Surabhi Das, Hong Joo Kim, Archana Jain, Winston Loh
Literature Review
The “Heel Pain Triad” has been recently described as a traction injury of the posterior tibial nerve resulting from the failure of the static (plantar fascia) and dynamic (tibialis posterior tendon) support of the longitudinal arch (Labib et al 2002). This clinical entity commonly presents as a combination of posterior tibial dysfunction, plantar fasciitis and tarsal tunnel syndrome.
Patients may present with pain, paraesthesia and anaesthesia at the medial heel and/or plantar aspect of the foot, which were commonly aggravated by weight-bearing activities (Lau and Daniel 1999). Physical examination may also reveal tenderness over the inferior calcaneous, posterior nerve and posterior tibial tendon, arch collapse, and weakness tibialis posterior. Thus, it is of clinical importance to explore the possible biomechanical mechanisms of each of plausible pathologies, such as posterior tibial dysfunction, plantar fasciitis and tarsal tunnel syndrome, when treating chronic foot and heel pain.
The current literature recognizes dysfunction of the posterior tendon as a possible cause of functional pes planus which may lead to tibial nerve injury (Francis et al 1987, Myerson 1996).
Radin (1983) previously hypothesized that a varus heel with a compensated forefoot pronation and shortened adductor hallucis could decrease the cross-sectional area of the tarsal runnel, causing tension on the tibial nerve. More recently, Daniels et al (1998) showed that tension of the tibial nerve is increased following surgical creation of a pes planus foot. Other studies (Francis et al 1987, Myerson 1996) found that tension on the tibial nerve was also increased with dorsiflexion and eversion. The tibial nerve divides into the medial calcaneal, medial plantar and lateral plantar nerves. There is some dissension in the current literature as to which branches of tibial nerve distal to the tarsal tunnel are involved in the Heel Pain Trial. Edwards et al (1969) previously postulated that medial heel pain was caused by entrapment of the calcaneal branches of the tibial nerve. On the other hand, Oztuna et al (2002) reported that 88% of subjects with heel pain resented with lateral plantar nerve entrapment, with or without medial plantar nerve involvement.
The integrity of the longitudinal arch is vital in the maintenance of optimal foot and ankle biomechanics (Thordarson et al 1995). Medial arch collapse has been postulated as failure of the static structures of spring ligament, long plantar ligament and plantar fascia. In a study of dynamic support of the longitudinal arch, the plantar fascia to be the most significant contributor to arch support, in addition to the consistent support from the tibialis posterior tendon (Thordarson et al 1995).
The current study aims to investigate the roles of the tibialis posterior tendon and the plantar fascia in the maintenance of the longitudinal arch and their contributions to the development of the Heel Pain Triad.
