Posterior Heel Pain

When I look at someone who presents to me with a foot complaint, I try to break it up into what the primary pathology is, and what are the secondary manifestations that they are coming to me to complain about? The foot is a complex weight bearing surface. There re 28 bones and nearly 60 articulating surfaces, so there are a lot of inter-relationships going on between the different segments of the foot, the hind foot, mid foot and forefoot, and problems in one region can have manifestations elsewhere. So it is very important to recognize what the root cause of the problem is, as well as identifying all the secondary manifestations. So when I think of the problems, I start to look at the structural malalignments that might be present in the patient’s foot, is the arch too high, is it too low? Is there some imbalance of the muscle forces that is causing that problem; or imbalance of those muscle balance forces driving the secondary manifestations. Also, as I talked about before, compensatory deformities. There could be a problem in the hindfoot, but the patient comes in to see you because there is a forefoot problem. That is where it hurts them, that is where it’s difficult for them to wear their shoes. So by way of the anatomy, the osteology of the foot, as I said, overall there are 28 bones.

There are the seven tarsal bones in the hindfoot region, we have that defined as the calcaneus, and the talus, that separates the hindfoot from the midfoot through the transverse tarsal joint. The remaining five tarsal bones are the middle, medial and lateral cuneiform, the cuboid bone, and the navicular. Then you enter into the forefoot which has the five metatarsal bones and the 14 phalanges. As you know, in the hallux, there are only two phalanges, whereas in the lesser toes, there are three, and then the two sesamoids that are under the first metatarsal head. Ligaments are important for static stabilization of the arch of the foot, both it’s longitudinal arch and the transverse arch. The spring ligament, if you look on the slide here, again we are looking up under the foot, here is the calcaneus, here are the metatarsals down here, the spring ligament is sort of a sling that runs from the calcaneus to the navicular, a sling for the arch and the medial aspect of the foot. The long plantar ligament is an important ligament for stabilizing the lateral border of the foot and then Lisfranc ligament, you may have heard about those in terms of people having foot dislocations, when the common location is through the Lisfranc joint, that is the joint that separates the midfoot bones, those five bones, the cuneiforms and the cuboid from the metatarsals, and there are strong ligaments on the plantar surface at that junction that helps stabilize the forefoot.

Another concept that I use frequently when I am looking at foot problems, is that the foot should have an axis of balance. That axis of balance runs along the sagittal plane. It goes from the center of the calcaneus, to the center of the midfoot, and runs between the second and third metatarsals in the forefoot. Weight bearing forces are balanced across that access medially and laterally, in fact, minimal muscle activity is required for quiet standing. The muscle forces, or the dynamic forces during the phases of gait are also balanced across this access for dorsiflexion, plantar flexion, but mostly for inversion and eversion of the foot to stabilize and square the foot up to the ground surface. Now that axis of balance is dynamic, you can lock and unlock the arch of your foot during gait when the primary movers of that is the posterior tibial tendon which attaches to the navicular and into the midfoot, and it maintains the arch. Then there are the everters of the foot, the peroneal tendons that help turn it out to the side, so those are the two main players in trying to stabilize that axis of balance. So your foot needs to effectively lock and unlock during gait.

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