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As with deformities of the forefoot, deformities of the rearfoot often respond well to conservative therapy. Rest and nonsteroidal anti-inflammatory medications are often used. Patients with plantar fasciitis may benefit from corticosteroid injections. Surgery may be helpful in refractory cases. Haglund's deformity is associated with pain in the area of the osseous ridge on the posterosuperior aspect of the calcaneus. The retrocalcaneal bursa may be inflamed. This disorder is diagnosed by palpation of the painful area. Conservative treatment consists of minimizing pressure over the osseous ridge. Corticosteroid injection is not advised since it may weaken the Achilles tendon. Surgical intervention consists of resection or reduction of the osseous ridge. Posterior calcaneal spur is another cause of heel pain. The spur can be visualized radiographically in the tendon insertion. Treatment is conservative, with footgear modification and nonsteroidal anti-inflammatory drug therapy. Surgery to remove the spur may be indicated if conservative measures fall to relieve the pain. Tarsal tunnel syndrome is characterized by pain and numbness from the medial malleolus to the sole of the foot. Conservative treatment includes reducing abnormal pronation with an orthosis.

Background: Malignant skin tumors rarely spread along nerves. Complete resection of involved nerves is often unsuccessful., Objective: In the treatment of tumors with perineural invasion, surgeons should accurately estimate the extent of distant spread., Methods: We report six cases of skin cancers, including two basal cell carcinomas, two squamous cell carcinomas, and two neurotropic malignant melanomas, that invaded nerve or perineural spaces., Results: In three of the cases, the tumors developed on the face and involved the infraorbital nerves or its branches. Two patients suffered from tumors on old burn scars of lower legs. Branches of posttibal nerves were involved in both cases. In the last case, tumor invasion of a branch of the greater occipital nerve was detected., Conclusion: The extent of surgical excision should include the area of skin supplied by the affected nerve, which must be resected in continuity.

The technique of free-tissue transfer for complex wounds has become a common tool in reconstructive surgery. The use of this modality in immunosuppressed transplant patients, who often have associated metabolic and vascular disease, has not been well-documented. The authors report three cases of lower-extremity reconstruction in renal-transplant recipients, utilizing microvascular free-tissue transfer. All three patients were hypertensive diabetic patients with symptomatic peripheral vascular disease and chronic wounds. One patient presented with an exposed Achilles tendon; the second had a complex wound of the forefoot; and the third patient had a large ulceration on the heel of the right foot. These three patients underwent successful free-tissue transfer, and have regained full use of their limbs and ambulation. Free-tissue transfer in the immunosuppressed transplant recipient is a viable reconstructive option. Careful perioperative metabolic monitoring and surgical care are critical for success. A multispecialty approach is advocated, to coordinate limb salvage in these patients.

Background: Eccrine porocarcinoma is an uncommon neoplasm of the intraepidermal sweat gland duct., Methods: A case of porocarcinoma of the right heel in a male age 51 years is described with a review of pertinent literature. The surgically excised neoplasm was evaluated by routine histology and transmission electron microscopy., Results: The porocarcinoma showed extensive nuclear pleomorphisms with frequent, multinucleated tumor giant cells, focal epidermotrophic spread within the epidermis, a peripheral, eccrine syringofibroadenoma-like growth pattern, and an origin in a contiguous eccrine poroma. Ultrastructurally, the squamous tumor cells contained rare intracytoplasmic lumens., Conclusions: The extensive nuclear pleomorphism with frequent tumor giant cells was an unusual feature of the porocarcinoma. Its epidermotrophic spread within the epidermis and its origin in a contiguous eccrine poroma supported the diagnosis of porocarcinoma. The eccrine syringofibroadenoma-like growth pattern in the periphery of the tumor was a unique and previously undescribed feature of the porocarcinoma. The presence of intracytoplasmic lumens in squamous tumor cells mimicked embryonic development of the intraepidermal sweat gland duct.

