What aspects should be evaluated in a patient presenting with heel pain?

Evaluation of Heel Pain: A Systematic Approach

When evaluating a patient with heel pain, begin by localizing the pain anatomically—plantar, posterior, or medial—as this directly guides your differential diagnosis and determines the specific physical examination maneuvers and imaging you'll need.

History: Key Details to Elicit

Pain Characteristics by Location

Plantar heel pain:

• Timing pattern: First-step pain in the morning or after prolonged sitting strongly suggests plantar fasciitis 1, 2
• Pain quality: Deep, bruise-like pain in the middle of the heel indicates heel pad syndrome 2
• Associated symptoms: Burning, tingling, or numbness points toward nerve entrapment 1, 2

Posterior heel pain:

• Aggravating factors: Pain worsened by shoes but relieved when walking barefoot suggests insertional Achilles tendinopathy or Haglund's deformity 1
• Activity relationship: Insidious onset with chronic swelling indicates insertional Achilles tendinitis 1

Bilateral vs. unilateral:

• Bilateral involvement, especially with night pain aggravated by standing, favors fat pad atrophy 3

Activity and Trauma History

• Recent activity changes: Progressive worsening after increased activity or harder walking surfaces suggests calcaneal stress fracture 1, 2
• Fall from height: Diffuse rearfoot pain indicates possible calcaneal fracture 1
• Repetitive loading: Increased walking activity before symptom onset raises suspicion for stress fracture 1

Age-Specific Considerations

• Adolescents: Calcaneal apophysitis (Sever disease) is the most common cause 1, 4
• Women 20-30 years: Consider Haglund's deformity with associated bursitis 1

Physical Examination: Specific Findings to Assess

Palpation Patterns

Plantar surface:

• Medial calcaneal tuberosity tenderness (increased with passive toe dorsiflexion): Plantar fasciitis 2, 3
• Diffuse central heel tenderness: Heel pad syndrome 2
• Tenderness 1 cm posterior to medial calcaneal tuberosity: Nerve to abductor digiti quinti entrapment 5

Posterior heel:

• Prominence medial and lateral to Achilles insertion with central tenderness: Insertional Achilles tendinitis 1
• Tenderness lateral to Achilles tendon with posterolateral prominence: Haglund's deformity with bursitis 1

Lateral heel:

• Tenderness at lateral calcaneal wall, slightly posterior to subtalar facet: Calcaneal stress fracture 1

Provocative Maneuvers

• Calcaneal squeeze test: Pain on compression is highly suspicious for stress fracture 1
• Passive toe dorsiflexion: Increases pain in plantar fasciitis 2
• Assess for swelling and warmth: Present in stress fractures even before radiographic changes 1

Biomechanical Assessment

• Heel cord tightness: Most common biomechanical abnormality in plantar heel pain 3
• Foot architecture: Assess for pes planus or pes cavus 3

Red Flags Requiring Subspecialist Referral

Neurologic symptoms:

• If burning, tingling, numbness, or sensory changes are present, consider subspecialist referral for electromyography, nerve conduction studies, or MRI to evaluate for tarsal tunnel syndrome or proximal nerve impingement 1
• Lumbar-origin symptoms require appropriate referral 1

Systemic concerns:

• Suspect tumors (malignant or benign), infections, or vascular compromise if clinical presentation is atypical—these require immediate diagnostic testing and consultation 1, 6

Imaging Strategy

Initial imaging:

• Radiographs are the first-line study for chronic heel pain 7
• Order foot radiographs to evaluate for heel spurs, calcaneal fractures, erosions at Achilles insertion, and Haglund's deformity 1, 7

Common pitfall: Radiographs have low sensitivity (12-56%) for stress fractures early on 7. If clinical suspicion is high despite negative radiographs, consider technetium bone scanning 1 or MRI.

Advanced imaging indications:

• MRI or ultrasound when diagnosis remains unclear after radiographs, particularly for soft tissue pathology, plantar fascia rupture, or when symptoms are refractory 7
• CT for suspected tarsal coalitions if radiographs show secondary signs 7

Differential Diagnosis Framework

Most Common Causes (in order of frequency):

1. Plantar fasciitis (53.2% of cases) 3
2. Fat pad atrophy (14.8% of cases) 3
3. Pes cavus (10.4%) 3
4. Combined plantar fasciitis and fat pad atrophy (9.2%) 3

Less Common but Important:

• Insertional Achilles tendinitis
• Haglund's deformity with bursitis
• Calcaneal stress fracture
• Nerve entrapment syndromes
• Plantar fascia rupture
• Calcaneal apophysitis (in adolescents)

Rare but Serious:

• Osteomyelitis
• Tumors
• Systemic inflammatory arthropathies (especially with bilateral involvement) 8

Clinical Decision Points

If first-step morning pain + medial calcaneal tuberosity tenderness: Plantar fasciitis is the diagnosis until proven otherwise 2, 3

If bilateral pain + night pain + pain with standing: Think fat pad atrophy 3

If pain relieved barefoot + posterior prominence: Insertional Achilles pathology or Haglund's deformity 1

If calcaneal squeeze test positive + recent activity increase: Stress fracture—don't wait for radiographic confirmation to initiate protective immobilization 1

Avoid this pitfall: Corticosteroid injections directly into the Achilles tendon are contraindicated in insertional tendinitis 1. If injecting for Haglund's bursitis, carefully avoid the tendon 1.