What is the cause of a clicking sensation in the heel and what is the appropriate management?

Clicking in the Heel: Causes and Management

A clicking sensation in the heel is most commonly caused by tendon subluxation (particularly peroneal tendons), snapping of the Achilles tendon over bony prominences, or inflamed bursae moving over irregular bone surfaces, though the provided guidelines do not specifically address "clicking" as a primary symptom.

Understanding the Clinical Context

The available evidence focuses on heel pain rather than clicking specifically 1. However, clicking sensations often accompany several heel pathologies described in these guidelines, particularly:

Most Likely Causes of Heel Clicking:

Posterior Heel Clicking:

• Insertional Achilles tendonitis with spurring - The clicking occurs when the tendon snaps over bony prominences or calcifications at its insertion. Look for tenderness medially and laterally to the Achilles insertion, with radiographs showing spurring or erosion 1.
• Haglund's deformity with retrocalcaneal bursitis - The inflamed bursa and prominent posterior-superior calcaneus create mechanical clicking. Expect tenderness lateral to the Achilles tendon with a palpable posterior-lateral prominence visible on X-ray 1.

Medial/Plantar Heel Clicking:

• Nerve entrapment (Baxter's nerve) - While primarily causing burning pain, the clicking may represent tendon movement over the entrapped nerve. This presents with medial plantar heel pain, burning, tingling, or numbness 2, 3, 4.

Diagnostic Approach

Key examination findings to differentiate:

1. Location of clicking and tenderness:

   • Posterior-lateral = Haglund's deformity 1
   • Posterior-central at Achilles insertion = Insertional tendonitis 1
   • Medial plantar = Nerve entrapment 2, 3

2. Provocative factors:

   • Worse with shoes, better barefoot = Haglund's or insertional Achilles 1
   • First steps in morning = Plantar fasciitis (though this rarely clicks) 5, 6
   • Neurologic symptoms (burning/tingling) = Nerve entrapment 2, 3

3. Imaging:

   • Plain radiographs first to identify bony prominences, spurring, or Haglund's deformity 1
   • High-resolution ultrasound or MRI if nerve entrapment suspected 2

Management Algorithm

Initial Conservative Treatment (First 6-8 weeks):

For Posterior Heel Clicking (Insertional Achilles/Haglund's):

• Open-backed shoes to eliminate pressure on posterior heel 1
• Heel lifts or orthoses to reduce Achilles tension 1
• NSAIDs for inflammation 1
• Stretching exercises (calf stretches) 1
• Activity modification - decrease running/jumping 1
• Accommodative padding around the prominence 1

Critical caveat: Avoid corticosteroid injections into or near the Achilles tendon due to rupture risk 1.

If No Improvement After 6-8 Weeks:

Refer to podiatric foot and ankle surgeon 1. Continue initial treatments and add:

• Immobilization cast or fixed-ankle walker 1
• Bursa injection (avoiding Achilles tendon) for Haglund's 1

Surgical Options (Refractory Cases):

• Haglund's deformity: Resection of prominent posterior-superior calcaneus and inflamed bursa; possible calcaneal osteotomy 1
• Nerve entrapment: Surgical decompression if conservative measures fail 2, 3

Common Pitfalls to Avoid

1. Don't inject corticosteroids near the Achilles tendon - this significantly increases rupture risk 1
2. Don't dismiss neurologic symptoms - burning, tingling, or numbness suggests nerve entrapment requiring different management 2, 3, 4
3. Don't delay imaging - plain radiographs are essential to identify bony abnormalities causing mechanical clicking 1
4. Don't rush to surgery - most cases respond to 6-8 weeks of conservative treatment 1

When to Suspect Alternative Diagnoses

If clicking is accompanied by:

• Diffuse pain with compression of calcaneus = stress fracture 1, 5
• Bilateral symptoms with joint pain elsewhere = systemic arthritis 6
• Progressive worsening despite treatment = consider rare lesions of heel fat pad or tumor 7

The key to managing heel clicking is identifying the specific anatomic structure causing the mechanical symptom through careful examination and appropriate imaging, then applying structured conservative treatment for 6-8 weeks before considering surgical referral 1.