This study demonstrates magnetic resonance findings in 16 patients (25 heels) with heel pain. Sixteen of 25 (64%) studies demonstrated abnormalities which could be related to the etiology of their heel pain. Eleven of 16 abnormal scans demonstrated thickening of the plantar aponeurosis with associated fibrosis (7 of 11), and a tear of the flexor digitorum brevis (1 of 11). One study demonstrated changes in the heel pad consistent with fluid. The other four abnormal studies demonstrated changes thought to be consistent with bilateral fibrous calcaneonavicular coalitions, subtalar arthrosis and tenosynovitis of the posterior tibial, flexor digitorum longus, and flexor hallucis longus tendons.

Between January 1987 and December 1989, a retrospective study was done of 42 patients with 56 closed intra-articular calcaneal fractures treated with no reduction and early mobilisation at the Department of Orthopaedic Surgery, Toa Payoh Hospital. There were 12 left, 16 right and 14 bilateral fractures. Using the Creighton-Nebraska Health Assessment for calcaneal fractures, 38 (67.9%) fractures were rated as excellent and good and the average follow-up period was 3.2 years. Thirty-five (83.3%) of the patients were able to work after an average interval of 4.5 months. The complications included residual pain in 34 (60.1%) fractures, heel deformity in 40 (71.4%), foot swelling in 31 (55.4%) and limitation of subtalar movement in 35 (62.5%). Early osteoarthritis of the subtalar joint was noted in 5 (8.9%) comminuted fractures and was associated with poor results.

Minor nail trauma may cause bluish discoloration of the nail, while tangential skin trauma on the heel can result in a so-called black heel. To rule out melanoma in such clinical situations, a biopsy is needed to reveal homogeneous eosinophilic masses deposited under the nail plate or within it (transepidermal elimination). Most dermatopathologists attempt to demonstrate the presence of hemoglobin in these eosinophilic masses with Prussian blue stain, which typically remains negative. In our experience, these traumatically induced blood deposits are always situated in avascular spaces, devoid of degrading phagocytes. Consequently, a histochemical stain for these deposits should be directed specifically toward hemoglobin, not hemosiderin. In the dermatopathologic literature, the various techniques to detect hemoglobin deposits in tissue sections are not well-known. We would like to emphasize benzidine stain, a highly selective and efficient method to demonstrate the presence of hemoglobin deposits in histologic sections. To date, benzidine stain has not been utilized to characterize splinter hemorrhage (subungual hematoma). Of concern, the use of benzidine in histopathology laboratories is restricted because this agent is a known carcinogen, while the non-mutagenic derivative, 3,3',5,5'-tetramethylbenzidine, does not stain histologic sections. Patent blue V, a completely different and less specific agent, stains hemoglobin an intense blue-green.

We evaluated 10 patients in which the initial reconstruction of the weight-bearing area of the sole and heel was performed in infancy or childhood and which had been followed up more than 10 years. In the initial operations, a cross-leg flap was used in 5, full-thickness skin graft in 5, and split-thickness skin graft in 1 (in 1 patient, both a cross-leg flap and a full-thickness skin flap was used). Secondary reconstruction was performed using skin graft from non-weight-bearing areas in 6 patients and a cross-leg flap in 1 patient. In infancy and childhood, temporary closure of a wound by skin graft from the inguinal area or a cross-leg flap was attempted. Initial reconstruction using the non-weight-bearing area must be performed carefully in infancy and childhood.

Light and electron microscopy was used for a histologic examination of normal heel fat pads and atrophic heel fat pads from patients with peripheral neuropathies. Histomorphometric analysis revealed an average 30% smaller mean cell area and 16% smaller mean cell diameters in the atrophic pads compared with the normal heel fat pads. Septal walls in the atrophic fat pads were often fragmented and approximately 75% wider than normal. Perineural fibrosis was also found in the atrophic heel fat pads. The Verhoeff elastic staining technique was used to determine the relative percentage of collagen to elastic tissue within the septae. No significant differences were noted between the normal and atrophic heels. The ultrastructure of the adipocytes from the normal and atrophic heel pads was similar to those found in abdominal subcutaneous fat. Lipid droplets of variable size and density thin the center of the adipocyte were surrounded by a thin border of cytoplasm. The interphase between adipocytes contained fine collagen and elastic fibers.

