Differential Diagnosis for a 38-year-old Female with Sudden Onset of Heel Pain

The patient's presentation of sudden onset of heel pain after a specific incident, such as feeling something pop while reaching, suggests an acute injury. The differential diagnosis can be categorized as follows:

• Single Most Likely Diagnosis

  • Achilles Tendon Rupture: This is the most likely diagnosis given the mechanism of injury (sudden contraction of the calf muscles, as when pushing off with the foot) and the symptoms described (feeling a pop, severe pain, and inability to bear weight). The location of the pain and edema in the posterior heel region further supports this diagnosis.

• Other Likely Diagnoses

  • Ankle Sprain: Although the primary complaint is heel pain, an ankle sprain could occur from a similar mechanism, especially if the patient twisted her ankle while reaching. However, the specific location of pain and the feeling of a pop make this less likely.
  • Heel Contusion or Bruise: Direct trauma to the heel, such as from a fall onto the heel or a kick, could cause severe pain and swelling. However, the history provided does not strongly suggest direct trauma to the heel.
  • Plantar Fascia Strain: This could be considered if the pain is more plantar than posterior, but the mechanism and location of pain make this less likely than an Achilles tendon rupture.

• Do Not Miss Diagnoses

  • Deep Vein Thrombosis (DVT): Although less common in this scenario, DVT can cause calf and heel pain and swelling. Given the potential severity of a missed DVT (pulmonary embolism), it's crucial to consider, especially if there are risk factors such as recent travel, immobilization, or family history.
  • Compartment Syndrome: This is a medical emergency that can cause severe pain, especially with passive stretching of the muscles within the compartment. It's less likely given the description but should be considered if pain is out of proportion to what is expected or if there are other concerning signs like paresthesias or pallor.

• Rare Diagnoses

  • Stress Fracture of the Calcaneus: This could be considered if the patient has been increasing her activity level or has risk factors for osteoporosis. However, the acute onset after a specific incident makes this less likely.
  • Retrocalcaneal Bursitis: Inflammation of the bursa that separates the Achilles tendon from the calcaneus can cause posterior heel pain. This could be a consideration if the pain and swelling are more localized to the area just in front of the Achilles tendon insertion.

Orders in the ER

• Imaging:
  • Ultrasound or MRI of the Achilles tendon to confirm the diagnosis of a rupture. Ultrasound is quick and can be done at the bedside, while MRI provides detailed images but takes longer.
  • X-rays of the ankle and heel to rule out fractures or other bony abnormalities.
• Lab Tests:
  • D-dimer if there's a concern for DVT, although this would be more relevant if the patient had risk factors or symptoms suggestive of DVT.
• Physical Examination:
  • A thorough examination, including the Thompson test (calf squeeze test) to assess for Achilles tendon rupture.
• Consultation:
  • Consider consulting orthopedics for further evaluation and management, especially if an Achilles tendon rupture is confirmed or suspected.