Management of pain beneath the heel and Achilles tendonitis with visco-elastic heel inserts.
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Achilles Tendon↗
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NY: nurse develops heel spur-files comp. claim: is heel spur an occupational disease?
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Disability Evaluation↗
[Drawer sign of the heel. Normal sagittal laxity of the heel].
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Adolescent↗
Heel spur and heel spur syndrome.
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Adult↗
Effectiveness and prognostic factors of radiotherapy for painful plantar heel spurs.
BACKGROUND AND PURPOSE: The efficacy of radiation treatment (RT) for plantar heel pain has been reported repeatedly. Yet, the results referring to the pain relief rate, to long-term effects and prognostic factors are not consistent. In this paper, the effectiveness (pain relief rate and long-term results) and prognostic factors of RT for plantar heel pain have been investigated. PATIENTS AND METHODS: From January 2000 to October 2000, 62 patients (73 heels) with painful plantar heel spurs and a minimum pain history of 3 months were treated and evaluated in a prospective study. Mean age was 54 years (range 28-84 years). All patients were treated with a total dose of 5 Gy in seven fractions (= one series), given twice a week at a single-dose sequence of 0.25-0.25-0.5-1.0-1.0-1.0-1.0 Gy (10-MV photons, source-skin distance [SSD] 100 cm, direct portal, field size 12 x 17 cm). The mean duration of heel pain before RT was 26 weeks (= 6.5 months; range 3-120 months). By means of a visual analog scale (VAS) the patients had to self-assess the quantity of their heel pain once before, three times during and four times after RT at a longterm median follow-up of 28 and 40 months. Additionally, the patients had to assess their mechanical heel stress extent during RT. Effectiveness was estimated according to the patients' judgment of pain reduction. RESULTS: A significant reduction of heel pain extent measured by VAS has been observed already during the RT series (before RT: 6.3 +/- 1.5 vs. 3.8 +/- 2.1 at the end of RT; p < 0.001). 6 weeks after RT (FU 1) pain reduction (> 20%) was achieved in 60 heels (82.3%; n = 73), in 64 heels (91.4%; n = 70) after a mean follow-up of 28 months (FU 2), and in 61 heels (89.7%; n = 68) after a mean follow-up of 40 months (FU 3), respectively. Sufficient pain relief (> 80% compared to initial extent) was observed in 18/73 heels (24.6%) at FU 1 (FU 2: 42/70; 60.0%; FU 3: 37/68; 54.4%), including 13/73 heels (17.8%) with complete pain relief (FU 2: 39/70; 55.7%; FU 3: 36/68; 52.9%). Partial improvement (50-80% pain reduction) was observed in 27/73 heels (37.0%) at FU 1 (FU 2: 14/70; 20.0%; FU 3: 15/68; 22.1%), and minor partial improvement (20-50% pain reduction) in 15/73 heels (20.5%) at FU 1 (FU 2: 8/70; 11.4%; FU 3: 9/68; 13.2%), respectively. No change was seen in 13/73 heels (17.8%) at FU 1 (FU 2: 6/70; 8.6%; FU 3: 7/68; 10.3%). Older patients (p = 0.04) and patients who avoided heel stress during the period of RT (p < 0.01) demonstrated a better short-term response (FU 1); both effects were lost 28 and 40 months after RT. Moreover, significant differences in the extent of heel pain reduction by RT were observed in dependence on previous pain duration (at FU 2-3). CONCLUSION: The results confirm the high efficacy of RT in painful plantar spur and add new aspects to formerly published data concerning the time course of changes in heel pain reduction. Pain relief can be expected during and shortly after RT. In addition, the initial success can be transformed into effective long-term results > 2 years after RT; however, further improvement is not to be expected. As a new prognostic factor, the reduction of mechanical heel stress during RT may ameliorate the short-term results, whereas short heel pain history improves the long-term results. Especially for older patients, RT should be taken into consideration as primary treatment.
Adult↗
The relationship of the heel pad compressibility and plantar pressure distribution.