The authors radiographed and dissected 200 fresh frozen cadaveric specimens selected randomly from the general United States population. A 21% incidence of inferior calcaneal exostosis formation was identified. Of those specimens identified as having an inferior calcaneal exostosis, there was a 52.4% incidence of heel spurs that were in the plantar fascia and a 47.6% incidence of heel spurs that were identified superior to the plantar fascia. After dissection of the specimens, the mean width and thickness of the medial, central and lateral bands of the plantar fascia, and the width of the medial and lateral subcutaneous fat were calculated. The presence of an inferior calcaneal bursa was identified in one specimen, and the presence of a heel neuroma was identified in 0 specimens of the 200 examined. The results of this study will assist the practitioner in performing the endoscopic plantar fasciotomy by providing the surgeon with quantitative averages of fascial dimensions. By knowing these fascial measurements, the practitioner will be aided intraoperatively in determining what level of fasciotomy to perform. This could help obviate some of the postoperative biomechanical sequelae that can occur with total releases, and immediate postoperative excessive ambulation by the patient. This study may help to gain insight into the true etiology of heel spur syndrome/plantar fasciitis.

The F-scan system was used to study plantar foot pressure in patients with a pronated foot type. Inshoe measurements were made under the first metatarsal head and medial heel with and without an orthotic in an extra depth shoe. The F-scan system was also used to compare the total contact area under the foot between each patient with and without the orthotic device. Data collected in this study demonstrated a reduced plantar pressure under the first metatarsal head and medial heel in the patients with an orthotic (30-40% reduction). Calculations of the total contact area under the foot revealed an increase in contact area with an orthotic in extra depth shoes (5-10% increase). Pressure-sensitive insoles, which were replaced as needed, provided reproducible measurements of dynamic plantar pressure and contact area through repeated measurements over the 3-month period of this study. Evaluations show that a custom-made foot orthotic can increase total contact area (redistribute force) and is able to reduce plantar pressures. Thus, an orthotic should reduce the risk of ulceration in the diabetic neuropathic foot.

Endoscopic plantar fasciotomy (EPF) is an efficacious, minimally invasive procedure for the surgical intervention of heel spur syndrome/plantar fasciitis. Because of the minimal trauma involved with the technique, patients are able to return to full activity much quicker than with traditional "open" heel spur surgery techniques. The EPF procedure is not difficult to perform but requires extreme precision to ensure a successful result and to avoid iatrogenic complications. The author strongly encourages proper training with cadaveric specimens before using this technique with patients to ensure the highest standard of care. As with all surgical techniques, there are inherent complications; these complications are usually biomechanical in nature and can be reduced greatly by proper surgical techniques.

Heel pain can be caused by disorders of either the plantar fascia, calcaneus, tendons, or adjacent nerves. Because these conditions can lead to pain located in a small area of the heel, a precise clinical diagnosis may be difficult. This article describes some of these various causes of heel pain and how MR imaging helps to characterize them.

The cuniculatum carcinoma is a rare type of epidermoid carcinoma. We report 6 cases with different localizations ("oral cavity and larynx", vulva, lower limb) treated over a 23-year period. Diagnosis is particularly difficult and requires careful clinical examination completed by deep surgical biopsy for histology. The aetiology of the tumour is not well defined. It presents as a slow growing wart with local malignancy and chronic suppuration. Extension to lymph nodes is rare. Histologically there is proliferative deep malpighian infiltration with an aspect of normal cell maturation. Galeries are hollowed out giving the aspect of a rabbit burrow (cuniculatum). Surgery is the only treatment, generally without lymph node curage. Radiotherapy is contraindicated due to anaplastic transformation.

Ultrasound measurements of heel pad thickness in 21 patients who had suffered unilateral fractures of the calcaneum were taken. Body weight was also recorded. Contrary to previous assertions in the literature, heel pad thinning was not found to occur and in fact a significant increase in heel pad thickness on the affected side was noted.

