AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

Black heel is a self-limited, asymptomatic, trauma-induced darkening of the posterior or posterolateral aspect of the heel that occurs primarily in young adult athletes. It was first described in a group of basketball players in 1961.¹ Although clinically insignificant, black heel is important because of its close clinical resemblance to malignant melanoma. A similar lesion termed black palm (tache noir) has been described on the thenar eminence in weightlifters, gymnasts, golfers, tennis players, and mountain climbers.

Pathophysiology

Black heel is caused by a repeated lateral shearing force of the epidermis sliding over the rete pegs of the papillary dermis, resulting in intraepidermal hemorrhage.

Frequency

United States

The exact incidence of black heel is unknown. One study involving 596 19-year-old sports participants revealed an incidence of 2.9%.² This sports-related dermatosis probably is much more common than has been reported.

Mortality/Morbidity

The lesion of black heel usually is asymptomatic, although both pain and tenderness can occur. The black areas always resolve spontaneously within several months if the traumatic inciting events are discontinued.

Age

Black heel primarily occurs in young adult athletes, but it may appear in persons of any age if the appropriate conditions occur.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

History

Black heel occurs in adolescents and young adults who participate in sports that involve frequent starts and stops, such as basketball, football, soccer, lacrosse, and racquet sports.

• Patients present with an irregular dark macule over the heel (see Media File 1).
• The lesion usually is asymptomatic and does not inhibit the patient from performing routine daily activities.
• The patient may or may not relate the onset of the lesions to participation in sports.

Physical

Examination reveals a blue-to-black macule or patch ranging in size from a few millimeters to several centimeters in diameter.

• The posterior and posterolateral heel are affected most commonly.
• On close inspection, multiple petechiae are centrally aggregated with a few scattered satellite macules.
• The dyschromia often is in a horizontal distribution; however, both circular and oval lesions may occur.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Other Problems to be Considered

Traumatic tattoo

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Lab Studies

• The most important goal is to differentiate this lesion from malignant melanoma. No specific workup is necessary to make the diagnosis of black heel.

Imaging Studies

• Epiluminescence techniques, such as dermatoscopy and video macroscopy, can be used to aid in the differentiation of malignant melanoma from black heel.^{3, 4}
• If doubt persists, rapidly process the shaved fragments of keratin with commonly available screening tests used for detection of occult blood.

Procedures

• The diagnosis is clinical and can be aided by paring down the lesion. Melanocytic lesions will not lose their pigmentation with paring, while black heel may clear completely after the stratum corneum is removed.
• A biopsy is indicated if the diagnosis remains in doubt, but this is seldom necessary.

Histologic Findings

Extravasated erythrocytes in the dermal papillae are characteristic. Changes may be limited to the stratum corneum, in which there are rounded yellow-brown, amorphous clumps representing lysed RBCs. Phagocytosis of extravascular RBCs and subsequent degradation of hemoglobin to hemosiderin does not occur; therefore, histochemical stains must be directed toward hemoglobin. Benzidine is the stain of choice and will reveal brown homogenous clusters of hemoglobin.⁵

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical Care

Treatment is not necessary because the lesion resolves spontaneously with discontinuation of the causative activity. The placement of a felt pad in the heel of the shoe may be curative.

Surgical Care

Paring down the lesion with a scalpel blade may result in a complete clearing of the dyschromia.

Activity

Sports participation can be continued without harm to the patient, although the lesion will persist unless padding is added to the heel of the athletic shoe.

FOLLOW-UP

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Prognosis

• Prognosis is excellent. Complete clearing is achieved with cessation of the causative activity.

MISCELLANEOUS

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical/Legal Pitfalls

• The only medicolegal pitfall in management of black heel is the failure to diagnose an acral melanoma, which may appear as a black spot on the heel. If melanoma is a realistic diagnostic consideration, a skin biopsy is indicated.

MULTIMEDIA

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Media file 1:  Linear petechiae on the heel, characteristic of black heel.
	View Full Size Image
Media type:  Photo

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

1. Crissey JT, Peachy JC. Calcaneal petechiae. Arch Dermatol. Mar 1961;83:501. [Medline].
2. Rufli T. Hyperkeratosis haemorrhagica. Hautarzt. Nov 1980;31(11):606-9. [Medline].
3. Akasu R, Sugiyama H, Araki M, Ohtake N, Furue M, Tamaki K. Dermatoscopic and videomicroscopic features of melanocytic plantar nevi. Am J Dermatopathol. Feb 1996;18(1):10-8. [Medline].
4. Saida T, Oguchi S, Ishihara Y. In vivo observation of magnified features of pigmented lesions on volar skin using video macroscope. Usefulness of epiluminescence techniques in clinical diagnosis. Arch Dermatol. Mar 1995;131(3):298-304. [Medline].
5. Hafner J, Haenseler E, Ossent P, Burg G, Panizzon RG. Benzidine stain for the histochemical detection of hemoglobin in splinter hemorrhage (subungual hematoma) and black heel. Am J Dermatopathol. Aug 1995;17(4):362-7. [Medline].
6. Adams BB. Dermatologic disorders of the athlete. Sports Med. 2002;32(5):309-21. [Medline].
7. Cho KH, Kim YG, Seo KI, Suh DH. Black heel with atypical melanocytic hyperplasia. Clin Exp Dermatol. Sep 1993;18(5):437-40. [Medline].
8. García-Doval I, de la Torre C, Losada A, Cruces MJ. Disseminated punctate intraepidermal haemorrhage: a widespread counterpart of black heel. Acta Derm Venereol. Sep 1999;79(5):403. [Medline].
9. Levine N. Dermatologic aspects of sports medicine. J Am Acad Dermatol. Oct 1980;3(4):415-24. [Medline].

Article Last Updated: Oct 2, 2006