Posterior heel pain

Abstract

Heel pain at or around the insertion of the Achilles tendon is a common presenting complaint affecting both young, active patients and those who are older and more sedentary. So-called posterior heel pain is often presumed to run a self-limiting course over a few months, resolving with rest, weight loss and stretching exercises. However, a small number of patients suffer with increasingly disabling symptoms that are refractory to this regimen. Posterior heel pain is classically split into insertional and non-insertional types, and in order to select an appropriate management plan the diagnosis must be precise. Further management without a clear understanding of the pathology is potentially detrimental to the patient. This review aims to provide a structured approach to careful clinical and radiological assessment and treatment of this condition.

The clinical diagnosis of Achilles tendinopathy: a scoping review

“…Location of pain was included as a diagnostic criteria of Achilles tendinopathy in 31 studies, with midportion tendinopathy defined as 'midportion' in two studies (Saini et al, 2015;Tan & Chan, 2008), distal 5 cm of the Achilles tendon in one study (Nichols, 1989), 2-5 cm above the calcaneal insertion in three studies ), 2-6 cm above the calcaneal insertion in 13 studies (Alfredson, 2003;Asplund & Best, 2013;Feilmeier, 2017;Fredericson, 1996;Kader et al, 2002;Longo, Ronga & Maffulli, 2009;Maffulli, Giai Via & Oliva, 2015;Maffulli, Sharma & Luscombe, 2004;Maffulli, Via & Oliva, 2014;Sharma & Maffulli, 2006), and 4-6 cm above the calcaneal insertion in one study . The third most common subjective criteria reported was tendon stiffness, with 24 studies including it as a diagnostic criteria (Millar et al, 2021;Alfredson, 2003;Alfredson & Cook, 2007;Asplund & Best, 2013;Baskerville et al, 2018;Benazzo, Todesca & Ceciliani, 1997;Chazan, 1998; Chimenti et al, 2017;Cook, Khan & Purdam, 2002;Feilmeier, 2017;Fredericson, 1996;Irwin, 2010;Jukes, Scott & Solan, 2020;Kader et al, 2002;Maffulli, Giuseppe Longo & Denaro, 2012;Maffulli et al, 2019;Nichols, 1989;Tan & Chan, 2008). As with previous study types, the most common clinical test used to diagnose Achilles tendinopathy was palpation, with all 43 included reviews including it as a clinical measure (Millar et al, 2021;Aldridge, 2004;Alfredson, 2003;…”

“…The third most common subjective criteria reported was tendon stiffness, with 24 studies including it as a diagnostic criteria (Millar et al, 2021;Alfredson, 2003;Alfredson & Cook, 2007;Asplund & Best, 2013;Baskerville et al, 2018;Benazzo, Todesca & Ceciliani, 1997;Chazan, 1998; Chimenti et al, 2017;Cook, Khan & Purdam, 2002;Feilmeier, 2017;Fredericson, 1996;Irwin, 2010;Jukes, Scott & Solan, 2020;Kader et al, 2002;Maffulli, Giuseppe Longo & Denaro, 2012;Maffulli et al, 2019;Nichols, 1989;Tan & Chan, 2008). As with previous study types, the most common clinical test used to diagnose Achilles tendinopathy was palpation, with all 43 included reviews including it as a clinical measure (Millar et al, 2021;Aldridge, 2004;Alfredson, 2003;Alfredson & Cook, 2007;Aronow, 2005;Asplund & Best, 2013;Baskerville et al, 2018;Benazzo, Todesca & Ceciliani, 1997;Bhatty, Khan & Zubairy, 2019;Chazan, 1998;Chimenti et al, 2017;Cook, Khan & Purdam, 2002;Den Hartog, 2009;Feilmeier, 2017;Fredericson, 1996;Irwin, 2010;Järvinen et al, 2001;Jukes, Scott & Solan, 2020;Kader et al, 2002;Longo, Ronga & Maffulli, 2009;…”

“…Of the 43 narrative reviews included in the scoping review, seven studies investigated insertional Achilles tendinopathy (Aldridge, 2004;Benazzo, Todesca & Ceciliani, 1997;Chimenti et al, 2017;Den Hartog, 2009;Irwin, 2010;Maffulli et al, 2019), 18 studies investigated midportion Achilles tendinopathy (Alfredson, 2003;Alfredson & Cook, 2007;Feilmeier, 2017;Järvinen et al, 2001;Kader et al, 2002;Longo, Ronga & Maffulli, 2009;Maffulli, Sharma & Luscombe, 2004;Maffulli, Via & Oliva, 2014;Scott, Huisman & Khan, 2011;Sharma & Maffulli, 2006;Tan & Chan, 2008), 13 studies investigated both insertional and midportion Achilles tendinopathy (Aronow, 2005;Asplund & Best, 2013;Bhatty, Khan & Zubairy, 2019;Chazan, 1998;Cook, Khan & Purdam, 2002;Fredericson, 1996;Jukes, Scott & Solan, 2020;Maffulli, Giai Via & Oliva, 2015;Saini et al, 2015), and five studies did not specify tendinopathy location (Table 10) (Millar et al, 2021;Baskerville et al, 2018;Maffulli, Giuseppe Longo & Denaro, 2012;Nichols, 1989;Sorosky et al, 2004). The most common subjective diagnostic criteria for diagnosing Achilles tendinopathy was pain with tendon loading, with all 43 included reviews utilising as a diagnostic criteria (Millar et al, 2021;Aldridge, 2004;…”

“…As with previous study types, the most common clinical test used to diagnose Achilles tendinopathy was palpation, with all 43 included reviews including it as a clinical measure (Millar et al, 2021;Aldridge, 2004;Alfredson, 2003;Alfredson & Cook, 2007;Aronow, 2005;Asplund & Best, 2013;Baskerville et al, 2018;Benazzo, Todesca & Ceciliani, 1997;Bhatty, Khan & Zubairy, 2019;Chazan, 1998;Chimenti et al, 2017;Cook, Khan & Purdam, 2002;Den Hartog, 2009;Feilmeier, 2017;Fredericson, 1996;Irwin, 2010;Järvinen et al, 2001;Jukes, Scott & Solan, 2020;Kader et al, 2002;Longo, Ronga & Maffulli, 2009;Maffulli, Giai Via & Oliva, 2015;Maffulli, Giuseppe Longo & Denaro, 2012;Maffulli et al, 2019;Maffulli, Sharma & Luscombe, 2004;Maffulli, Via & Oliva, 2014;Nichols, 1989;Saini et al, 2015;Scott, Huisman & Khan, 2011;Sharma & Maffulli, 2006;Sorosky et al, 2004;Tan & Chan, 2008). There was then significant variation in other clinical tests used to diagnose Achilles tendinopathy, with nine studies including the Painful Arc Sign (Millar et al, 2021;Aronow, 2005;Feilmeier, 2017;Kader et al, 2002;…”