point
ity. In an evidence-based review of the posterior tibial nerve as it courses pressure threshold as measured by
use of NCV and EMG in the diag- behind the medial malleolus as well as monofilament examination but not
nosis of TTS, sensory NCV was release of the fascia over the abductor two-point discrimination 8 to 9 months
determined more likely to be abnor- hallucis. Complete release minimizes postoperatively.66 Another report sug-
mal than motor NCV; however, the the chance of persistent or recurrent gests that in patients with diabetes,
actual sensitivity and specificity of symptoms. To this end, anatomic and a positive Tinel sign has a 90% positive
these tests could not be determined.61 clinical studies also suggest release of predictive value of symptom relief
the medial septum deep to the abductor following extended decompression.67
hallucis, under which the lateral and, In patients with TTS resulting from
Management sometimes, the medial plantar nerves a space-occupying ganglion in the
Nonsurgical options for TTS include pass.54,62 tarsal tunnel, excision of the ganglion
NSAIDs and immobilization. Pa- In a recent series, all patients demon- results in satisfactory outcomes.68
tients with pes planus deformity may strated improvement in mean sensory
benefit from custom orthoses.58,59 threshold as defined by monofilament
Local corticosteroid injection into examination 12 months after surgical Summary
the tarsal tunnel has been advocated decompression.63 Surgical interven-
by some authors, but its use should tion should be carefully considered, Pain of the plantar and medial heel is
be carefully considered because of however, because results can be a common complaint. A thorough
the potential for tendon rupture and unpredictable. For example, surgical history and physical examination is
intravascular injection.59 decompression successfully relieves paramount to establish an accurate
Surgery is reserved for patients who symptoms in only approximately diagnosis. In most patients, the diag-
do not respond to nonsurgical treat- 50% of patients for whom a definite nosis can be made clinically, taking
ment and who have no other reason- etiology cannot be identified.64 care to characterize the quality, loca-
able explanation for their symptoms as In one study, 56% of patients had tion, timing, and duration of pain. On
well as for those with identifiable space- fair or poor results at long-term occasion, advanced imaging or neuro-
occupying lesions. Traditional tarsal follow-up.65 In patients with diabe- diagnostic studies may be necessary

378 Journal of the American Academy of Orthopaedic Surgeons

Copyright Ó the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Craig R. Lareau, MD, et al

when radiographs and clinical exami- 7. Riddle DL, Schappert SM: Volume of 22. Donley BG, Moore T, Sferra J, Gozdanovic J,
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agement is typically nonsurgical. For A national study of medical doctors. Foot the treatment of plantar fasciitis: A
the small percentage of patients whose Ankle Int 2004;25(5):303-310. randomized, prospective, placebo-controlled
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2159-2166. Effectiveness of foot orthoses to treat
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plantar aponeurosis and the arch. J Anat
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