Causes and Effects of Hindfoot

## **Chapter 5** Hindfoot Pathologies

*Elif Tuğçe Çil*

## **Abstract**

Foot pain (FP) is widespread throughout the population, with prevalence estimates ranging from 17 to 30%, while a comprehensive study found that more than one-quarter of people over the age of 45 have regular hindfoot pain (HP). HP has been linked to limitations in daily living activities, poor balance, gait issues, and poor health-related quality of life. According to studies, at least two-thirds of people have moderate functional daily living issues. Aging, female gender, obesity, chronic medical conditions (such as osteoarthritis and diabetes), biomechanical factors (excessive external rotation of the lower extremity, increased pronation of the subtalar joint, plantar flexor weakness, Achilles tendon shortening), and anatomical changes (pes planus, pes cavus) have all been identified as risk factors for HP. People with HP have bone and soft-tissue overload, foot anatomic disorders, and a decreased range of motion (especially ankle dorsiflexion). There are several hindfoot pathologies that can lead to HP. The aim of this study is to overview the pathologies of the hindfoot that cause hindfoot pain.

**Keywords:** disorder, foot, hindfoot, pain, pathologies

## **1. Introduction**

The hindfoot is the area of the foot located behind the ankle joint, and it is made up of several bones, including the calcaneus (heel bone), talus (ankle bone), and the navicular and cuboid bones [1]. The hindfoot is an important part of the foot and ankle, as it provides support and stability when standing and walking [2]. However, the hindfoot is also susceptible to a wide range of pathologies that can cause pain, swelling, and difficulty moving the foot and ankle [2, 3].

Hindfoot pathologies can be caused by a variety of factors, including overuse, trauma, degeneration, and underlying medical conditions [3]. Some common hindfoot pathologies include posterior tibial tendinopathy, flexor halluces longus tendinopathy, posterior ankle impingement syndrome, heel contusion, calcaneal and talar stress fractures, rheumatoid arthritis of the hindfoot, Paget disease of the hindfoot, osteomyelitis of the calcaneus, and metastatic disease of the foot and ankle [3, 4].

Symptoms of hindfoot pathologies may include pain, swelling, and tenderness in the affected area, as well as difficulty moving the foot and ankle [2, 3]. The condition may also cause deformities or other changes in the appearance of the foot and ankle [4, 5]. Hindfoot sensations occur beneath the ankle and are sometimes mistaken for ankle discomfort [5, 6]. Flat feet and soreness are caused by issues such as posterior tibial tendon insufficiency. On the inside or outside of hindfoot, pain might occur [6].


#### **Table 1.**

*Categorization of hindfoot pathologies.*

This also causes symptoms of weakness and instability around the ankle and hindfoot [2, 3]. Stress fractures, ankle instability, and peroneal tendonitis can all be caused by having a high-arch foot [4, 5]. Arthritis can also affect the hindfoot, causing dull discomfort, stiffness, and deformity later on. Swelling or edema in the hindfoot area may indicate inflammatory or joint soft-tissue processes [6]. It is important to seek medical treatment for hindfoot pathologies to prevent the condition from worsening and to maintain good function of the foot and ankle. Early diagnosis and treatment can help to alleviate symptoms and prevent further damage to the foot and ankle.

The pathologies that present with HP are presented in **Table 1**.

## **2. Hindfoot pathologies**

#### **2.1 Chronic conditions**

#### *2.1.1 Plantar fasciitis (PF)*

The most common cause of plantar heel pain is plantar fasciitis, which is a chronic degenerative irritation of the plantar fascia origin at the medial calcaneal tuberosity as well as surrounding perifascial structures such as the plantar aponeurosis of the foot [7]. This condition is primarily a degenerative process [7, 8]. Histologic samples from PF patients undergoing plantar fascia surgery demonstrate myxoid degeneration with fragmentation, collagen disarray, granulation tissue, micro-tears, bone marrow vascular ectasia, and lack of traditional inflammation [8, 9]. Additionally, ultrasound assessment often finds calcifications, tears, thickening, and plantar fascia heterogeneity. These changes, commonly seen on ultrasound, induce a non-inflammatory condition and dysfunctional vasculature. According to these findings, the condition is a degenerative fasciosis without inflammation, not fasciitis. That is why plantar fasciopathy is a more accurate definer. Although the diagnosis includes the portion "itis," the condition is characterized by a lack of inflammatory cells [8, 9].

Although the decisive incidence and prevalence of PF by age are unclear, estimations show that it affects roughly 10% of the general public, with 83% of these patients being active working individuals aged 25–65 [10]. Additionally, it is common in athletic and sedentary populations and associated with a diversity of sports but is primarily reported in elite and recreational runners with 5–10% incidence [7, 10].

The reason for PF is multifactorial, but most cases are due to overuse stress. A heel spur may be found in some cases, but it is not a causative factor. It often takes place in middle-aged (40–60 years) women and is vast in military servicemen, longdistance runners (repetitive strain), and obese people (BMI >27 kg/m<sup>2</sup> ) [10, 11]. Pes planus, pes cavus, limited ankle DF, and excessive pronation or supination are all predisposing factors. The gastro-soleus and other posterior leg muscles are frequently observed to be tight. Tight muscles can alter typical motion biomechanics. Weight-bearing, age, leg length asymmetry, heel pad atrophy, vocations requiring extended standing, and low-heeled shoes with solid bottoms or tightly fitting shoes are additional risk factors [9–11].

