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Heel Pain

- Diff Dx:
     - distal tibial tarsal tunnel syndrome;
           - expect tenderness superior to the origin of the plantar fascia (medial tubercle of os calcis);
     - plantar fascitis
           - expect tenderness at the origin of the plantar fascia (medial tubercle of os calcis);
     - calcaneal apophysitis
     - heel pain syndrome
     - systemic syndromes:
             - metabolic: gout and pseudogout;
             - diabetes:
             - Paget's disease:
             - inflammatory arthritides (RA, Reiter's Syndrome, AS, Psoriatic arthritis, ...)
     - neoplastic: benign and malignant tumours:
     - trauma:
             - fat pad trauma: symptoms may last well over 6 months;
             - stress fracture (identified on 45 deg medial oblique view)
             - acute fracture
             - soft tissue contusion / repetitive trauma;
             - puncture wound
     - fat pad atrophy:
             - heel pad has a specialized anatomy with small chambers of adipose tissue divided by fibrous septae,
                     but there are no documented changes in heel pain patients)

- Lab studies: (useful to r/o RA or Reiter's)
    - ESR;
    - RF;
    - Uric acid;

- X-rays:
    - may demonstrate spurring of the medial calcaneal tuberosity;
    - heel spurs are not in the plantar fascia as is commonly thought but are found in the origin of the short flexors;
           - they are present in 16% of normal population

- Orthotics:
    - with plantar heel tenderness consider a cushioned heel insert, to lessen the loading forces during heel strike

Chronic heel pain. Treatment rationale.