Loss of heel pad elasticity has been suggested as one of the possible explanations of heel pain. This study aimed to determine the effect of heel pad thickness and its compressibility to heel pressure distribution, in 47 (94 feet) normal subjects and 59 (94 feet) patients with heel pain, using radiological measurements and EMED-SF (Novel, Munich) plantar pressure distribution measurement system. Both heels of the patients and control group were radiographed with and without weight bearing. The ratio of the heel pad thickness in loading to unloading position was defined as "the heel pad compressibility index." The plantar peak pressure of the heel was measured at heel strike phase of the gait cycle. The compressibility index for control and patient groups were found to be 0.60 and 0.69, respectively. The peak pressure under the heel pad was recorded to be 28.4 N/cm2 for patients and 31.7 N/cm2 for control group. No significant difference was found for heel pad compressibility index and heel pad pressures between patient and control groups (p > 0.05). This study revealed that there is no relationship between heel pad compressibility and pressure distribution of the heel pad both in control and patient group. We feel the flexibility of the heel pad does not have any influence on heel pain syndromes.
Adult↗
Shock absorbency of factors in the shoe/heel interaction--with special focus on role of the heel pad.
The heel pad acts as a shock absorber in walking and in heel-strike running. In some patients, a reduction of its shock-absorbing capacity has been connected to the development of overuse injuries. In this article, the shock absorption of the heel pad as well as external shock absorbers are studied. Individual variation and the effect of trauma and confinement on the heel pad were specifically investigated. Drop tests, imitating heel impacts, were performed on a force plate. The test specimens were cadaver heel pads (n = 10); the shoe sole component consisted of ethyl vinyl acetate (EVA) foam and Sorbothane inserts. The shock absorption was significantly greater in the heel pad than in the external shock absorbers. The mean heel pad shock absorption was 1.1 times for EVA foam and 2.1 times for Sorbothane. The shock absorption varied by as much as 100% between heel pads. Trauma caused a decrease in the heel pad shock absorbency (24%), whereas heel pad confinement increased the shock absorbency (49% in traumatized heel pads and 29.5% in nontraumatized heel pads). These findings provide a biomechanical rationale for the clinical observations of a correlation between heel pad shock absorbency loss and heel strike-dependent overuse injuries. To increase shock absorbency, confinement of the heel pad should be attempted in vivo.
Adult↗
Influence of heel height and shoe insert on comfort perception and biomechanical performance of young female adults during walking.
BACKGROUND: The possible negative effects of high-heeled shoes on subjective comfort perception and objective biomechanical assessment have been noted. Although shoe inserts have been widely applied in footwear to increase comfort and to reduce the frequency of movement-related injury, no study has attempted to identify insert effectiveness in high heels. The purpose of this study was to determine the effects of heel height and shoe inserts on comfort and biomechanics as represented by plantar pressure and ground reaction force (GRF). METHODS: Twenty young female adults performed the test conditions formed by the cross-matching of shoe inserts (shoe without insert and shoe with total contact insert [TCI]) and heel height (a flat, a low heel [3.8 cm] and a high heel [7.6 cm]). Two-way analyses of variance for repeated measures design were used to test condition effects on comfort rating, plantar pressure, and GRF during gait. To determine the biomechanical variables that can predict comfort, a multiple linear regression with stepwise method was done. RESULTS: The results showed that discomfort increased with heel height. In high heels, the plantar pressure in the heel and midfoot shifted to the medial forefoot, and the vertical and anteroposterior GRF increased. Use of the TCI reduced the peak pressure in the medial forefoot. Interestingly, the effectiveness of the TCI was greater in the higher heels than in the lower heels and in flat heels. The peak pressure in the medial forefoot, impact force, and the first peak vertical GRF could explain 75.6% of the variance of comfort in high-heeled gait. CONCLUSIONS: These findings suggest that higher heels result in decreased comfort, which can be reflected by both the subjective rating scale and biomechanical variables. Use of a TCI altered the biomechanics and therefore improved the comfort in high-heeled shoes.
Adult↗
Heel lifts and the stance phase of gait in subjects with limited ankle dorsiflexion.