Patients will generally present with low-medial heel progressive pain. In more complicated situations, the pain might radiate proximally. The pain is commonly described as severe and worse with the first few steps in the morning by patients. Long durations of standing or sitting will further aggravate the discomfort. The pain usually subsides after ambulation or the start of athletic activity but often returns later in the day [11, 12]. It may be replicated in most cases by palpating the plantar medial calcaneal tubercle and passive DF of the toes and foot. The windlass test refers to the passive DF of the first metatarsophalangeal joint (positive) [7, 11]. Second, the causative factors may contain a tight AT and pes cavus or planus. That is why assessing a patient's gait may be beneficial [10, 11]. Stress fractures, fat pad contusion or atrophy, and nerve entrapments such as tarsal tunnel syndrome should all be examined in the differential diagnosis of PF [7]. In most cases, clinical diagnosis and imaging are not required [8]. If there is another indication of other injuries or if the patient fails, it may be essential to obtain X-rays or an ultrasound evaluation. Soft-tissue calcifications or heel spurs on the inferior surface of the heel may be seen on X-rays or ultrasonic assessment. The plantar fascia may seem thickened and swollen on ultrasound. Ultrasound findings consistent with PF contain plantar fascia thickness greater than 4.0 mm. If the patient does not respond to conservative therapy after more prolonged periods, then MRI may be considered to assess for fascial tears, stress fractures, or osteochondral defects. Additionally, MRI can demonstrate increased plantar fascia thickness and signal intensity. For evaluating and distinguishing PF, ultrasonography is a cost-effective, precise, and dependable alternative to MRI. Plain radiography can detect bone abnormalities, and lateral heel radiographs can reveal a heel spur. Even though people with chronic HP are more likely to have a spur, it can remain after symptoms resolve [7, 11, 13].

Most cases are managed non-surgically (90%), but the recurrence of pain is an obstruction. An inter-professional approach is necessary because there is no single treatment for everyone. Even when a treatment option works, symptoms frequently take weeks or months to subside [10–12]. It is important to note that surgery for PF is usually only recommended for patients who have not responded to other forms of treatment and are experiencing severe, chronic pain. Plantar fasciitis can be treated surgically using a variety of techniques. These are some examples: plantar fascia release, calcaneal spur excision, tenotomy, and neurectomy. It should be noted that surgery for plantar fasciitis is usually only indicated for people who have not responded to other treatment options.

It is also worth noting that surgery carries risks and is not always successful in relieving pain. It is important to carefully consider all treatment options and discuss the risks and benefits with a healthcare provider before deciding on surgery.

#### *2.1.2 Tarsal tünel syndrome*

Tarsal tunnel syndrome is a condition that involves compression of the posterior tibial nerve, which runs through the tarsal tunnel in the hindfoot. The tarsal tunnel is a narrow passageway in the ankle that is formed by bones, ligaments, and tendons. The posterior tibial nerve passes through this tunnel to provide sensation to the foot and toes [14].

Symptoms of tarsal tunnel syndrome may include:


Tarsal tunnel syndrome is often caused by overuse, injury, or other conditions that put pressure on the posterior tibial nerve. It can also be caused by structural abnormalities in the foot, such as flat feet or high arches [15].

Treatment for tarsal tunnel syndrome may include rest, ice, physical therapy, stretches, and over-the-counter or prescription pain medication. In some cases, a splint or brace may be used to support the foot and reduce pressure on the nerve. Surgery may be necessary if other treatments are not effective [14, 15]. Tarsal tunnel syndrome is usually treated conservatively; however, in some cases, surgery (tarsal tunnel release, decompression surgery, nerve decompression) may be necessary to relieve the pressure on the tibial nerve.

#### *2.1.3 Achilles tendinopathy (AT) & Haglund deformity*

Tendinopathy is the degeneration or inability to heal the tendon due to recurrent stress without proper recuperation. AT is a widespread overuse injury, resulting from excessive compression or triceps surae mechanical loading [16]. It divides into midportion (non-insertional) and insertional tendinopathy. Discomfort at 2–6 cm from the calcaneal insertion and insertional pain at the Achilles tendon insertion make up the mid-portion. AT is a clinical diagnostic that occurs when a patient has localized discomfort, Achilles tendon edema, and loss of function. In terms of pain localization, Achilles tendon injuries are divided into three categories: midportion tendinopathy (55–65% of injuries), insertional tendinopathy (20–25%), and proximal musculotendinous junction injuries (9–25%) [16–18]. On the other hand, patients have discomfort at the insertion and midportion simultaneously, with around 30% experiencing bilateral pain. Tendinopathy is also marked by increased tissue thickness (tendinosis), a lack of typical collagen, an increase in proteoglycans, and a general breakdown in tissue structure [16, 18]. In both asymptomatic and symptomatic tendons, these structural alterations increase cross-sectional area, reduce tendon stiffness, and modify viscoelastic properties. Furthermore, tendon alteration (tendinosis) is commonly accompanied by other disorders, such as the spread of intratendinous calcifications, bone abnormalities, and the retrocalcaneal bursa in the insertional one [16, 17].

The risk of developing AT is assumed to be multifaceted, with intrinsic and extrinsic variables contributing to either a reduction in load tolerance or a change in

#### *Hindfoot Pathologies DOI: http://dx.doi.org/10.5772/intechopen.109784*

movement-pattern stress on the tendon. Reduced PF strength, hip neuromuscular control problems, abnormal DF and subtalar-joint ROM, increased foot pronation, and body weight are all intrinsic risk factors that can be determined. Aside from family history, systemic illness and genetic variations have also been identified as inherent risk factors [17, 19]. Tendinopathy and tendon rupture have been connected to fluoroquinolone antibiotics, with symptoms appearing 8 days after therapy begins. Sport involvement, footwear, surface, training-load mistakes (such as an immediate increase in training length or intensity, a reduction in recovery time), and ambient variables have all been linked to AT development because of a lack of data [18, 19].

The primary symptoms are pain and decreased function. Patients generally explain a gradual onset of symptoms with morning stiffness or after prolonged sitting, pain with palpation and activity (jumping or running), and damages in strength or performance. Activity pain can vary in terms of severity. The initial symptom can merge with the start of the activity. It is relatively unusual for an athlete to have poor athletic performance (e.g., decreased jogging time or jump performance) before experiencing discomfort during the activity. Athletes who overlook small indications may feel discomfort during and after exertion and experience a decline in performance. It is crucial to note that in the absence of loading, people with AT typically experience no discomfort [18, 20].

