Heel pain: diagnosis and treatment, step by step

The differential diagnosis of heel pain is broad and can be overwhelming if a systematic approach is not used. Focused questions and physical examination can help identify heel pain as Achilles tendinopathy or plantar fasciitis, or as due to a less common cause such as gout, spondyloarthropathy, or hypercholesterolemia.

Evidence-Based Soft Tissue Rheumatology. V

Present evidence indicates that the main cause of plantar talalgia (PT) is a noninflammatory derangement at the proximal insertion of the plantar fascia. In athletes, predisposing ankle and rear-foot biomechanical abnormalities have been identified; in nonathletes, risk factors for the condition remain controversial. PT diagnosis is largely clinical, the key findings being pain and tenderness on the plantar aspect of the rear foot. Ultrasonography is a reliable confirmatory study in doubtful cases. Therapies in PT include nonsteroidal anti-inflammatory drugs, orthotic devices, night ankle dorsiflexion splints, physiotherapy, local glucocorticoid, and extracorporeal shockwave therapy. In recalcitrant cases, surgery may be offered. Of these therapies, only local glucocorticoid, as delivered by injection or iontophoresis, has shown short-term efficacy in controlled trials. The efficacy of ankle dorsiflexion splints and extracorporeal shockwave therapy is still controversial. Thus, important knowledge gaps remain on etiology, diagnosis, and treatment of PT.

Evidence-Based Soft Tissue Rheumatology

Trochanteric bursitis is a term used to name a syndrome that features pain and tenderness over the greater trochanter. Present evidence suggests that in the majority of cases, symptoms result from pathology of the gluteus medius or minimus muscles rather than a bursa. Lower limb length discrepancy, iliotibial band contracture, hip osteoarthritis and lumbar spondylosis are often mentioned, but no proved as predisposing factors. After a lumbar spine or hip and other local pathology have been considered and clinically excluded, the clinical features of the syndrome, ie lateral location of pain plus characteristic trochanteric tenderness are usually sufficient to reach a diagnosis. Most patients with trochanteric bursitis can be successfully treated with a NSAID, physiotherapy plus a local corticosteroid injection. The few refractory cases are often treated surgically. Disappointingly, none of the therapeutic interventions used in trochanteric bursitis have been validly assessed.

Evidence-Based Soft Tissue Rheumatology. Part I

Impingement into the coracoacromiohumeral space, a common cause of rotator cuff tendinopathy, may result from an impinging osteoligamentous upper boundary, abnormalities in the tendon itself, or failure of muscles that retain the humeral head on the glenoid. An overuse mechanism is clearly a risk factor in throwing athletes, whereas occupational overuse may contribute to its development in nonathletes. The subacromial anesthetic injection test remains as the acknowledged gold standard for diagnosis. There is evidence on the therapeutic efficacy of nonsteroidal antiinflammatory drugs, glucocorticoid subacromial injection, and acupuncture as compared with placebo. Also, acromioplasty appears to be better than physiotherapy. Patients with rotator cuff tendinopathy may be successfully treated with nonsteroidal antiinflammatory drugs, a glucocorticoid subacromial injection, or acupuncture. In failures of conservative therapy, surgery should be considered. Further research is required on etiology, diagnosis, natural course, and validity of many treatments currently used in this common condition.

Soft tissue infections

Several infectious processes ranging in severity from mild to overwhelming that affect the soft tissues are reviewed. Superficial infections such as impetigo, erysipelas, cellulitis, and subcutaneous bursitis are common and, for the most part, can be easily treated. Because suppurative tenosynovitis has the potential to destroy tendons, consultation with a hand surgeon should be obtained immediately. Mycobacterial and fungal tenosynovitis is usually chronic and patients present with a mass which, when excised and examined with appropriate stain and culture, reveals the unexpected diagnosis. Tropical myositis (muscle abscesses) is seen in temperate climates, primarily as a complication of AIDS. Necrotizing fasciitis and gas gangrene represent the hyperacute end of the spectrum of soft tissue restrictions. Although in most cases a history of trauma is present, spontaneous gas gangrene may arise from occult and colonic cancer. Patients do poorly unless immediate and extensive surgery is performed and appropriate antibiotics are given.

