Surgical decisions in athletes subcalcaneal pain

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1 Surgical decisions in athletes subcalcaneal pain LOWELL D. LUTTER,* MD From the Sports Medicine Center, St. Anthony Orthopaedic Clinic, St. Paul, Minnesota ABSTRACT A group of 182 patients with subcalcaneal pain related to sports activity was studied to determine injury types and patterns. Running/jogging produced the greatest percentage of subcalcaneal injuries, 76%. A survey was done of the specific types of heel pain, plantar fasciitis and median calcaneal neuritis. A review of each entity was given and surgical approach was detailed. Subcalcaneal surgical decision making is based on six specific tenets: 1) correct diagnosis; 2) approximately 12 months of conservative treatment; 3) EMG for diagnosis and appropriate nerve blocks; 4) thorough knowledge of the anatomy or complete review; 5) patient understanding that surgery may not give a good enough result to allow the return to high performance athletics; and 6) correct and appropriately directed surgery. The number of patients seeking treatment for heel pain has increased since the beginning of fitness awareness in the last decade. This increase is related to the fact that more people are participating in running/jogging sports. If treatment is to be effective it must encompass an understanding of the etiologic mechanisms. Changing the underlying causes allows a chance to produce symptom relief, but merely rest and the return to activity is associated with a high recurrence rate. Surgical decisions as to time and type of operations on the heel must be based on occurrence or recurrences after prolonged conservative measures. The use of rest, immobilization, physiotherapy, antiinflammatory medications, orthosis, and local injections of steroids are time honored and must be thoroughly exhausted. It is axiomatic that appropriate diagnosis be made since ligament injury, tendinitis, bursitis, or systemic inflammatory conditions can result in subcalcaneal pain. * Address correspondence and repnnt requests to: Lowell D. Lutter, MD, Sports Medicine Center, St. Anthony Orthopaedic Clmic, 1661 St. Anthony Avenue, St Paul, MN The terms plantar fasciitis, medial calcaneal neuritis, tuber calcanei pain, and tarsal tunnel syndrome will be used in this paper as those maladies producing subcalcaneal pain (Fig. 1). There exists a confusing array of terms such as calcaneal spur, calcaneal exostosis, heel spur syndrome, and runners heel, fat pad syndrome. These are often combinations or parts of the previous four diagnoses and will not be used. Other hindfoot conditions such as Achilles tendinitis and bursitis, retrocalcaneal bursitis, and posterior and adductor longus tendinitis are not specific heel pain and are not included in this study. RESULTS Patients from this study were from a general orthopaedic practice without the skew of a university or clinic population. One hundred eighty-two (39%) of 465 heel complaints which were seen over a 4 year period were related to sports injuries. Running constituted the greatest number, being 76%. Racquet sports were 9%, basketball, 5%; soccer, 4%; the remaining 6% were a mixture of football, gymnastics, and other sports associated with running (Fig. 2). In patients with plantar fasciitis, a hyperpronated foot was present in 52%. This diagnosis, in which the medial longitudinal arch pronation is greater than average, is made by clinical judgment. A cavus configuration foot, which correlates with rigidity in the longitudinal arch, subtalar joint, and/or foot rigidity, was present in 42%. Six percent of the patients had neither a hyperpronated foot nor a cavus configuration; their condition was defined as a neutral foot. Tuber-calcaneal pain was present in 30% of patients with hyperpronation configuration and 46% with cavus configuration. Patients with median calcaneal neuritis showed a hyperpronation configuration and 50% cavus configuration. Athletes with tarsal tunnel syndrome had a high percentage of hyperpronation; specific numbers are not available. Plantar fasciitis was seen in 52% of patients with hyperpronation and 42% with cavus configuration. In our studies of all runners, hyperpronation was present in 57% and cavus was present in 12%. Heel pain constituted

482 Figure 1. The white triangle is most frequent area of plantar fasciitis pain; the black triangle is most frequent area of tuber calcaneal pain. body weight in a runner.