The subjective report of discomfort and pain with tendon palpation is a reliable and valid diagnostic for AT. Palpation of pain can help distinguish between insertional-midportion damage and a diagnosis. For example, if palpating the anterior tendon causes more discomfort than the tendon, os trigonum syndrome or posterior ankle impingement may be a more likely diagnosis. Acute AT rupture, accessory soleus, systemic inflammatory illness, sural nerve, and fat-pad irritation are more factors to consider in posterior ankle discomfort [16, 18, 19]. Additionally, diagnostic tests like the Royal London Hospital test and the arc sign may be performed to confirm AT [16, 20]. Patient-reported pain and symptoms have traditionally been used to determine the severity of the condition.

Nevertheless, patients also have increased fear of movement, or kinesiophobia; impaired lower extremity function; altered tendon structure; and decreased muscle performance. The patient's overall condition rating, participation, pain on loading or activity or over a certain length of time, function, psychological aspects, physical function capacity, disability, and quality of life are all factors that contribute to a consensus [16, 17]. Patients with AT have varying degrees of impairment and symptoms in each domain. Each component of tendon health must be assessed for diagnostic progress, patient objectives and expectations, and athlete return-to-sport decisions. In addition, structural changes might occur without causing any symptoms. Other patients may experience symptoms and functional impairments with no structural change. Furthermore, complete symptomatic healing does not guarantee complete functional recovery. As a result, the effective reinjury rates (27–44%) for AT may be due to merely using symptom resolution as a recovery guide without confirming tendon health [17–19].

Pathophysiology related to AT is frequently determined by imaging. Existence of osteophyte and enthesophyte formation, Haglund deformity, and intratendinous calcifications, evaluation may all be determined with lateral weight-bearing radiographs of the foot. The form and lucency of the Kager triangle on a radiograph may also be utilized to determine whether or not a patient has retrocalcaneal bursitis. Ultrasound and MRI may be used to evaluate soft-tissue (bursitis, neovascularization, paratendinitis, tendon degeneration) as well as bony (intratendinous calcification, enthesophytes) changes [19, 20].

Haglund deformity is a bony enlargement at the back of the heel that can cause pain and discomfort when walking or wearing certain types of shoes. It is also known as "pump bump" because it is often caused by the irritation and pressure that can occur when wearing high-heeled pumps. The deformity is caused by a combination of genetics and the way that a person walks. It is more common in people who have high arches and who walk with a gait that places extra stress on the heels. It can also be caused by inflammation of the bursa, a small fluidfilled sac that acts as a cushion between the heel bone and the Achilles tendon. Symptoms of Haglund deformity include pain and swelling at the back of the heel, redness and warmth in the affected area, and difficulty wearing certain types of shoes. Treatment may include wearing shoes with a low heel or wide toe box, using padding or inserts in the shoes, and taking over-the-counter pain medications. In severe cases, surgery may be necessary to remove the bony growth and relieve pressure on the heel.

Debridement: This procedure involves removing damaged tissue from the Achilles tendon to reduce inflammation and pain.

Tenotomy: This procedure involves cutting the Achilles tendon to release tension and alleviate pain.

Haglund deformity excision: This procedure involves removing the bony growth on the back of the heel.

It is important to note that surgery for AT and Haglund deformity is usually only recommended for patients who have not responded to other forms of treatment and are experiencing severe, chronic pain [21, 22].

#### *2.1.4 Sinüs tarsi syndrome*

Sinus tarsi syndrome is a condition that affects the sinus tarsi, a small cavity located in the ankle joint. It is characterized by pain, swelling, and instability in the ankle and can be caused by a variety of factors, including injury, arthritis, and structural abnormalities in the foot [23].

The sinus tarsi is a small, triangular-shaped space located between the talus (ankle bone) and the calcaneus (heel bone). It is filled with a fibrous tissue called the interosseous talocalcaneal ligament, which helps to stabilize the ankle joint and absorb shock during movement [3].

Sinus tarsi syndrome is often caused by trauma to the ankle, such as a sprain or fracture. It can also be caused by structural abnormalities in the foot, such as flat feet or high arches, which can put extra strain on the ligaments and joints of the ankle. Arthritis, particularly osteoarthritis, can also lead to sinus tarsi syndrome, as the degenerative changes in the joint can cause pain and instability [24].

Symptoms of sinus tarsi syndrome can include pain, swelling, and instability in the ankle, as well as difficulty walking or standing on the affected foot. The pain is typically worse when the foot is rotated outward or when weight is placed on the outer edge of the foot [24, 25].

Treatment for sinus tarsi syndrome may include rest, ice, and physical therapy to help strengthen the muscles and ligaments in the ankle. In severe cases, surgery may be necessary to repair any damage to the sinus tarsi or surrounding structures. Sinus tarsi decompression, sinus tarsi stabilization, or sinus tarsi fusion surgical procedures may be necessary to relieve pain and improve stability [24, 25].

#### *2.1.5 Piezogenic papules*

Piezogenic papules are small, painless bumps that typically appear on the heels of the feet. They are caused by the herniation of fat through the fascia, a connective tissue layer that surrounds the muscles [26].

Piezogenic papules are often seen in people who are overweight or obese, as excess body fat can put extra pressure on the fascia and cause the fat to protrude through the tissue. They are also more common in people who engage in activities that involve a lot of running or jumping, as the impact on the heels can cause the fat to herniate [27].

Piezogenic papules are typically harmless and do not cause any symptoms. They may be cosmetically unpleasant for some people, but they do not require treatment. However, if you are experiencing pain or discomfort in your heels, it is important to speak with a healthcare provider to determine the cause and discuss treatment options. In some cases, piezogenic papules may be a sign of underlying issues with the feet, such as flat feet or high arches, which can lead to discomfort and other problems if left untreated [26, 27]. There is no specific treatment for piezogenic papules, and they often resolve on their own over time. In some cases, however, people may choose to have them removed surgically. The surgical procedure used to remove piezogenic papules is called a fat-pad excision. During this procedure, a small incision is made in the skin over the papule, and the protruding fat is removed. The incision is then closed with sutures. It is important to note that surgery for piezogenic papules is usually only recommended for patients who are bothered by the appearance of the papules and have not responded to other forms of treatment.

