Differential Diagnosis for Heel Pain

The patient presents with heel pain that worsens with weight-bearing activities and improves with rest, suggesting a condition related to mechanical stress or inflammation. The following differential diagnoses are considered:

• Single Most Likely Diagnosis

  • Plantar Fasciitis: This is the most common cause of heel pain in adults. The patient's symptoms of pain on weight-bearing, worsening with the first steps in the morning, and tenderness on palpation of the left heel are classic for plantar fasciitis. The possible garden injury, where the patient stood on a stone, could have precipitated the condition.

• Other Likely Diagnoses

  • Achilles Tendinopathy: Given the patient's age and the presence of pain with activities such as walking, Achilles tendinopathy is a plausible diagnosis. The pain is typically located at the back of the heel and can be exacerbated by activities that increase the demand on the Achilles tendon.
  • Heel Fat Pad Atrophy: This condition can cause heel pain, especially in older adults, due to the loss of the fat pad's cushioning effect. However, it is less likely given the acute onset and the specific exacerbating factors mentioned.
  • Peroneal Tendinopathy: The patient's complaint of pain with eversion of the ankle suggests involvement of the peroneal tendons, which could be a contributing factor to the heel pain.

• Do Not Miss Diagnoses

  • Calcaneal Stress Fracture: Although less common, a stress fracture of the calcaneus must be considered, especially given the history of a possible garden injury. This diagnosis is critical to rule out due to the potential for significant morbidity if not properly managed.
  • Infection or Osteomyelitis: While the absence of erythema, ulceration, and systemic symptoms makes this less likely, it is crucial to consider, especially in diabetic patients or those with compromised immune systems, due to the risk of severe complications.
  • Rheumatological Conditions: Conditions like rheumatoid arthritis or seronegative spondyloarthropathies can present with heel pain among other symptoms. Although the patient's blood work is normal, clinical correlation is essential.

• Rare Diagnoses

  • Baxter's Neuritis: Involvement of the inferior calcaneal nerve can cause heel pain. This is a less common condition and might be considered if other diagnoses are ruled out.
  • Tarsal Tunnel Syndrome: Although more commonly associated with pain and numbness in the foot, tarsal tunnel syndrome could potentially cause heel pain if the posterior tibial nerve is compressed near the heel.