The ability of the longitudinal arch to pronate, allowing some of the force to be absorbed in the midtarsal joints and ligaments, is the key to this mechanism.

2 482 Figure 1. The white triangle is most frequent area of plantar fasciitis pain; the black triangle is most frequent area of tuber calcaneal pain. body weight in a runner.10 It is necessary for the foot to dissipate these forces through a unique system of its anatomy. The ability of the longitudinal arch to pronate, allowing some of the force to be absorbed in the midtarsal joints and ligaments, is the key to this mechanism. If something is present that hinders this pronating ability or changes the manner in which it works, injury may result. In the running gait, as the foot reaches the ground the heel is in supination. In the kinetics of supination to pronation, various amounts of stress are absorbed in the heel pad, plantar fascia, midtarsal joints, ligaments, and finally the forefoot. Interference with a smooth transition of these kinetic events will allow stress concentration at one point, with subsequent injury or pain. The mechanics of a cavus configuration foot have been discussed previously and it will suffice to say there is an undue amount of rigidity throughout the foot. When this is present normal pronation and, therefore, normal stress absorption ceases. Other tissues in the area must absorb the stress. These are most often the plantar fascia and the fat pad. In the athlete with rigid feet and plantar fasciitis, one must carefully study the forefoot. A unique combination occurs with hindfoot rigidity and excessive forefoot supination. With the forefoot unable to pronate, the pronation that is necessary to place the foot on the surface occurs only at the midtarsal area. This produces pronation type of moment through the midfoot without forefoot or hindfoot contribution. The consequent plantar fasciitis is probably due to increased torsion through the &dquo;bowstrung&dquo; plantar fascia. The biomechanics of excessive pronation are explained with reference to heel pain. The pronated foot allows the midfoot area to overstretch and the plantar fascia becomes injured. Laterally, the configuration of the fat pad allows stress absorption (Fig. 3). This configuration is like a ripple sole, specifically designed to absorb stress in the anteroposterior direction. The calcaneus has a mild varus curvature. In addition to this, the soft tissue of the plantar fascia and fat pad also have a curving configuration toward the medial Figure 2. Various sports contributing to heel pain: A, running/ jogging, 76%; B, racquet sports, 9%; C, basketball, 5%; D, soccer, 4%; and E, miscellaneous, 6%. 19% of all of the athletes foot problems. The time of recovery from heel pain injuries was a median of 7.5 weeks, compared to a median of 5.2 weeks for general running injuries. Of interest is the fact that there is not a bell-shaped curve for this injury recovery period. Approximately 20% of patients require 3 to 4 months before recovery to sports activity and 5% may not recover within 9 to 12 months. It is in this latter group that surgical decisions need to be made. BIOMECHANICS Mechanical forces that pass through the heel at first contact are very high, being estimated in the range of 2 to 21/2 times Figure 3. Closeup of fat pad, cut at plantar fascia insertion to calcaneus, showing vertical arrangement of fat columns.

483 Figure 5. Medial surface right foot. Triangle, medial plantar nerve. Square, lateral plantar nerve. Circle, medial calcaneal nerve (note its relationship to border of abductor hallucis muscle.

These structures allow stress absorption in the lateral to medial (supination to pronation) motion at the foot and leg. Interference with this produces heel pain. DISCUSSION - Figure 4.