#### *2.1.6 Subtalar arthritis*

Subtalar arthritis is a type of arthritis that affects the subtalar joint, which is a small joint located between the talus (ankle bone) and the calcaneus (heel bone). This joint is responsible for allowing the foot to move and rotate, and it plays an important role in the normal function of the foot and ankle [28].

Subtalar arthritis is characterized by inflammation and degeneration of the subtalar joint. It can be caused by a variety of factors, including injury, overuse, or wear and tear on the joint. Symptoms of subtalar arthritis may include pain, swelling, stiffness, and limited range of motion in the foot and ankle [29].

Treatment for subtalar arthritis may include a combination of conservative measures such as rest, ice, physical therapy, and medications to reduce pain and inflammation. In more severe cases, surgery (arthrodesis, osteotomy, arthroplasty) may be necessary to repair or reconstruct the joint. It is important to seek medical treatment for subtalar arthritis to prevent the condition from worsening and to maintain good function of the foot and ankle. Early diagnosis and treatment can help to alleviate symptoms and prevent further damage to the joint [28, 29].

#### **2.2 Overuse tendon conditions**

#### *2.2.1 Peroneal tendon injury*

Peroneal tendon injuries are injuries to the tendons in the lower leg that are responsible for moving and stabilizing the ankle and foot. The peroneal tendons are located on the outside of the lower leg, just behind the bone on the outside of the

ankle (the fibula). There are two main peroneal tendons: the peroneus longus and the peroneus brevis. These tendons are responsible for moving the foot and ankle outward (everting) and helping the ankle stabilize [30].

Peroneal tendon injuries can occur due to a variety of causes, including overuse, sudden trauma, or degeneration of the tendons. Symptoms of a peroneal tendon injury may include pain, swelling, and difficulty moving the foot and ankle. In severe cases, the tendons may become partially or completely torn, which can lead to instability of the ankle and foot [31].

Treatment for a peroneal tendon injury may include rest, physical therapy, and medications to reduce pain and inflammation. In severe cases, surgery, which includes tendoscopy, tendon repair, and tendon reconstruction, may be necessary to repair or reconstruct the damaged tendons. It is important to seek medical treatment for a peroneal tendon injury to prevent the condition from worsening and to maintain good function of the foot and ankle. Early diagnosis and treatment can help to alleviate symptoms and prevent further damage to the tendons [30, 31].

#### *2.2.2 Posterior tibial tendinopathy*

Posterior tibial tendinopathy is a condition that affects the posterior tibial tendon, which is a large tendon located in the lower leg that is responsible for supporting the arch of the foot and helping the ankle stabilize. The posterior tibial tendon runs from the back of the tibia (shin bone) and attaches to the bones of the foot. It is an important part of the "arch support" system of the foot, and it helps to maintain proper alignment and stability of the ankle and foot when standing and walking [32].

Posterior tibial tendinopathy is a condition that occurs when the posterior tibial tendon becomes inflamed or damaged. It can be caused by overuse, injury, or degeneration of the tendon. Symptoms of posterior tibial tendinopathy may include pain, swelling, and difficulty moving the foot and ankle. The condition can lead to instability of the ankle and foot, and it may cause the arch of the foot to collapse, leading to a condition called "flatfoot" [33].

Treatment for posterior tibial tendinopathy may include rest, physical therapy, and medications to reduce pain and inflammation. In severe cases, surgery may be necessary to repair or reconstruct the damaged tendon. These surgical procedures that can be used to treat posterior tibial tendinopathy include: tendoscopy, tendon repair, and tendon reconstruction. It is important to seek medical treatment for posterior tibial tendinopathy to prevent the condition from worsening and to maintain good function of the foot and ankle. Early diagnosis and therapy can assist in relieving symptoms and avoiding further tendon damage [32, 33].

#### *2.2.3 Flexor hallucis longus tendinopathy*

Flexor hallucis longus (FHL) tendinopathy is a condition that affects the flexor hallucis longus tendon, which is a long, thin tendon located in the lower leg. The flexor hallucis longus tendon runs from the back of the tibia (shin bone) down to the bones of the foot, and it is responsible for flexing (bending) the big toe. The tendon also helps to stabilize the foot and ankle when standing and walking [34].

FHL tendinopathy is a condition that occurs when the flexor hallucis longus tendon becomes inflamed or damaged. It can be caused by overuse, injury, or degeneration of the tendon. Symptoms of FHL tendinopathy may include pain, swelling,

#### *Hindfoot Pathologies DOI: http://dx.doi.org/10.5772/intechopen.109784*

and difficulty moving the big toe and foot. The condition can lead to instability of the ankle and foot, and it may cause problems with balance and gait [33, 34].

Treatment for FHL tendinopathy may include rest, physical therapy, and medications to reduce pain and inflammation. Early diagnosis and treatment can help to alleviate symptoms and prevent further damage to the tendon. It is important to point out that surgery for flexor hallucis longus tendinopathy (tendoscopy, tendon repair, tendon reconstruction) is often reserved for patients who have failed to respond to various types of treatment and are experiencing significant, chronic pain or impairment. Before deciding on surgery, it is critical to carefully explore all treatment choices and discuss the risks and benefits with a healthcare expert [23, 33].

#### **2.3 Traumatic conditions**

#### *2.3.1 Posterior ankle impingement syndrome*

Posterior ankle impingement syndrome is a condition that affects the back of the ankle and is characterized by pain and inflammation in the soft tissues and bones of the ankle. It is often caused by repetitive stress or overuse of the ankle, and it can also be caused by trauma or injury to the ankle. There are two main types of posterior ankle impingement syndrome: soft-tissue impingement and bone impingement. Softtissue impingement occurs when the tendons, ligaments, or muscles at the back of the ankle become inflamed or pinched, causing pain and discomfort. Bone impingement occurs when the bones of the ankle rub against each other or become stuck, causing pain and limited range of motion in the ankle [35, 36].

