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Foot and ankle problems: II

In the second of two articles, rheumatologist Dr Phillip Helliwell and colleagues look at common problems of the rearfoot

In the second of two articles, rheumatologist Dr Phillip Helliwell and colleagues look at common problems of the rearfoot

The most common heel and ankle problems encountered in primary care are: pain at the back of the heel and Achilles tendon pain, ankle sprain and instability, plantar fasciitis and flat foot deformity and tibialis posterior dysfunction.

A lot of simple advice can be given but – like problems involving the forefoot – these conditions encompass a huge spectrum of disability and pathology. If simple measures fail then seek help from a podiatrist, physiotherapist or musculoskeletal doctor. Reliable internet-based advice and simple patient leaflets are also available .

Pain at back of the heel and Achilles tendon pain

Pain around the posterior heel has four main causes:

• Achilles paratendonitis – by far the most common and due largely to mechanical factors. A typical history is someone who has just completed a 25-mile hike in boots that haven't been worn for four years. In other cases the patient may have severe hyperpronation – or flat foot deformity. But beware the elderly patient on steroids or recent courses of a quinolone antibiotic such as ciprofloxacin which can cause tendonitis and partial or complete rupture.

• Haglunds ‘one' – due to bony prominence on posterior superior aspect of heel. This may present with persistent Achilles pain proximal to the insertion and associated with the posterior superior aspect of calcaneum. MRI scanning shows high signal at this point.

•Haglunds ‘two' – "pump bumps" – due to bony prominence on posterior lateral aspect of heel. Pump bump is primarily bony but may have an adventitious bursa overlying it.

•Achilles insertional tendonitis which is primarily seen in spondyloarthropathy (such as reactive arthritis, psoriatic arthritis and ankylosing spondylitis). Pain and swelling are found at the point of insertion of the tendon, rather than the substance of the Achilles proximal to the insertion. This may be associated with other features such as back pain and stiffness, dactylitis and skin disease.


Ankle sprain and instability

Inversion sprains around the ankle are common both in and out of sport. Most sprains are minor but the severest can result in ligamentous rupture and osteochondral defects in the articular surface of the talus and the tibia.

The most important risk factor for sprain is a previous sprain so adequate treatment of a first sprain is very important.

Most sprains go to A&E and have an X-ray. Often, they also receive inappropriate advice on early management. Investigations are rarely of help initially.


Plantar fasciitis

Pain in the plantar fascia region (deep to the heel pad) is a common foot problem that arises from repeated trauma to the fascia and attachment. The symptoms include discomfort along the fascia which is aggravated by weight bearing and painful at the origin of the fascia.

It is often characterised by a focal tenderness at the attachment on initial weight bearing after rest, particularly when getting out of bed. This pain generally dissipates within half an hour or so.


Flat foot deformity and tibialis posterior dysfunction

Flat foot deformity is common and occurs in about a quarter of the population. It has been associated with plantar fasciitis, Achilles tendon pain, ‘shin splints' and even osteoarthritis of the knee. Tibialis posterior dysfunction (TPD) is the most common cause of acquired flatfoot deformity in otherwise healthy adults.


Dr Philip Helliwell is consultant rheumatologist at the Academic Unit of Musculoskeletal and Rehabilitation Medicine, University of Leeds.

This article was co-written by Heidi Davys, Ann-Maree Keenan, Anthony Redmond, Carl Ferguson, Lee Short and Brian Welsh.

Competing interests None declared

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