3 483 Figure 5. Medial surface right foot. Triangle, medial plantar nerve. Square, lateral plantar nerve. Circle, medial calcaneal nerve (note its relationship to border of abductor hallucis muscle. Arrow shows nerve to abductus digiti quinti pedis muscle. Open triangle, border of abductor hallucis muscle. side. These structures allow stress absorption in the lateral to medial (supination to pronation) motion at the foot and leg. Interference with this produces heel pain. DISCUSSION - Figure 4. A, medial surface, left foot. Diamond, medial calcaneal nerve branch. Circle, nerve to abductor digiti quinti perdis muscle. Arrow shows its course under the calcaneus. Plantar fascia divided and held in instrument. Triangle, lateral plantar nerve. Square, medial plantar nerve. B, medial aspect, left foot. Diamond, medial calcaneal branch. Circle, nerve to abductus digiti quinti pedis. Square, lateral plantar nerve. Open triangle, border of adductus hallucis nerve. Triangle, lateral plantar nerve. That a large number of athletes in running sports have heel pain is not surprising; the surprising fact is that the heel pain in this group constitutes only 19% of all foot problems. As noted previously,&dquo; any athlete engaged in any sport with running as a component is applying at least 21/2 times body weight at heel contact. The differential diagnosis of heel pain must include a wide variety of conditions. Tarsal tunnel syndrome, plantar fasciitis, tuber calcaneal pain, and median calcaneal neuritis must be ruled out. Calcaneal stress fracture and tarsal coalitions are diagnosed with appropriate x-ray films, bone scans, or computed tomography. Various inflammatory conditions such as rheumatoid arthritis, Reiter s syndrome, and ankylosing spondylitis must be ruled out. The decision when to perform surgery on an athlete s heel has been dealt with in numerous ways. The literature reflects the fact that heel surgery in nonathletes is a last attempt to allow the patients to walk comfortably.3, 11 Generally, results from these surgeries have been 60% to 80% effective in allowing pain relief and possible return to activity. 1,3,4,10,11,13 The need to do surgery is present in those patients who fall into the 5% with chronic heel pain. Murphy and Baxter 12 reported 15 heels operated on over a 10 year period with good results. Bordelon3 reported five heels in a 3 year period. The current series covers four surgical procedures in athletes

484 TABLE 1 Procedures for subcalcaneal pain TABLE 2 Postoperative treatment If pain at any step, cut back 5 minutes, hold until pain-free, then progress. over a 4 year period.

4 484 TABLE 1 Procedures for subcalcaneal pain TABLE 2 Postoperative treatment If pain at any step, cut back 5 minutes, hold until pain-free, then progress. over a 4 year period. The literature generally supports the fact that operative procedures for chronic pain can give relief. 1, 3, There is not verification of the level of a patient s return to his or her preinjury activity level except in one report.&dquo; It is imperative that conservative treatment previously mentioned be exhausted. The current protocol is to offer surgery to a patient only after all conservative treatment has been tried over at least a 12 month period. Once this has been done, it is worthwhile to perform a series of nerve blocks to evaluate the causative factor. A series of blocks to the median calcaneal nerve, nerve to abductor digiti quinti pedis, and the tarsal tunnel are necessary. These anatomical locations of the nerves are easily found in standard anatomy texts (Fig. 4). This selective blocking of each nerve should localize the offending anatomical structure. Nerves are blocked as correlated with their anatomical position (Fig. 5). Then appropriate decisions regarding the surgery should be made. It is mandatory that the surgeon review the specific anatomy of the area, even to the point of returning to the anatomical laboratory dissection. The small nerve branches in question are intimately placed in heel fat and muscle. Inadvertent division of these nerves often causes postoperative pain and is a leading cause of the need for reoperation. The various entities that must be addressed are tarsal tunnel syndrome, tuber calcaneal pain (compartment syndrome of the abductor hallucis muscle), plantar fasciitis, and medial calcaneal neuritis. There are numerous surgical procedures dealing with subcalcaneal pain (Table 1). Tarsal tunnel syndrome was first described in 1962.~ The symptoms consist of plantar fascia surface paresthesias and nonlocalized pain. On occasion, the pain is localized on the median plantar, lateral plantar, or median calcaneal branch and a Tinel s sign is present. Occasionally the pain radiates proximally from the medial malleolar area. EMG is occasionally helpful in localizing the specific area of irritation. The operative approach follows guidelines reported in standard texts.&dquo; The posterior tibial nerve is found and is carefully followed to the point where it divides into the medial and lateral plantar nerves. The medial nerve is then followed to the point where it dives below the border of the abductor hallucis. The fibro-osseous tunnel is then inspected for any firm constriction and any constriction is divided. The same procedure is followed with the lateral plantar nerve relieving any pressure onto the nerve. Median calcaneal neuritis should be suspected when pain along the medial heel area is relieved by blocking the nerve.