Symptoms of posterior ankle impingement syndrome may include pain and swelling at the back of the ankle, difficulty moving the ankle, and limited range of motion. The condition may also cause difficulty with activities that involve flexing or pointing the foot, such as walking or running [37].

Treatment for posterior ankle impingement syndrome may include rest, ice, physical therapy, and medications to reduce pain and inflammation. In severe cases, surgery may be necessary to remove any bone spurs or repair damaged tendons or ligaments. There are various surgical options, including debridement, tenotomy, osteophyte removal, and ankle fusion. These surgical techniques may be required to reduce discomfort and improve function. It is important to seek medical treatment for posterior ankle impingement syndrome to prevent the condition from worsening and to maintain good function of the ankle. Early detection and management can help relieve the pain and avoid additional ankle damage [35–37].

#### *2.3.2 Heel contusion*

A heel contusion is a type of injury that occurs when the heel bone (calcaneus) is struck or compressed, resulting in pain, swelling, and bruising. Heel contusions are often caused by falls, accidents, or impacts to the heel, such as when landing on the heel after a jump. Symptoms of a heel contusion may include pain and swelling at the site of the injury, difficulty walking or bearing weight on the foot, and bruising or discoloration of the skin around the heel. In severe cases, a heel contusion may cause a fracture or crack in the heel bone, which can lead to additional symptoms such as deformity or instability of the foot [38].

Rest, ice, and elevation of the foot are common treatments for a heel contusion to minimize swelling and inflammation. Over-the-counter pain medications may also

be used to help alleviate discomfort. In severe cases, a heel contusion may require more advanced treatment, such as immobilization with a cast or crutches, or surgery to repair any fractures or cracks in the heel bone. Surgery may be necessary if the injury has caused significant damage to the bones, tendons, or other structures in the heel. Debridement, tenotomy, and fracture repair surgical methods can be used for a heel contusion. It is crucial to remember that surgery for a heel contusion is usually indicated only for individuals who have not responded to other forms of treatment and are suffering from significant, chronic pain or impairment [23].

#### *2.3.3 Calcaneal and talar stress fractures*

Calcaneal (heel bone) and talar (ankle bone) stress fractures are small cracks or fractures that occur in the bones of the foot as a result of repetitive stress or overuse. Stress fractures are a common injury among athletes, particularly those who engage in high-impact activities such as running or jumping [39].

Symptoms of calcaneal or talar stress fractures may include pain, swelling, and tenderness at the site of the fracture, as well as difficulty bearing weight on the affected foot. The pain may be worse with activity and may improve with rest. Stress fractures can also cause changes in the way a person walks or moves, as they try to avoid putting pressure on the affected foot [23].

Treatment for calcaneal or talar stress fractures typically involves rest, ice, and elevation of the foot to reduce swelling and inflammation. Non-weight-bearing activities, such as swimming or biking, may be recommended to allow the bone to heal. In severe cases, a cast or crutches may be necessary to fully immobilize the foot and allow the fracture to heal. It is important to prevent the injury from worsening and to ensure proper healing and recovery. Conservative treatment for calcaneal and talar stress fractures includes rest, physical therapy, and medicines. However, in some circumstances, surgery, including fracture repair, bone grafting, and bone fusion, may be required to heal the fractured bone [23, 39].

#### **2.4 Medical conditions**

#### *2.4.1 Rheumatoid arthritis of the hindfoot*

Rheumatoid arthritis (RA) is a chronic autoimmune disorder that causes inflammation in the joints. It can affect any joint in the body, including the hindfoot (the area of the foot behind the ankle joint). RA of the hindfoot can cause pain, swelling, stiffness, and deformity of the foot and ankle [40].

The hindfoot is made up of several bones, including the calcaneus (heel bone), talus (ankle bone), and the navicular and cuboid bones. These bones are connected by joints, and in people with RA, these joints can become inflamed and damaged. This can lead to a range of symptoms, including pain, stiffness, and difficulty moving the foot and ankle. RA of the hindfoot may also cause the foot to become misshapen or deformed, leading to problems with balance and gait [41].

Treatment for RA of the hindfoot typically involves a combination of medications and lifestyle changes to reduce inflammation and manage pain. Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) and disease-modifying antirheumatic drugs (DMARDs) may be used to reduce inflammation and slow the progression of the disease. Physical therapy and other rehabilitation techniques may also be recommended to help improve mobility and function of the foot and ankle. However, in severe cases, joint fusion, joint replacement, and osteotomy surgical procedures may be necessary to repair or reconstruct damaged joints. It is important to seek medical treatment for RA of the hindfoot to prevent the condition from worsening and to maintain good function of the foot and ankle [23, 40, 41].

#### *2.4.2 Paget disease*

Paget disease is a chronic bone disorder that causes abnormal bone growth and weakening of the bone. It can affect any bone in the body, including the bones of the hindfoot (the area of the foot behind the ankle joint). In people with Paget disease of the hindfoot, the bones may become thickened, enlarged, and weakened, leading to a range of symptoms, including pain, swelling, and deformity of the foot and ankle. The condition may also cause problems with balance and gait [23, 42].

Treatment for Paget disease of the hindfoot may involve a combination of medications and lifestyle changes to slow the progression of the disease and manage symptoms. Medications such as bisphosphonates and calcitonin may be used to reduce bone resorption and slow the rate of bone growth. Physical therapy and other rehabilitation techniques may also be recommended to help improve mobility and function of the foot and ankle. Paget disease is typically treated with drugs that delay the disease's course and alleviate bone discomfort. However, surgery may be required in some cases to repair abnormalities or support weakening bones. Paget disease can be treated by using a variety of surgical methods (osteotomy, bone grafting, or joint replacement for repairing or reconstructing damaged bones). Treatment as soon as possible can help to ease symptoms and avoid additional bone loss [42].