Tumors of soft tissues and bone

The recent literature pertaining to tumors of articular structures and bone is reviewed. In pigmented villonodular synovitis, the bone resorptive cell is a macrophage polykaryon rather than an osteoclast. Complete arthroscopic synovectomy was successful in most diffuse articular forms of the disease. The early synovial changes in synovial chondromatosis were described; the lesion may be difficult to distinguish from synovial chondrosarcoma. Free body removal may be sufficient to treat synovial chondromatosis. Magnetic resonance imaging has been found useful in association with plain radiographs in the diagnosis of hemangioma and synovial sarcoma. Intracapsular osteoid osteoma, a benign neoplasm, may cause chronic monoarthritis. Computed tomography is essential in the diagnosis of this lesion. Aneurysmal bone cysts frequently show fluid-fluid levels on magnetic resonance imaging. Osteosarcoma, predominantly a tumor of childhood or adolescence, may occur in individuals over age 40 with underlying bone conditions. Computed tomography and magnetic resonance imaging are complementary in defining the extent of this lesion.

Subcutaneous bursitis in scleroderma

We encountered 3 types of subcutaneous bursitis in our patients with scleroderma: dry bursitis characterized by a rub, sterile bursitis characterized by inflammatory effusions without crystals by polarizing microscopy, and septic (staphylococcal) subcutaneous bursitis. The latter, which occurred in 6 of 40 consecutive patients, had a protracted course, was often complicated by fistulas, and tended to involve several bursae particularly in patients with extensive calcinosis.

Lupus-like presentation of human parvovirus B19 infection

The diagnosis of systemic lupus erythematosus (SLE) was a leading initial consideration in 2 patients with rash, arthritis and hypocomplementemia. One patient also had leukopenia and thrombocytopenia. Spontaneous regression occurred. In both patients antinuclear antibodies were negative. Serologic studies indicated recent human parvovirus B19 infection. We propose adding human parvovirus B19 infection to the list of conditions that may masquerade as SLE.

Remitting, seronegative (A) symmetrical synovitis with pitting edema--two cases of RS3PE syndrome

The sparing effect of neurological damage on the development and progression of several arthritic conditions has been documented. We describe the first 2 cases of unilateral remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome in individuals with neurologic disorders. Case 1 suffered from birth trauma resulting in paresis of the right upper extremity and developed RS3PE syndrome in the nonaffected extremities. Case 2 developed RS3PE syndrome on the nonparetic side 7 years after a cerebrovascular accident resulting in hemiparesis.

Hemorrhagic subcutaneous bursitis

Hemarthrosis is a well recognized complication of a number of conditions. Hemorrhagic subcutaneous bursitis is less understood. We encountered a patient with a myeloproliferative disease who developed hemorrhagic olecranon bursitis. Upon reviewing other patients with subcutaneous bursitis, we found that hemorrhagic bursitis also occurs in the setting of traumatic or idiopathic bursitis, rheumatoid arthritis, gout, and septic bursitis.

Dynamic injection of the digital flexor tendon sheaths

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Arthralgias as a presenting manifestation of primary biliary cirrhosis

Two patients presenting with arthralgias had associated minor elevations in liver enzymes. Each patient's serum had a cytoplasmic pattern of fluorescence on HEp-2 cells which led to the detection of antimitochondrial antibodies. Liver biopsy in both patients revealed primary biliary cirrhosis. Awareness of this limited, articular presentation of primary biliary cirrhosis may result in early treatment and the potential to arrest liver damage in some patients.

Physiology of the retrocalcaneal bursa

To clarify the function of the retrocalcaneal bursa the hindfoot was studied by magnetic resonance imaging at various positions of the ankle joint. In normal individuals a tongue-like extension of the retromalleolar fat pad entered the bursa during plantar flexion as the angle between Achilles tendon and calcaneus widened. The reverse occurred in dorsiflexion. In contrast, in a patient with spondyloarthritis and retrocalcaneal bursitis excessive cavitary fluid prevented the intrusion of the fat pad. The sliding motion of the fat pad in and out of the bursa during ankle motion allows a more caudal, advantageous insertion of the Achilles tendon into the calcaneus.

The acute phase response in gout

We studied the acute phase response in gout. Oral temperature, white blood cell count and differential, platelet count, Westergren erythrocyte sedimentation rate (ESR), and serum levels of the acute phase reactants serum amyloid A protein (SAA) and C-reactive protein (CRP) were all elevated. The number of involved joints correlated with levels of ESR, SAA and CRP. CRP correlated with temperature, differential count, ESR and SAA. The acute phase response resolved rapidly with treatment.

Foucher's sign of the Baker's cyst

We investigated the mechanism of Foucher's sign, the change in pressure in the Baker's cyst with extension and flexion of the knee, by echography, arthrography, and computed tomography. With extension the gastrocnemius and the semimembranosus muscles approximate each other and the joint capsule compressing the cyst against the deep fascia. Opposite effects in flexion allow the cyst to relax.

Femoral osteonecrosis following soft tissue corticosteroid infiltration

A case of osteonecrosis of the hip following an 18-year course of repeated soft tissue corticosteroid infiltration in a man with ill-defined musculoskeletal complaints is described.