Capillary gas-liquid chromatography was used to analyze the fatty acid composition of normal heel fat pads from subjects without systemic disease (N = 8) and atrophied heels from patients with diabetic peripheral neuropathy (N = 4), rheumatoid arthritis (N = 1), peripheral vascular disease (N = 1), and hereditary sensory neuropathy (N = 1). In the normal subjects, the fatty acid composition of subcutaneous abdominal fat was also obtained for comparison. Three saturated fatty acids (myristate, palmitate, and stearate) and four unsaturated fatty acids (palmitoleate, oleate, vaccenate, and linoleate) comprised over 90% of the total fatty acid composition. Higher percentages of unsaturated fatty acids and lower percentages of saturated fatty acids were found in the normal heel fat pads when compared to subcutaneous abdominal fat. The increase in the ratio of unsaturated fatty acids to saturated fatty acids (4.4 versus 2.5, P < .01) may decrease triglyceride viscosity and enhance the biomechanical efficiency of the heel fat pad. Though the number of patients is small, no statistically significant compositional differences were noted between the heel fat from normal subjects and from subjects with peripheral neuropathies, rheumatoid arthritis, or peripheral vascular disease. However, the heel fatty acid composition of the one subject with a hereditary sensory neuropathy was less unsaturated and more saturated than normal with a ratio of unsaturates to saturates similar to that of the abdomen (2.8).

The authors present the case of an adult female patient with bilateral posterior heel masses. These were removed and histologically found to be rheumatoid-like nodules. There was no clinical or laboratory evidence of rheumatoid disease. A review of the literature is presented.

Forty-four patients who had had fifty-two calcaneal fractures were managed with open reduction and internal fixation. The results were reviewed retrospectively, between four and fourteen years after the operation, with use of an evaluation system for the hindfoot and with plain radiographs. The characteristics of the patients that were associated with an unsatisfactory outcome were an age of more than fifty years, a greater body weight, work involving strenuous labor, and increased time missed from work due to the injury. Other prognostic variables associated with an unsatisfactory result included subtalar incongruity, osteoarthrosis of the talonavicular joint and the ankle, an increased heel width, a decreased fibulocalcaneal space, and a decreased Böhler-angle ratio of the fractured to the normal side. The heel height, fat-pad height, arch angle, talocalcaneal angle, and length of the Achilles-tendon fulcrum were not related to the outcome. Patients who had had a tongue-type fracture had a better result than those who had had a central depression fracture, while those who had had a central depression fracture had a better outcome than those who had had a comminuted fracture. Comminution of tongue and large central-depression fractures was associated with a worse prognosis. The most common most painful area in the patients who had a satisfactory outcome was the lateral aspect of the hindfoot, while in those who had an unsatisfactory result, it was the heel pad.

The Harris and Beath footprint is an inexpensive, noninvasive method of recording foot/ground pressure patterns to aid clinical diagnosis, decision making, and follow-up. Studies of normal children and skeletally mature individuals have identified the wide variations found in normal feet, a knowledge of which is fundamental to the interpretation of the footprint in the clinical situation.

Acquired fibrokeratomas traditionally have been classified by both appearance and anatomical location. They are benign, solitary lesions that characteristically involve the digits of the hands and feet. The authors present a case with unusual involvement of the plantar surface of the heel.

The fat pads of the heel have a structure that is optimized for load bearing. In various diseases and aging, the load-carrying ability of the heel pad is clinically impaired. The loading pattern was examined in subjects having normal heel pads and those with atrophic heel pads, both with and without clinical symptoms. Normal heel pads showed a broad region of high pressure, which accounted for a high percentage of the total load transmission. In contrast, the atrophic heels showed a high but narrow peak pressure. However, most of the load was transmitted over a large area of low pressure. There was no difference between symptomatic and asymptomatic heels. The mechanical behavior of the fat pad is discussed with particular reference to the anatomic structure of the pads. Pad thickness and septal integrity are both important to the mechanical characteristics of the fat pad. The load-bearing patterns observed are discussed in terms of the mechanical components influencing fat pad resilience. These results have direct relevance to understanding the pathophysiology of heel pain secondary to degeneration of the fat pad.