CONTEXT: Heel lifts are often prescribed as part of the treatment program for patients with overuse injuries associated with limited ankle dorsiflexion. However, little is known about how joint kinematics and temporal variables are affected by heel lifts. OBJECTIVE: To determine the effects of heel lifts on selected lower extremity kinematic and temporal variables during the stance phase of gait in subjects with limited ankle dorsiflexion. DESIGN: Two-way, fully repeated-measures design. The 2 factors were side (right or left) and walking condition (shoes alone, 6-mm heel lifts in shoes, 9-mm heel lifts in shoes). SETTING: University biomechanics laboratory. PATIENTS OR OTHER PARTICIPANTS: Twenty-six volunteers (21 females, 5 males) with no more than 5 degrees of ankle joint dorsiflexion. INTERVENTION(S): Subjects were tested in shoes alone and in shoes with 6-mm and 9-mm heel lifts. MAIN OUTCOME MEASURE(S): We used the Qualisys Motion Analysis System to measure ankle dorsiflexion excursion, maximal knee extension, and time to heel off during the stance phase of gait under the 3 walking conditions. RESULTS: On the right side, ankle dorsiflexion excursion increased significantly with the 6-mm and 9-mm heel lifts compared with shoes alone (P < .05). On the left side, ankle dorsiflexion increased significantly with the 9-mm heels lifts over shoes alone and with the 9-mm heel lifts compared with the 6-mm heel lifts (P < .05). Time to heel off increased significantly for walking with the 9-mm heel lifts compared with shoes alone (P < .05). No differences were noted for maximal knee extension (P > .05). CONCLUSIONS: Clinicians may consider prescribing heel lifts for patients with limited dorsiflexion range of motion if increasing ankle dorsiflexion excursion and time to heel off during the stance phase of gait may be beneficial.
Journal Article↗
Comparison of the mechanical properties of the heel pad between young and elderly adults.
OBJECTIVE: To compare the mechanical properties of the human heel pad between young and aged adults. DESIGN: A 7.5-MHz linear-array ultrasound transducer was incorporated into a specially designed device to measure the thickness of the heel pad under different loads. The heel pad was compressed with serial increments of 0.5kg to a maximum of 3kg and then relaxed sequentially. Then the load-displacement curve of the heel pad during a loading-unloading cycle was plotted. PARTICIPANTS: Convenience sample of 33 volunteers without heel problems, aged 18 to 78 years, were divided into young (less than 40 years) and elderly (older than 60 years) groups. MAIN OUTCOME MEASURES: Unloaded heel-pad thickness, compressibility index, stiffness, and energy dissipation ratio were calculated from the load-displacement curves. Student's t-test was used to compare the mechanical properties of the heel between these two groups. RESULTS: The average unloaded heel-pad thickness was 1.76+/-.20cm in the young group and 2.01+/-.24cm in the elderly group (p < .001). The average compressibility index was 53.3%+/-7.7% in the young group and 61.3%+/-5.5% in the elderly group (p < .001). Energy dissipation ratio representing shock absorbency of the heel pad, was 23.7%+/-6.9% in the young group and 35.3%+/-10% in the elderly group (p < .001). CONCLUSION: Unloaded heel-pad thickness, compressibility index, and energy dissipation ratio of the heel pad were significantly increased in the elderly group, indicating loss of the elasticity of the heel pad. The loss of elasticity may be responsible for the higher incidence of heel injury in elderly individuals.
Adolescent↗
Diagnosing heel pain in adults.
Heel pain is a common condition in adults that may cause significant discomfort and disability. A variety of soft tissue, osseous, and systemic disorders can cause heel pain. Narrowing the differential diagnosis begins with a history and physical examination of the lower extremity to pinpoint the anatomic origin of the heel pain. The most common cause of heel pain in adults is plantar fasciitis. Patients with plantar fasciitis report increased heel pain with their first steps in the morning or when they stand up after prolonged sitting. Tenderness at the calcaneal tuberosity usually is apparent on examination and is increased with passive dorsiflexion of the toes. Tendonitis also may cause heel pain. Achilles tendonitis is associated with posterior heel pain. Bursae adjacent to the Achilles tendon insertion may become inflamed and cause pain. Calcaneal stress fractures are more likely to occur in athletes who participate in sports that require running and jumping. Patients with plantar heel pain accompanied by tingling, burning, or numbness may have tarsal tunnel syndrome. Heel pad atrophy may present with diffuse plantar heel pain, especially in patients who are older and obese. Less common causes of heel pain, which should be considered when symptoms are prolonged or unexplained, include osteomyelitis, bony abnormalities (such as calcaneal stress fracture), or tumor. Heel pain rarely is a presenting symptom in patients with systemic illnesses, but the latter may be a factor in persons with bilateral heel pain, pain in other joints, or known inflammatory arthritis conditions.
Bursitis↗
Heel contact as a function of substrate type and speed in primates.