#### *2.4.3 Osteomyelitis of calcaneus*

Osteomyelitis is an infection of the bone that can affect any bone in the body, including the calcaneus (heel bone). Osteomyelitis of the calcaneus is a serious condition that can cause pain, swelling, and difficulty moving the foot and ankle. It can also lead to bone deformities and other complications if left untreated. It is usually caused by bacteria entering the bone through an open wound or a surgical incision. It can also occur as a result of a blood infection (septicemia) that spreads to the bone. Symptoms of osteomyelitis of the calcaneus may include fever, chills, redness and swelling at the site of the infection, and severe pain. The condition may also cause difficulty walking or bearing weight on the affected foot [43].

Treatment for osteomyelitis of the calcaneus typically involves a combination of antibiotics to kill the infection and surgery, which contains debridement, bone grafting, and amputation procedures, to remove any infected or damaged bone tissue. In severe cases, hospitalization may be necessary to monitor the infection and manage the patient's symptoms. Rehabilitation and physical therapy may also be recommended to help improve mobility and function of the foot and ankle. It is important to get early diagnosis and treatment to prevent the infection from spreading and to ensure proper healing, recovery, and prevention of further complications [44].

#### *2.4.4 Sickle cell disease*

Sickle cell disease is a group of inherited blood disorders that affect the production of red blood cells. People with sickle cell disease produce abnormal red blood cells that are shaped like crescent moons (or "sickles") instead of the normal round shape.

These abnormal red blood cells are more fragile and prone to breaking down, which can lead to a range of symptoms and complications. It is caused by a genetic mutation that affects the production of the protein hemoglobin, which carries oxygen in the blood. People with sickle cell disease have abnormal hemoglobin in their red blood cells, which causes them to be misshapen and brittle. As a result, the red blood cells are unable to carry oxygen effectively to the body's tissues, leading to a range of symptoms and complications [45].

Symptoms of sickle cell disease may include anemia (low red blood cell count), fatigue, shortness of breath, and repeated infections. The condition may also cause pain crises, which are episodes of severe pain that can occur in any part of the body. People with sickle cell disease may also have an increased risk of developing other health problems, such as stroke, kidney disease, and vision loss [23, 44].

Treatment for sickle cell disease typically involves a combination of medications, blood transfusions, and other supportive care to manage symptoms and prevent complications. There is no cure for sickle cell disease, but with proper treatment and management, people with the condition can lead full and active lives. The specific surgical procedures used to treat sickle cell disease will depend on the specific complications and individual needs of the patient. Some common surgical procedures used in the treatment of sickle cell disease include: splenectomy, vaso-occlusive crisis management, and bone marrow transplant. It is important to note that surgery for sickle cell disease is usually only recommended for patients who experience severe, chronic complications or who have not responded to other forms of treatment. It is also critical to seek medical treatment and adhere to a treatment plan in order to avoid significant problems and retain good health [46].

#### *2.4.5 Gout*

Gout is a type of arthritis that causes inflammation and pain in the joints, most commonly the joints of the feet and ankles. It is caused by the buildup of uric acid crystals in the joints, which leads to inflammation and pain. Gout is characterized by sudden, severe attacks of pain and inflammation in the affected joints. The most common symptoms of gout include redness, warmth, and swelling in the affected joint, as well as intense pain and tenderness. The attacks of gout can last for a few days to a few weeks, and they may occur repeatedly over time. It is more common in men than in women, and it is more likely to occur in people who are overweight, have high blood pressure, or have a family history of gout. It can also be caused by certain medications, alcohol use, and other medical conditions [47, 48].

Treatment for gout may include medications to reduce inflammation and pain, as well as lifestyle changes to help prevent future attacks. These may include changes to diet (such as reducing intake of foods high in purines, which can increase uric acid levels), weight loss, and avoiding triggers such as alcohol and certain medications. In severe cases, surgery may be necessary to remove the uric acid crystals from the affected joints. There are several surgical procedures that may be used to treat gout. These include: debridement, joint fusion, and joint replacement. It is important to carefully consider all treatment options and discuss the risks and benefits with a healthcare provider before deciding on surgery. Getting medical treatment for gout to prevent the condition from worsening and to maintain good function of the joints is important [47].

#### *2.4.6 Metastatic disease*

Metastatic disease of the foot and ankle is a type of cancer that occurs when cancer cells from another part of the body spread (metastasize) to the bones of the foot and ankle. This can lead to pain, swelling, and other symptoms in the affected area. It is most commonly caused by breast, lung, or prostate cancer, but it can also occur as a result of other types of cancer [23, 49]. Symptoms of metastatic disease of the foot and ankle may include pain, swelling, and tenderness in the affected area, as well as difficulty moving the foot and ankle. The condition may also cause deformities or other changes in the appearance of the foot and ankle [49].

Treatment for metastatic disease of the foot and ankle depends on the type and stage of cancer, as well as the overall health of the patient. Options may include surgery to remove the affected bone, chemotherapy or radiation therapy to kill the cancer cells, or a combination of these treatments. Pain management and rehabilitation may also be necessary to help alleviate symptoms and improve mobility and function of the foot and ankle. The specific surgical procedure used to treat metastatic disease will depend on the location and size of the metastases, as well as the overall health of the patient. Some common surgical procedures used in the treatment of metastatic disease include resection, amputation, and palliative surgery. It should be noted that surgery for metastatic disease is usually only suggested for individuals who have severe, chronic symptoms or have not responded to other forms of treatment. It is important to get medical treatment for metastatic disease of the foot and ankle as soon as possible to prevent the cancer from spreading and to ensure the best possible outcomes. Early diagnosis and treatment can help to alleviate symptoms and improve the chances of a successful [49, 50].

## **3. Conclusion**

The hindfoot is a complex and important part of the foot and ankle, and it is susceptible to a wide range of pathologies that can cause pain, swelling, and difficulty moving the foot and ankle. Some common hindfoot pathologies include posterior tibial tendinopathy, FHL tendinopathy, posterior ankle impingement syndrome, heel contusion, calcaneal and talar stress fractures, RA of the hindfoot, Paget disease of the hindfoot, osteomyelitis of the calcaneus, and metastatic disease of the foot and ankle.

