Evaluation of Rear Foot Pain

Differential Diagnosis

Common

1. Plantar Fasciitis

2. Fat Pad Contusion

Less Common

1. Calcaneal Fractures (traumatic and Stress Fracture)

2. Medial Calcaneal nerve entrapment

3. Tarsal Tunnel Syndrome

4. Talar stress fractures

5. Retrocalcaneal Bursitis

Not to be Missed

1. Spondylarthropathies

2. Osteoid Osteoma

3. Regional complex pain syndrome.

History

• Sudden versus gradual onset of pain

• Jumping from height

• Repeated heel strike

• Improvement or aggravation with exercise

• Night or Morning Pain

Physical Examination

Remember that a complete examination should include the joint above and below. Always examine the ankle

Inspection

1. Assess for swelling

2. View ankle from behind: loss of definition of acchilles tendon indicates significant swelling

3. Check condition of skin

Palpation

1. Medial process of the calcaneal tubersosity

2. Palpate plantar fascia attachement

3. Heel fat pad

4. Achilles Tendon

5. Retrocalcaneal bursa

6. Posterior Talus

7. Calf Muscle

Motion

Muscular Strength

Muscular strength is graded on the MRC Scale

1. Plantarflexion; Gastrocnemius and Soleus,

2. Dorsiflexion; Tibialis anterior, extensor digitorum longus, extensor hallicis longus, peroneus tertius

3. Inversion; Tibialis anterior,

4. Eversion; peroneus longus, peroneus brevis

Neurovascular

1. Check the Heel Jerk Reflex (S1 S2) and grade

2. Check Distal Sensation

Investigations

1. Plain Films: May reveal a calcaneal spur (symptomatic or asymptomatic). Calcaneal stress fractures may be visible if chronic or subacute.

Appendix

Muscular Movers of the Ankle

Index

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