In this report we provide detailed data on the patterns and frequency of heel contact with terrestrial and arboreal supports in primates. These data can help resolve the question of whether African apes and humans are uniquely "plantigrade" (Gebo [1992] Am. J. Phys. Anthropol. 89:29-58; Gebo [1993a] Am. J. Phys. Anthropol. 91:382-385; Gebo [1993b] Postcranial Adaptation in Nonhuman Primates), or if plantigrady is common in other primates (Meldrum [1993] Am. J. Phys. Anthropol. 91:379-381). Using biplanar and uniplanar videotapes, we recorded the frequency and timing of heel contact for a variety of primates (32 species) walking on the ground and on simulated arboreal supports at a range of natural speeds. Our results indicate that Pongo as well as the African apes exhibit a "heel-strike" at the end of swing phase. Ateles and Hylobates make heel contact on all supports shortly after mid-foot contact, although spider monkeys do so only at slow or moderate speeds. Data available from uniplanar videotapes suggest that this pattern occurs in Alouatta and Lagothrix as well. No other New or Old World monkey or prosimian in this study made heel contact during quadrupedalism on any substrate. Thus, heel contact occurs in all apes and atelines, but only the great apes exhibit a heel-strike. We suggest that heel contact with the substrate is a by-product of an active posterior weight-shift mechanism involving highly protracted hindlimbs at touchdown. Force plate studies indicate that this mechanism is most extreme in arboreally adapted primate quadrupeds walking on arboreal supports. Although heel contact and heel-strike may have no evolutionary link, it is possible that both patterns are the result of a similar weight shift mechanism. Therefore, the regular occurrence of heel contact in a variety of arboreal primates, and the absence of a true biomechanical link between limb elongation, heel contact, and terrestriality, calls into question the claim that hominid foot posture was necessarily derived from a quadrupedal terrestrial ancestor.
Animals↗
Observations on the fibrous retinacula of the heel pad.
BACKGROUND: The original purpose of the study was to clarify whether or not there is continuity of the Achilles tendon and the plantar fascia. Those findings have been previously published. In the course of that study, observations of the anatomy of the retinacular tethers of the heel pad were made. These observations included the discovery of the medial calcaneal retinaculum. METHODS: Ten adult cadaver feet were dissected. A longitudinal midline incision was made along the Achilles tendon and on the plantar surface of the foot. The heel pad was incised and the skin and heel pad were reflected side-to-side to reveal the calcaneal tuberosity. In this way the retinacular tethers of the heel pad could be seen. RESULTS: Two types of retinacular fibers were observed. Abundant small retinacula were seen coming off the plantar fascia and calcaneal tuberosity. Less abundant larger retinacula originated from the calcaneus only. Both types anchored the heel pad by branching into the fibrous stroma of the heel pad. In nine of 10 feet, a much larger retinacular structure was the principle tether of the heel pad to the medial process of the calcaneal tuberosity. We named this the medial calcaneal retinaculum. CONCLUSIONS: The heel pad is anchored by retinacula that vary in number, location, and size. The most consistent and significant tether of the heel pad appears to be the medial calcaneal retinaculum. CLINICAL RELEVANCE: Dislocation of the fat pad of the heel is a relatively rare but potentially devastating injury. An understanding of the anatomical anchoring of the heel pad and its mechanical function can lead to a surgical procedure to restore stability to the heel pad.
Achilles Tendon↗
The HPC-device: a method to quantify the heel pad shock absorbency.
Previous studies have indicated that the shock absorbency of the heel pad is significant in the pathophysiology of pain conditions connected with heel strike. The purpose of this study was to develop a simple clinically usable method for quantification of the heel pad shock absorbency. The results of our efforts was the HPC-device which consists of a fixing device and a transducer. The HPC-device was found suitable in the evaluation of the heel pad force/deformation characteristics. The reproducibility of heel pad deformation was 0.96. Tests of six cadaver heel pads revealed a high correlation between the HPC result and the shock absorbency found by drop tests. In a normal material (200 heel pads), it was found that the shock absorption decreased with age and that men had significantly higher shock absorbency than women. Men also had significantly thicker heel pads than women. However, there was no linear correlation between the thickness of the heel pad and the shock absorbency, although the thinnest heel pads had the lowest shock absorbency. The HPC-device was found clinically usable and will be used in further testing of the significance of heel pad shock absorption for the development of heel strike dependent over-use injuries.
Adolescent↗
Utility of heel ultrasound bone density in men.
