Pain in heels: Two cases with piezogenic pedal papules

Introduction: Piezogenic pedal papules (PPP), which are forms of responses to internal mechanical pressure, appear on the wrists and especially on feet. Repeated trauma or an inherent collagen defect mainly as Ehlers–Danlos syndrome can cause pain symptoms in heels. The PPP are mostly asymptomatic and noticed incidentally. Case Reports: Unlike the majority of PPP cases, two patients (both housewives), who took part in the present study, were older and they had severe pain associated with PPP. One injection of a solution of equal amounts of betamethasone and prilocaine was applied in treatment of pain in both patients. Conclusion: During follow-ups the patients did not report any clinical complaints considering the PPP and their VAS score remained significantly low. (This page in not part of the published article.) International Journal of Case Reports and Images, Vol. 7 No. 2, February 2016. ISSN – [0976-3198] Int J Case Rep Images 2016;7(2):81–84. www.ijcasereportsandimages.com Hayta et al. 81 CASE REPORT OPEN ACCESS Pain in heels: Two cases with piezogenic pedal papules Emrullah Hayta, Sibel Berksoy Hayta, Melih Akyol, Ozlem Sahin, Sedat Ozcelik


INtrODUctION
Piezogenic pedal papules (PPPs), which are forms of responses to internal mechanical pressure and weakness in the connective tissue in the dermis, appear commonly over the medial aspect of the heel, but in some cases on the wrists mostly in bilateral and benign forms. The PPPs, which are typically flesh-colored or yellowish, are thought to represent herniations of adipose tissue through the plantar fascia retinaculum [1,2].
Piezogenic pedal papules, which range in size from 2 mm to 2 cm, are mostly asymptomatic and noticed incidentally. However, people with repeated trauma or an inherent collagen defect such as Ehlers-Danlos syndrome can experience some pain symptoms. Though PPPs are common in a healthy population, more frequently among healthy adults and children, they may not seek medical treatment as papules seldom show any clinical signs [3][4][5].
Although in most of the studies in literature, PPP are generally observed in healthy individuals, sportsmen and especially marathon runners, which leads us to consider PPP as among the frictional and mechanical dermatoses related to sports [6,7], our study focuses on two housewives having a completely different life style in comparison to sportsmen/women.
Unlike the majority of PPP cases, two patients, who took part in the present study, were older and they had severe pain associated with PPP. A 62-year-old female patient was first seen in the dermatology outpatient clinic for intense pain in the both heels of one week duration, aggravated by standing or walking.

CASE SERiES PEER REviEwEd | OPEN ACCESS
Examination revealed no abnormality except for slight obesity (BMI 29). When she was sitting, the heels appeared normal, but when she stood with dispersing the body weight equally to the foot surface, numerous yellowish round papules appeared on the posterior, medial and lateral aspect of both heels, causing moderate pain in both heels (Figure 1a-b). However, when she stood with full weight on the heels, the number of detectable papules increased almost immediately in parallel with sudden increase in pain, but when she stood on the toes, the papules disappeared gradually and the pain subsided.

case 2
A 73-year-old female patient was admitted to our clinic with widespread pain, in both the heels for four month duration, aggravated by standing or walking.
Examination revealed no abnormality except for obesity (BMI 35). When she was sitting, the heels appeared normal, but when she stood with dispersing the body weight equally to the foot surface, numerous yellowish round papules appeared on the posterior, medial and lateral aspect of both heels, causing severe pain in both heels (Figure 2a-b).
In both patients, the papules were tender to pressure and differed both in location and in the severity of the pain (VAS score 9) from nodules found in plantar fasciitis. Also, lateral foot X-rays and ultrasonography showed no abnormality in terms of plantar fasciitis and epin calcanei. Two patients were diagnosed with the painful PPP by clinical examination and findings. Other possible factors resulting in heel pain are excluded.
Although the patients were put through electrotherapy for a consecutive ten days period along with some forms of conservative treatments such as regular relaxation, taping or padding the foot by heel cups, almost no significant clinical improvement was recorded (VAS score 8). As a result, one injection of a solution of equal amounts of betamethasone and prilocaine was applied in treatment of pain in both patients ( Figure 3). According to the patients' reports, in the clinical evaluation of the patients in the following day, their VAS score were dramatically reduced to 1.
In order to prevent the relapse of the same condition, they were recommended to reduce their body weight, to use heel cups. In their six-months follow-ups, the patients did not report any clinical complaints considering the PPP and their VAS score remained significantly low. Moreover, in the follow-ups of both patients, it was noted that they lost weight, 5.4 and 4.2 kg.

DIscUssION
For the last four decades, although the majority of the reported cases of PPP have focused on healthy children, adults, sportsmen/women, and people with connective tissue disorders such as Ehler-Danlos, as it is in our cases, PPP may also occur in old population resulting not only from prolonged weight-bearing but also from degenerative loss and structural defect of connective tissue. Although there are some studies demonstrating   the link between obesity and PPP, the studies in the related literature are limited [7]. The resulting peripheral fat chambers on the heels may cause pain by triggering ischemia [8]. In old population, the major factor of the heel pain is generally accepted as plantar fasciitis [9]. However, as can be seen in our cases, in old patients with heel pain, PPP can cause severe pain. For this reason, in the diagnosis regarding the causes of the heel pain in old population, PPP may be seen as one of the significant factors.
Because PPP lesions are benign, laboratory evaluation X-rays and ultrasonography might not be necessary. However, these diagnostic tools might be useful only for distinguishing PPP from the causes of other heel pain [10]. In traditional treatment of PPP, there is a range of supportive measures and choices that can range from avoiding prolonged standing, taping or padding the foot by heel cups or orthotics to a series of electro acupuncture treatments, a series of injections of equal amounts betamethasone and bupivacaine at the site. In the nonresolving cases, surgical intervention might be seen as a last choice [11][12][13].
cONcLUsION Painful piezogenic pedal papules (PPP) might be considered in differential diagnosis in old patients with no sports background who complain with heel or foot pain, aggravated by long-term standing. The PPP can lead to heel pain in almost all age groups and as its diagnosis is easy, it should be kept in mind as a possibility in patients complaining with heel pain.

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