What is the most common cause of heel pain?

Most Common Cause of Heel Pain

Plantar fasciitis is the most common cause of heel pain in adults, affecting more than 1 million persons per year in the United States. 1

Common Causes of Heel Pain by Age Group

• Adults: Plantar fasciitis is the leading cause of heel pain 2, 1
• Adolescents: Calcaneal apophysitis (Sever's disease) is the most common cause 3, 4

Anatomical Classification of Heel Pain

• Plantar heel pain:

  • Plantar fasciitis - characterized by pain and tenderness predominantly on the medial aspect of the calcaneus near the sole of the heel 5
  • Pain is typically worst with first steps in the morning or after prolonged sitting 1

• Posterior heel pain:

  • Achilles tendonitis or retrocalcaneal bursitis 6
  • Pain is aggravated by activity and shoe pressure 6

• Lateral heel pain:

  • May suggest Haglund's deformity or sinus tarsi syndrome 6

• Diffuse heel pain:

  • Could indicate stress fracture or heel pad syndrome 6

Risk Factors for Plantar Fasciitis

• Obesity 2, 1
• Excessive foot pronation 2, 1
• Excessive running or prolonged standing 2, 1
• Sedentary lifestyle 1
• Anatomical deformities such as pes planus (flat foot) 2

Traumatic Causes of Heel Pain

• Acute trauma: Most common osseous cause is acute trauma to the calcaneus, typically from a fall onto the heel from height 3
• Stress fracture: Repetitive loading can lead to calcaneal stress fracture, often reported after increased walking activity 3
• Soft tissue trauma: Acute rupture of the plantar fascia can cause heel pain 3

Neurologic Heel Pain

• Caused by irritation or entrapment of nerves innervating the heel 3
• Presents with burning or tingling sensations 6
• May require specialized diagnostic testing (electromyography, nerve conduction studies, MRI) 3

Diagnostic Approach

• Key clinical finding: Sharp pain with palpation of the medial plantar calcaneal region 1
• Provocative test: Discomfort in the proximal plantar fascia elicited by passive ankle/first toe dorsiflexion 1
• Timing pattern: Pain with first steps in the morning or after prolonged sitting is highly suggestive of plantar fasciitis 1
• Imaging: Rarely needed for initial diagnosis; reserved for recalcitrant cases or to rule out other pathology 1

Treatment Algorithm

1. Initial patient-directed treatments (first 4-6 weeks):

   • Rest and activity modification 1, 7
   • Ice massage 1
   • Oral analgesics (NSAIDs) 1
   • Stretching techniques (plantar fascia-specific stretch, calf stretching) 1, 7

2. Physician-prescribed treatments (if pain persists):

   • Physical therapy modalities 1
   • Foot orthotics or arch supports 1, 7
   • Night splinting 1, 7
   • Corticosteroid injections (with caution) 1, 7

3. Advanced interventions (for chronic cases lasting 6+ months):

   • Extracorporeal shock wave therapy 1, 7
   • Surgical intervention (plantar fasciotomy) - considered only after failure of conservative treatment for 6-12 months 1, 5

Common Pitfalls and Caveats

• Corticosteroid injections should be used judiciously due to risk of fat pad atrophy and plantar fascia rupture 6, 7
• Failure to consider other causes of heel pain can lead to inappropriate treatment 5
• Approximately 90% of patients improve with conservative techniques, making surgery rarely necessary 1, 5
• Proper footwear with appropriate support is crucial for recovery 4

When to Refer to a Specialist

• No improvement after 6-8 weeks of appropriate conservative treatment 6
• Need for advanced imaging or diagnostic testing 6
• Consideration of surgical intervention 6
• Suspected neurologic cause of heel pain 3