Bilateral Heel Pain—Softball

HISTORY: A 19-year-old female university softball athlete presented for bilateral heel pain, more severe on the left side than right, that progressively worsened over five weeks. Pain was associated with swelling in her left Achilles region and tightness and mild pain in her left upper calf area. She endorsed briefly experiencing similar symptoms during her previous season of play that resolved spontaneously. Conservative measures including rest, physical therapy, and icing the affected areas only provided temporary relief with recurrence of pain upon return to sport. Of note, she previously wore orthotic spikes during play but changed cleat brands due to team sponsorship reasons. PHYSICAL EXAMINATION: Examination revealed exquisite tenderness with palpation of the region anterior to the Achilles tendons bilaterally, and only mild tenderness along the bilateral Achilles tendons 2-3 cm proximal to the attachments. There was 5-10 degrees of dorsiflexion of the bilateral ankles past neutral and symmetric subtalar movement within normal limits. There was no pain with palpation of the plantar fascia origin or calcaneal squeeze bilaterally, resisted dorsiflexion, plantar flexion, eversion, or inversion. DIFFERENTIAL DIAGNOSIS: 1.Achilles tendonitis2.Retrocalcaneal bursitis3.Posterior ankle impingement syndrome FINAL/WORKING DIAGNOSIS: Posterior ankle impingement syndrome secondary to distalized and hypertrophic soleus muscle bilaterally TESTS AND RESULTS: Musculoskeletal ultrasound- No evidence of significant retrocalcaneal bursitis or Achilles tendinopathy or tearing. XR bilateral ankles- Bilateral effacement of superior Kager’s fat pad, L > R concerning for peritendinitis or soft tissue edema MRI bilateral ankles- Prominence of the soleus muscle extending inferiorly to the calcaneal insertion with short tendinous part measuring approximately 1 cm- Effacement of Kager’s fat pad secondary to a prominent soleus muscle- Normal fibers of the Achilles tendon TREATMENT AND OUTCOMES: 1.Activity modification with participation only in stationary batting, throwing, exercise2.Resume wearing orthotic cleats or orthotics with heel lift3.Use voltaren gel as needed4.Physical therapy with deep friction massage and mobilization of the solei