6 All insertional pain should be treated holistically as a tendinopathy, as the bursa is rarely affected in isolation. The Achilles insertion is a complex structure that includes the retrocalcaneal bursa. 3,4 FHL tenosynovitis is seen in younger people, especially dancers because of the repetitive movement of the ankle and foot between extremes of plantarflexion and dorsiflexion. Tibilais posterior pain (tendon and/or sheath) is most commonly seen in older women. The medial and lateral tendons are surrounded by tenosynovial sheaths that can be irritated by friction or compression at the malleolus.
The key tendons that may be involved in heel pain are the Achilles tendon at its insertion, flexor hallucis longus (FHL), tibialis posterior and the peroneal tendons ( Figure 1). The history and further clinical examination remain important. Palpation pain is a poor diagnostic test in isolation, as many structures are painful on palpation without being the cause of symptoms. As with other soft tissue structures, pathology on imaging is not always correlated with pain and a good clinical examination is required to reveal the painful structure. Most pain arises from pathology in soft tissue structures (tendons, fascia and nerves) apophyses and other sources of bony pain are less common. This review, therefore, will consider the structures that may cause pain from the calcaneus, extending to both lateral and medial perimalleolar regions, the Achilles enthesis and proximal plantar fascia attachment. 2 However, patients consider a more broad area as their heel. Anatomically, the heel refers to the fatty tissue that forms a pad under and around the calcaneus to protect structures of the foot during weight-bearing activity. Heel pain is a vague term describing pain surrounding the calcaneus, most commonly felt posteriorly or inferiorly.