LATERAL HEEL PAIN IN A RUNNER

Abstract

HISTORY û A 39 year old avid recreational runner presented with a four week history of right heel, ankle, and leg pain with parasthesias. He denied lower extremity weakness. He denied low back pain. Symptoms improved with two weeks of rest but returned when running was resumed. There was no history of trauma or constrictive clothing, boots, or shoes over the symptomatic area. There was no history of prior injury at the back or lower extremity. He reported frequently crossing his legs in a manner, which placed pressure over the right posterior lateral calf. Symptoms were generally aggravated several hours after running, and relieved with rest, ice, and minimally with Aleve. PHYSICAL EXAMINATION û General examination revealed normal stance and gait. Examination of the lumbar spine revealed full, active, pain free, range of motion. The right lower extremity was without swelling or deformity. There was full active range of motion at the right ankle with some tenderness to palpation at the distal Achilles tendon. A positive Tinel's sign was present at the right mid calf musculotendinous junction, but absent at the lateral malleolous. Sensation to light touch and pinprick were diminished from mid lateral calf distally including the lateral ankle and foot. Strength was normal at bilateral lower extremities to include eversion, inversion, dorsiflexion, and plantar flexion. Reflexes were normal and symmetric at bilateral patellar and Achilles tendons. DIFFERENTIAL DIAGNOSIS Sural sensory neuropathy Gastrocnemius strain at the musculotendinous junction Achilles tendonitis Lumbar radiculopathy Peripheral polyneuropathy TEST AND RESULTS Electrodiagnostic Studies Markedly diminished right sural sensory nerve action potential (SNAP) amplitude compared to the left by 70% with a mildly diminished SNAP conduction velocity, SNAP temporal dispersion, and normal latency. Left sural SNAP with normal amplitude, conduction velocity, and latency. Bilateral tibial and peroneal compound motor action potentials (CMAP's) with normal amplitudes, conduction velocities, latencies, and temporal dispersions. Normal right lower extremity needle electromyography (EMG) at the biceps femoris, gastrocnemius, peroneous longus, and tibialis anterior muscles. FINAL/WORKING DIAGNOSIS Right sural neuropathy and Achilles tendonitis secondary to right gastrocnemius strain at the musculotendinous junction. TREATMENT Medication û NSAID's. Modalities û ice. Relative rest with cross training for four weeks. Physical Therapy with stretching, strengthening, balance and gait training, progressing to running specific exercises.