Calcaneal Enthesopathy Management
Clinical Presentation
- Plantar fasciitis typically presents with pain at the medial plantar aspect of the heel, worst with first steps in the morning 1
- Insertional Achilles tendinopathy is characterized by chronic posterior heel pain and swelling, with pain aggravated by increased activity and pressure from shoes 2
- Bursitis with Haglund's deformity presents as acute pain and inflammation lateral to the Achilles tendon, often with a visible posterior lateral prominence 3
Diagnosis
- Ultrasonography and MRI can be helpful in unclear cases or for preoperative evaluation of calcaneal enthesopathy 4
Treatment Approach
- The American Academy of Family Physicians recommends regular calf-muscle stretching, cryotherapy, and activity modification for plantar fascia-related enthesopathy 5, 4
- Over-the-counter heel cushions, arch supports, and appropriate footwear are recommended for plantar fasciitis 1
- Weight loss is indicated if necessary, and avoidance of flat shoes and barefoot walking is recommended 6
- NSAIDs are used for pain relief and anti-inflammatory effects in calcaneal enthesopathy 4
- Corticosteroid injections are recommended for plantar fasciitis, but not for Achilles tendinopathy due to risk of tendon rupture 1, 2
- Open-backed shoes, orthoses, and accommodative padding are recommended for bursitis with Haglund's deformity 3
- Customized orthotic devices, night splinting, and immobilization may be considered for advanced conservative measures 6, 2, 3
Special Considerations
- Corticosteroid injections should be avoided near the Achilles tendon due to risk of tendon rupture 2
- Complete immobilization should be avoided to prevent muscular atrophy and deconditioning 4
- Referral to a podiatric foot and ankle surgeon is considered if no improvement after 6 weeks of initial treatment 1
- Other causes of heel pain, including neurologic conditions, stress fractures, or systemic inflammatory diseases, should be ruled out when standard treatments fail 7
- Evaluation for underlying rheumatic disease is considered for patients with multiple symptomatic tendons 4