Two closed calcaneal fractures with interposition of the flexor hallucis longus tendon in the subtalar joint are reported. The radiographic findings of dissociation of the superior medial fragment of the posterior facet from the sustentaculum talus are presented. The rationale for surgical treatment is discussed.

Squamous cell carcinoma (SCC) arising in a focus of chronic osteomyelitis is a rare but potentially fatal disease. Because of the possibility of metastases, amputation proximal to the site of the tumor is the current standard of therapy. We report the first case of SCC arising in chronic osteomyelitis treated by Mohs micrographic surgery as an alternative method of treatment.

Lateral calcaneal flaps were used to cover the skin necrosis of bilateral posterior heels, and a favorable result was obtained. During the first 5 years after surgery, the patient enjoyed hiking as before and made favorable progress, having no trouble in the region covered with the flap and attaining sensory cortical reorientation soon after surgery. Paresthesia of donor sites was reduced in its extent and caused no difficulties in everyday life, but it remained after the lapse of 5 years. The medical record of this patient during the 5 years is reviewed, and we discuss the indications of a lateral calcaneal flap.

The value of serial measurements of heel pad thickness as a clinical predictor of biochemical remission in acromegaly was assessed in 25 patients followed for up to 20 years after treatment by interstitial irradiation using yttrium-90 implantation. Growth hormone (GH) levels fell to 50% of baseline values within 12 months of therapy (P less than 0.001) and to 21% at 5 years, reaching normal levels after 10 years, constituting a biochemical cure maintained to the end of the study period. By contrast, heel pad thickness remained relatively stable, falling to 95% of baseline after 5 years (P less than 0.05) and to 87% after 20 years. There was no overall correlation between the measured parameters (r = 0.033, P greater than 0.05) suggesting that heel pad thickness is a poor predictor of biochemical remission in acromegaly.

We have attempted to show a correlation between heel pain and tumors and tumor-like conditions. The anatomy and size of the calcaneus predisposes it to increased incidence of trauma. Furthermore, the increased vascularity of the heel versus other areas of the foot may contribute to a higher incidence of both local and metastatic tumors. Most tumors and tumor-like conditions initially present with pain as the patient's primary complaint. Therefore, any complaint of heel pain must be thoroughly evaluated and treated. Accordingly, when biopsy or excision is necessary, the surgeon must plan his approach while considering the unique position and anatomic properties of the calcaneus.

The following is a report about two cases of pseudoangiosarcoma (Masson). The pseudoangiosarcomatous changes developed in one case in a cavernous hemangioma and in the other on the heel, presumably in the lumen of a vessel of the dermis. In our opinion thrombosis precedes the pseudoangiosarcomatous proliferation, which can be interpreted as a manifestation of a peculiar form of the organization of thrombotic material. Another possibility is discussed namely that the papillary endothelial proliferation is the earliest event in the formation of pseudoangiosarcoma.

The joints of 124 young adult patients with bilharziasis were examined. Heels, sacroiliac joints, cervical spine, knee joint, dorsal spine, and tarsal joints were affected. Biopsy of the knee synovia showed synovitis, vasculitis, and the presence of bilharzial ova in three cases. Radiologically the heels and sacroiliac joints showed inflammatory changes. Schistosomiasis may cause an arthropathy.

A prospective study was undertaken to accurately classify open tibial fractures and to evaluate the benefit of muscle flaps in the management of these injuries. From 191 open tibial fractures, 59 type III and 14 type IV open fractures were identified and managed prospectively. Fractures managed with open-wound techniques have a much higher complication rate than those closed with flaps. Results with flap coverage are affected by the biologic phase of the wound. The best results are seen in the acute flap coverage group and are thought to be secondary to removal of devitalized tissue with provision of a vascularized soft-tissue envelope prior to wound colonization. Flap coverage of the colonized subacute wound is subject to invasive infection with additional tissue loss. The subacute wound should be managed with open-wound technique until the parameters of a chronic localized wound are established, at which time flap coverage is again indicated. Microvascular free flaps are the preferred cover for type IV wounds because the local tissues are too ischemic and devitalized for transfer. With meticulous wound care and adherence to the enumerated surgical procedures, limb salvage may be achieved in most injuries.