Treatment for hindfoot pathologies may include a combination of medications, physical therapy, and lifestyle changes to reduce inflammation and manage pain. In severe cases, surgery may be necessary to repair or reconstruct damaged tissues or bones. It is important to seek medical treatment for hindfoot pathologies to prevent the condition from worsening and to maintain good function of the foot and ankle. Early diagnosis and treatment can help to alleviate symptoms and prevent further damage to the foot and ankle.

## **Conflict of interest**

The authors declare no conflict of interest.

*Foot and Ankle Disorders – Pathology and Surgery*

## **Author details**

Elif Tuğçe Çil Yeditepe University, İstanbul, Turkey

\*Address all correspondence to: tugce.cill@gmail.com

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

## **References**

[1] Gates LS, Arden NK, Hannan MT, Roddy E, Gill TK, Hill CL, et al. Prevalence of foot pain across an international consortium of population based cohorts. Arthritis Care and Research. 2019;**71**(5):661-670

[2] Perry J. Anatomy and biomechanics of the hindfoot. Clinical Orthopaedics. 1983;**177**:9-15

[3] Ghanem I, Massaad A, Assi A, Rizkallah M, Bizdikian AJ, Abiad RE, et al. Understanding the foot's functional anatomy in physiological and pathological conditions: The calcaneopedal unit concept. Journal of Children's Orthopaedics. 2019;**13**(2):134-146

[4] Choo YJ, Park CH, Chang MC. Rearfoot disorders and conservative treatment: A narrative review. Annals of Palliative Medicine. 2020;**9**(5):3546-3552

[5] Zimbler S, Craig C. Foot deformities. The Orthopedic Clinics of North America. 1976;**7**(29):331-339

[6] Maughan KL, Jackson J. Evaluation and Diagnosis of Common Causes of Hindfoot Pain in Adults—UpToDate. 2022. Available from: https://www. uptodate.com/contents/evaluationand-diagnosis-of-common-causes-ofhindfoot-pain-in-adults

[7] Trojian T, Tucker AK. Plantar fasciitis. American Family Physician. 2019;**99**(12):744-750

[8] Lemont H, Ammirati KM, Usen N. Plantar fasciitis: A degenerative process (fasciosis) without inflammation. Journal of the American Podiatric Medical Association. 2003;**93**(3):234-237 [9] La Porta GA, La Fata PC. Pathologic conditions of the plantar fascia. Clinics in Podiatric Medicine and Surgery. 2005;**22**(1):1-9

[10] Buchanan BK, Kushner D. Plantar Fasciitis. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2022. Available from: http://www.ncbi.nlm. nih.gov/books/NBK431073

[11] Rhim HC, Kwon J, Park J, Stein JB, Tenforde AS. A systematic review of systematic reviews on the epidemiology, evaluation, and treatment of plantar fasciitis. Life. 2021;**11**(12):1287

[12] Çil ET, Şaylı U, Subaşı F. Outpatient vs home management protocol results for plantar fasciitis. Foot & Ankle International. 2019;**40**(11):1295-1303

[13] Drake C, Whittaker GA, Kaminski MR, Chen J, Keenan AM, Rathleff MS. Medical imaging for plantar heel pain: A systematic review and meta-analysis. Journal of Foot and Ankle Research. 2022;**15**(1):4

[14] Nelson SC. Tarsal Tunnel Syndrome. Clinics in Podiatric Medicine and Surgery. 2021;**38**(2):131-141

[15] McSweeney SC, Cichero M. Tarsal tunnel syndrome—A narrative literature review. Foot (Edinburgh, Scotland). 2015;**25**(4):244-250

[16] Grävare Silbernagel K, Malliaras P, de Vos R-J, Hanlon S, Molenaar M, Alfredson H, et al. ICON 2020—International scientific tendinopathy symposium consensus: A systematic review of outcome measures reported in clinical trials of Achilles tendinopathy. Sports Medicine. 2021;**52**(3):613-641

[17] van der Vlist AC, Breda SJ, Oei EHG, Verhaar JA, Jan de Vos R. Clinical risk factors for Achilles tendinopathy: A systematic review. British Journal of Sports Medicine. 2019;**53**(21):1352-1361

[18] Maffulli N, Sharma P, Luscombe KL. Achilles tendinopathy: Aetiology and management. Journal of the Royal Society of Medicine. 2004;**97**(10):472-476

[19] Kozlovskaia M, Vlahovich N, Ashton KJ, Hughes DC. Biomedical risk factors of Achilles tendinopathy in physically active people: A systematic review. Sports Medicine—Open. 2017;**3**(1):20

[20] Li H-Y, Hua Y-H. Achilles tendinopathy: Current concepts about the basic science and clinical treatments. BioMed Research International. 2016;**2016**:6492597

[21] Kang S, Thordarson DB, Charlton TP. Insertional Achilles tendinitis and Haglund's deformity. Foot & Ankle International. 2012;**33**(6):487-491

[22] Vaishya R, Agarwal AK, Azizi AT, Vijay V. Haglund's syndrome: A commonly seen mysterious condition. Cureus. 2016;**8**(10):e820

[23] Damiano J, Bouysset M. Douleurs de l'arrière-pied [Hindfoot pain]. Revue du praticien. 2010;**60**(3):353-360. French

[24] Arshad Z, Bhatia M. Current concepts in sinus tarsi syndrome: A scoping review. Foot and Ankle Surgery. 2021;**27**(6):615-621. DOI: 10.1016/j. fas.2020.08.013. Epub 2020 Sep 16

[25] Dozier TJ, Figueroa RT, Kalmar J. Sinus tarsi syndrome. Journal of the Louisiana State Medical Society. 2001;**153**(9):458-461

[26] André R, Laffitte E. Piezogenic pedal papules. Presse Médicale. 2019;**48**(1 Pt 1): 88. DOI: 10.1016/j.lpm.2018.09.018. Epub 2018 Dec 7