5 485 Surgical approach entails an oblique incision beginning proximally enough to find the posterior tibial nerve. With meticulous dissection along the median calcaneal nerve, any fibrous bands or constrictions can be relieved. It is not recommended that the nerve be sectioned. In some athletes with recalcitrant intractable pain, particularly after a previous operative procedure, a neuroma in this nerve has been found. The neuroma must be excised, the nerve fully released, and fat used to cover the end. The same approach should be used to deal with tuber calcaneal pain (abductor hallucis compartment) and plantar fascia pain. The tuber calcaneal pain is probably from compression of the nerve to the abductor digiti quinti muscle. By release of the abductor hallucis from its calcaneus insertion, the deep fascia which blends into the border of the plantar fascia is visible. This fascia is divided and the nerve released.&dquo; If there is pain at the plantar fascia, release of the plantar fascia and the proximal abductor hallucis muscle is necessary. Some athletes have heel pain that cannot be localized.3 The appropriate procedure would be the one outlined by Bordelon that would entail exploration of the three branches of the nerve releasing the medial portion of the plantar fascia and exploration of the nerve to the abductor digiti quinti. POSTOPERATIVE TREATMENT Postoperative treatment of all surgical procedures is to allow soft tissue healing to occur. Cycling or swimming at approximately 2 weeks, and gentle run/walk training and a gradual escalation up to running at approximately 6 weeks is allowed (Table 2). SUMMARY Decision making and successful results in subcalcaneal pain in athletes must be based on a series of tenets: 1. That correct diagnosis has been made and other nonmechanical or compression causes have been ruled out. 2. That appropriate conservative treatment of at least 12 months has been performed, encompassing physiotherapy, medications, orthosis, and adequate rest. 3. That the selective nerve blocks and the EMG have been performed for specific localization. 4. That the surgeon be totally conversant with the anatomy of the area. If that is not the case then he must dissect and review the anatomy prior to surgery. 5. That the athlete is unable to compete with the current level of pain and that he or she understands the results may not be satisfactory enough for return to high level of competition. 6. That surgery be done in the correct area relieving or decompressing adequate tissues and avoiding injury to other branches from the posterior nerve. REFERENCES 1 Ali E Calcaneal spur. West Indian Med J , Blechschmidt The structure of calcaneal padding. Foot Ankle , Bordelon RL Subcalcaneal pain Clin Orthop 177: 49-53, Furey JG Plantar fasciitis The painful heel syndrome. J Bone Joint Surg 44A , Kech C The tarsal tunnel syndrome J Bone Joint Surg 44A , Lam S: A tarsal tunnel syndrome. Lancet , Leach RE, Schepes A Hindfoot pain in athletes why and what can be done J Musculoskel Med , Lutter L Cavus foot in runners Foot Ankle , Lutter L Injuries in runners and joggers Minn Med , Mann RA, Baxter D, Lutter L Running symposium Foot Ankle , Mann RA Duvries Surgery of the Foot Fourth edition St Louis, CV Mosby, Murphy PC, Baxter DE: Nerve entrapment of the foot and ankles in runners. Clin Sports Med , Snook GA, Chnsman OE The management of calcaneal pain Clin Orthop 82: 163, Sorrels RB, Mann R, Morrey B: The painful heel syndrome. Arches Pains , Tanz S Heel pain Clin Orthop 28: , 1963

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