Some possible conditions • Heel Pain – Inside of Heel
Adult acquired flatfoot is characterized by a fallen arch and outward pointed toes. This condition is a gradual progression in most cases, as the posterior tibialis tendon becomes weakened and loses the ability to maintain the height of the arch. Adult acquired flatfoot is different from a flatfoot condition in children. Adults with flatfeet remain permanently flat without surgical intervention, while children usually outgrow the condition on their own with or without treatment.
Patients typically present with pain along the course of the posterior tibialis tendon, which is on the inside of the foot and ankle. Pain is usually worse with activities, especially high impact like running and jumping. The heel bone can shift toward the outside of the foot putting more pressure on the outside ankle bone. Patients that develop arthritis and joint spurring may have nerve impingement (trapping/pinching of the nerve) which can lead to numbness, tingling or burning in the arch and toes of the foot. Diabetic patients may notice swelling or a bump on the bottom of the foot if the condition progresses. Due to the presence of diabetic neuropathy in some patients, pain is not always an indicator of this condition.
The most common cause of adult acquired flatfoot is damage to the posterior tibial tendon. This tendon starts at the calf and travels down to the inside of the foot. If the tendon becomes swollen, irritated or torn, the arch will begin to collapse due to lack of support and strength from the tendon. Studies have shown that women over 40 years of age are the most likely to develop an issue with the posterior tibialis tendon. Risk factors that can increase the chances of posterior tibialis tendon dysfunction include but are not limited to obesity, diabetes, hypertension. There is a small population of patients with inflammatory arthritis such as rheumatoid arthritis, that develop a painful flatfoot condition. Inflammatory arthritis typically causes dysfunction of the tendon, ligaments and joints leading to a more severe flatfoot deformity. Diabetic patients can progress to a condition called Charcot foot which is severe flattening and rocker bottom deformity of the midfoot. Bones can break and coalesce as the arch collapses, requiring an even more specialized brace in order to maintain weight bearing.
Patients with adult acquired flatfoot deformity are often treated with orthotics and braces, and require an examination by a Certified Pedorthist or a Registered Chiropodist. Often patients require non-steroidal anti-inflammatory medication due to pain and swelling which can limit mobility. Patients also benefit from physical therapy to help treat and prevent further injuries with the tendon involved. Patients that do not respond to conservative therapy may require surgical intervention.
Piezogenic pedal papules are a benign condition consisting of normal fat tissue that has extruded through the skin in the area of the heel. The papules usually appear on the inner side of the heel; they may also occur near the wrist. They are visible only when standing (weight bearing) and immediately disappear when non–weight-bearing. Occasionally, the papules will be painful but that is rare.
Piezogenic papules are most commonly diagnosed in otherwise healthy patients. Usually, they are not suggestive of systemic diseases.
Piezogenic papules present with firm, yellowish to skin-coloured papules that protrude from the inside (most common), outside or back aspects of the heel. The papules become more prominent when you stand in a full weight-bearing position and, by definition, go away when you remove weight. They are typically present on both the right and left side. The pain associated with them, which is rare, is felt differently; sometimes as a stinging, burning, or achy sensation.
In the rare case when these papules are painful, the pain has been attributed to the herniated fatty tissue having compression to its blood supply. The papules themselves are said to be more common in women, and appear spontaneously. There may a genetic component but this has not been proven. Finally, they can occur at any age and it is said that those who stand for long periods, and those who are obese are more at risk.
If no pain is present, treatment is typically not necessary. However, if pain or discomfort is present, it is recommended to wear compression stockings, orthotics and properly fitted footwear. Also, to avoid standing for long periods of time and consider weight loss if directed by your physician/nurse practitioner.
Tarsal tunnel syndrome is sometimes referred to as tibial nerve dysfunction or posterior tibial nerve neuralgia. The tarsal tunnel runs along in the inner ankle and foot. Within it is the posterior tibial nerve and other tendons and vascular structures. Tarsal tunnel syndrome is the compression of these structures within the tarsal tunnel. It is similar to carpal tunnel syndrome which occurs in the wrist, but occurs at the ankle and is much less common than carpal tunnel syndrome.
The predominant complaint is pain directly over the tarsal tunnel (inner ankle) that radiates to the arch and under the foot. Patients with tarsal tunnel syndrome will frequently report a sharp shooting pain in the foot, numbness on the plantar foot surface, and radiation of pain and along the distribution of the posterior tibial nerve. They may also experience pain with extremes of ankle movement and note that foot muscles may be weaker.
Tarsal tunnel syndrome causes are divided into 2 categories; intrinsic (factors within the foot/ankle) and extrinsic (outside factors). Extrinsic causes include poorly fitting shoes, trauma, biomechanical abnormalities, post-surgical scarring, systemic diseases such as inflammatory arthritis and diabetes. Intrinsic causes include tendon disease, nerve scarring, bone osteophytes and a mas, such as a tumor or ganglion, etc.
Tarsal Tunnel Syndrome can be managed non-operatively or with surgery. The more conservative approach concentrates on pain reduction with medications, such as Advil and Tylenol, and addressing the biomechanical abnormalities and reducing other extrinsic factors. Properly fitting footwear and custom orthotics will work to manipulate the foot to have better alignment and open the tarsal tunnel space up to minimize impingement. Physical therapy is an important adjunct, and kinesio taping can also be very helpful.