[27] Rocha Bde O, Fernandes JD, Prates FV. Piezogenic Pedal Papules. Anais Brasileiros de Dermatologia. 2015;**90**(6):928-929. DOI: 10.1590/ abd1806-4841.20154884

[28] Kim JS, Amendola A, Barg A, Baumhauer J, Brodsky JW, Cushman DM, et al. Summary report of the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society's symposium on targets for osteoarthritis research: Part 1: Epidemiology, pathophysiology, and current imaging approaches. Foot & Ankle Orthopaedics. 2022;**7**(4):24730114221127011. DOI: 10.1177/24730114221127011

[29] Andersen LB, Stauff MP, Juliano PJ. Combined subtalar and ankle arthritis. Foot and Ankle Clinics. 2007;**12**(1):57-73. DOI: 10.1016/j.fcl.2006.12.009

[30] Willegger M, Hirtler L, Schwarz GM, Windhager RH, Chiari C. Peronealsehnenpathologien: Von der diagnose bis zur Behandlung [Peroneal tendon pathologies: From the diagnosis to treatment]. Orthopade. 2021;**50**(7):589-604. DOI: 10.1007/ s00132-021-04116-6. German. Epub 2021 Jun 23

[31] Roster B, Michelier P, Giza E. Peroneal tendon disorders. Clinics in Sports Medicine. 2015;**34**(4):625-641. DOI: 10.1016/j.csm.2015.06.003. Epub 2015 Jul 31

[32] Ling SK, Lui TH. Posterior tibial tendon dysfunction: An overview. The Open Orthopaedics Journal. 2017;**11**:714- 723. DOI: 10.2174/1874325001711010714

[33] Simpson MR, Howard TM. Tendinopathies of the foot and ankle. *Hindfoot Pathologies DOI: http://dx.doi.org/10.5772/intechopen.109784*

American Family Physician. 2009;**80**(10): 1107-1114

[34] Michelson J, Dunn L. Tenosynovitis of the flexor hallucis longus: A clinical study of the spectrum of presentation and treatment. Foot & Ankle International. 2005;**26**(4):291-303. DOI: 10.1177/107110070502600405

[35] Ishibashi MA, Doyle MD, Krcal CE Jr. Posterior Ankle Impingement Syndrome. Clinics in Podiatric Medicine and Surgery. 2023;**40**(1):209-222. DOI: 10.1016/j.cpm.2022.07.014. Epub 2022 Sep 28

[36] Nikolopoulos D, Safos G, Moustakas K, Sergides N, Safos P, Siderakis A, et al. Endoscopic treatment of posterior ankle impingement secondary to Os trigonum in recreational athletes. Foot & Ankle Orthopaedics. 2020;**5**(3):2473011420945330

[37] Bojanić I, Janjić T, Dimnjaković D, Križan S, Smoljanović T. Stražnji sindrom sraza gležnja [Posterior ankle impingement syndrome]. Lijec Vjesn. 2015;**137**(3-4):109-115. Croatian

[38] Conklin RJ. Common cutaneous disorders in athletes. Sports Medicine. 1990;**9**(2):100-119. DOI: 10.2165/ 00007256-199009020-00004

[39] Perry DR, O'Toole ED. Stress fracture of the talar neck and distal calcaneus. Journal of the American Podiatry Association. 1981;**71**(11):637-638. DOI: 10.7547/87507315-71-11-637

[40] Cimino WG, O'Malley MJ. Rheumatoid arthritis of the ankle and hindfoot. Rheumatic Diseases Clinics of North America. 1998;**24**(1):157-172. DOI: 10.1016/s0889-857x(05)70383-5

[41] Aronow MS, Hakim-Zargar M. Management of hindfoot disease in rheumatoid arthritis. Foot and Ankle Clinics. 2007;**12**(3):455-474, vi. DOI: 10.1016/j.fcl.2007.05.003

[42] Kravets I. Paget's disease of bone: Diagnosis and treatment. The American Journal of Medicine. 2018;**131**(11):1298-1303. DOI: 10.1016/j. amjmed.2018.04.028. Epub 2018 May 10

[43] Torre A, De Monti M. Osteomyelitis of the calcaneus with pathologic fracture. The Journal of Foot and Ankle Surgery. 2020;**59**(3):641. DOI: 10.1053/j. jfas.2019.09.022

[44] Chen K, Balloch R. Management of calcaneal osteomyelitis. Clinics in Podiatric Medicine and Surgery. 2010;**27**(3):417-429. DOI: 10.1016/j. cpm.2010.04.003

[45] Rees DC, Williams TN, Gladwin MT. Sickle-cell disease. Lancet. 2010;**376**(9757):2018-2031. DOI: 10.1016/ S0140-6736(10)61029-X. Epub 2010 Dec 3

[46] Meier ER. Treatment options for sickle cell disease. Pediatric Clinics of North America. 2018;**65**(3):427-443. DOI: 10.1016/j.pcl.2018.01.005

[47] Dalbeth N, Gosling AL, Gaffo A, Abhishek A. Gout. Lancet. 2021;**397**(10287):1843-1855. DOI: 10.1016/S0140-6736(21)00569-9. Epub 2021 Mar 30. Erratum in: Lancet. 2021;397(10287):1808

[48] Bernal JA, García-Campos J, Marco-LLedó J, Andrés M. Gouty involvement of foot and ankle: Beyond flares. Reumatología Clínica (English Edition). 2021;**17**(2):106-112. DOI: 10.1016/j. reuma.2019.12.003. English, Spanish. Epub 2020 Feb 14

[49] Gall RJ, Sim FH, Pritchard DJ. Metastatic tumors to the bones of the *Foot and Ankle Disorders – Pathology and Surgery*

foot. Cancer. 1976;**37**(3): 1492-1495. DOI: 10.1002/1097- 0142(197603)37:3<1492:: aid-cncr2820370335>3.0.co;2-q

[50] Wu KK, Guise ER. Metastatic tumors of the foot. Southern Medical Journal. 1978;**71**(7):807-808, 812. DOI: 10.1097/00007611-197807000- 00021

Section 5