In women, heel ultrasound (US) bone mineral density (BMD) has been shown to predict fracture risk, but the usefulness of this screening tool in men is not known. We measured the heel quantitative ultrasound index (QUI( in a convenience sample 185 of men (136 Caucasian, 1 Asian, and 48 African-American) with an average age of 63 yr (range of 25-85) undergoing BMD of the spine and hip by dual X-ray absorptiometry (DXA) to determine whether the heel measurement could predict central BMD. The average DXA T-score was -0.97, -1.20, and -1.61 for the spine, total hip, and femoral neck, respectively. The mean heel US BMD T-score (using the only available T-score, which was defined for Caucasian postmenopausal women) was -0.92. There were significant correlations among the various DXA measurements and the heel US BMD T-score (r = 0.373-0.483, p < 0.001). We defined arbitrarily osteopenia as a spine, total hip, or femoral neck T-score by DXA of < -1.5. We also made two different arbitrary definitions of osteoporosis by DXA: < -2.0 and < -2.5. Using these numbers as disease definitions, we determined the specificity, sensitivity, as well as positive and negative predictive values of using the heel US T-score to predict osteopenia or osteoporosis. Using various cutoffs for the heel T-score, we found that increasing the cutoff toward 0 increased the sensitivity but lowered the specificity. No cutoff was found that provided both good sensitivity and specificity. By analyzing the men by ethnic and age groups, we found that the best set of receiver operating characteristic (ROC) curves was derived from data using heel US to predict osteopenia and osteoporosis in men younger than age 65, although the areas under the ROC curve were approx 0.8. In conclusion, despite a strong correlation between the heel QUI and the spine and hip BMD by DXA, no heel T-score could predict osteopenia or osteoporosis with satisfactory sensitivity and specificity. It is possible that the use of risk factor assessment plus heel QUI might have better predictive value, and further studies are needed to determine whether heel QUI or other US determination is an independent risk factor for fracture in men.
Absorptiometry, Photon↗
Kinematics of high-heeled gait.
High-heeled shoes cause postural changes, a loss in foot function, and increased shock loadings during gait, which must be compensated by accommodations in the kinematics of body segments proximal to the feet. The hypothesis tested in this study was that there are differences in the three-dimensional kinematics of the tibia, knee, hip, pelvis, trunk, and upper trunk between low-heeled and high-heeled gait. Gait analysis of 14 subjects showed that during high-heeled gait subjects walked more slowly (p less than .001), had shorter stride lengths (p less than .001), and had higher stance time percentages (p less than .05). Kinematically, high-heeled gait compared to low-heeled gait, was characterized by significantly increased knee flexion at heelstrike (5.4 degrees vs 2.1 degrees, p less than .05) and during stance phase (22.6 degrees vs 19.2 degrees, p less than .05). During swing phase, high-heeled gait, compared to low-heeled gait, resulted in significantly lower knee flexion (66.1 degrees vs 72.1 degrees, p less than .05) and hip flexion (33.5 degrees vs 34.8 degrees, p less than .05). The range of motion of the pelvis in the sagittal plane was slightly lower in high-heeled gait than in low-heeled gait (7.0 degrees vs 7.9 degrees, p less than .05). No significant differences between low-heeled and high-heeled gait were found in the motions of the pelvis and trunk in the frontal and transverse planes. Statistical tests of intrasubject variability of angles of gait showed that five repeated trials were adequate for analysis of the tibia and knee in all planes of motion and for the hip in frontal and transverse planes.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Variations in heel pad mechanical properties variation between children and young adults.
The purpose of this study was to compare the mechanical properties of the heel pads of adults and children, using ultrasound to assess the responses of the heel pad during compression. Thirty volunteers without heel problems, aged from 4 to 36 years, were recruited. There were 10 children (< 15 years old) and 20 adults (> 18 years old). A 7.5-MHz linear array ultrasound transducer was incorporated into a specially designed device to measure the thickness of the heel pad under different loads. The load on the heel pad was increased serially in increments of 0.5 kg, to a maximum of 3 kg, and then reduced sequentially. The load-displacement curve of the heel pad during a loading-unloading cycle was then plotted. Mechanical properties of the heel, including unloaded heel-pad thickness (UHPT), compressibility index, elastic modulus, and energy dissipation ratio (EDR), were calculated from the load-displacement curves. The average UHPT was 1.53 +/- 0.09 cm in children and 1.76 +/- 0.20 cm in adults (p < 0.001). The EDR, which represents the shock absorbency of the heel pad, was 13.5 +/- 2.0% in the children and 23.7 +/- 6.9% in adults (p < 0.001). The average compressibility index and elastic modulus were also higher in adults than in children, although the differences were not statistically significant. These findings suggest that the mechanical properties of the heel pad change from childhood to adulthood. Less energy is absorbed in the heel pad of children, which may partially explain why children tend to have fewer heel problems than adults.
Adolescent↗