Pictorial case study: Heel pain

The case: This young man was experiencing pain at the back of both heels. He said it was aggravated by the pressure of his shoes when walking, and that it seemed to have worsened since he had to wear heavy boots while working on a building site. On examination there were tender, slighty inflamed and fluctuant 'bumps' at the back of each heel.

Diagnosis and management
A diagnosis of Haglund's deformity with overlying bursae was made. Haglund's deformity refers to a bony enlargement at the back of the heel. It is sometimes referred to as a 'pump bump' as rubbing of the rigid backs of pump-style shoes on the deformity adds to pressure on the area. As in this case, the bursae overlying the area became inflamed and swollen, adding to the problem.

The cause of the deformity may be of congenital origin; it is also more likely in those with high arches that tend to throw the calcaneum backwards into the Achilles tendon. Another contributory factor may be walking on the outside of the heel, rotating the heel against the tendon and leading to formation of a bursa.

Several approaches may be tried to reduce inflammation of the bursae. These include anti-inflammatory drugs, ice packs, exercises to relieve tension in the Achilles tendon, heel pads or orthotic devices and/or a change of footwear to soft-back or backless shoes. Rest may be necessary in acute phases.

Some recommend corticosteroid injection into the bursae, but suggest that patients sign consent to this procedure and fully understand the potential risk of a rupture to the Achilles tendon.

If all else fails, and after full evaluation of the bone structure by X-ray, surgery may be considered.

Rheumatoid factor, CRP and uric acid level should be checked if rheumatoid arthritis or gout is suspected.

Possible differential diagnoses
  • Achilles tendon rupture.
  • Achilles tendonitis.
  • Plantar fasciitis.
  • Rheumatoid arthritis.
  • Gout.

Differential diagnosis: Plantar fasciitis

  • Most common in men aged 40 to 70 years.
  • A common problem, often associated with obesity, flat or high-arched feet, repeated pressure from walking or running, and tightness of the Achilles tendon.
  • Symptoms of pain at the bottom of the heel; tends to be worse in the mornings.
  • Examination may show slight swelling, inflammation and tenderness under the heel.
  • X-ray may be indicated to exclude other causes.
  • Resolution usually occurs within nine months to two years with conservative treatment.
  • Initial treatment involves rest, heel stretching exercises, anti-inflammatory drugs, ice pack (10 to 15 minutes twice a day), heel pads and well-fitted shoes.
  • Corticosteroid injection may induce relief but patients find this very painful.
  • Very occasionally, for persistent problems, surgery may be considered.

Contributed by Dr Jean Watkins, a retired GP in Hampshire

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Item Code: MINT/PPR-12008

Date of Preparation: May 2012

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