Gout in the Heel
In some instances the first manifestations of gout occur in the heel, while in others the sheath of the neighbouring tendo Achillis is the part first invaded. Probably there is no region of the foot in which there exist more pitfalls, and doubly careful should we be before concluding that any painful or inflammatory condition thereof is one of “gout.”
Referred Pain.—Pain in the heel affords many loopholes for misinterpretation. It may, as Sir James Paget pointed out many years ago, be symptomatic of a renal calculus. In my own experience it is sometimes complained of by the subjects of internal hæmorrhoids, the pain waxing and waning with the variations in the rectal trouble, and only disappearing permanently when the piles have been radically treated. It is, again, a symptom sometimes complained of by the victims of enlarged prostate.
Local Sources of Fallacy
If the pain and tenderness be located on the under-surface of the os calcis, there are several misconceptions possible.
(1) Careful examination may reveal a tendency to flatfoot, the pain being referable to strain on the posterior insertion of the plantar fascia.
(2) The root of the trouble may be a gonococcal inflammation of the plantar fascia, or of the periosteum covering the os calcis.
(3) A skiagram may show the existence of a bony spur on the inferior surface of the os calcis.
(4) The bursa under the os calcis may be inflamed.
(5) Also, as Tubby has pointed out, pain in the heel may be referable to shortening of one leg or constant standing, and more rarely to tuberculous disease of the os calcis.