What does heel pain indicate?

What Heel Pain Indicates

Heel pain location and characteristics point to specific underlying conditions, with plantar fasciitis being the most common cause, but the exact location of pain is critical for accurate diagnosis. 1, 2

Diagnostic Approach Based on Pain Location

The location and quality of heel pain directly indicates the underlying pathology:

Inferior/Plantar Heel Pain

• Plantar fasciitis is the most common cause of heel pain in adults, characterized by pain on the bottom of the heel that is particularly severe with the first few steps in the morning or after prolonged sitting 1, 3, 4
• Pain typically occurs on weight bearing and when transitioning from sitting to standing 1
• Physical examination reveals tenderness on palpation along the medial plantar calcaneal region 3

Posterior Heel Pain

• Achilles tendonitis or bursitis should be suspected when pain localizes to the back of the heel 1, 2
• Insertional Achilles tendonitis specifically affects the insertion point of the Achilles tendon 2

Lateral Heel Pain

• Haglund's deformity or sinus tarsi syndrome are indicated by pain on the outer side of the heel 2
• Pain that is relieved when walking barefoot but worsened by shoes strongly suggests Haglund's deformity or bursitis 1, 2

Diffuse Heel Pain

• Stress fracture or heel pad syndrome should be considered when pain is widespread throughout the heel 2
• Traumatic heel pain with a history of injury suggests stress fracture and requires imaging 2

Burning or Tingling Heel Pain

• Neurologic causes including tarsal tunnel syndrome or nerve entrapment are indicated by burning, tingling, or radiating sensations 2, 5
• This presentation requires immediate subspecialist referral for electromyography, nerve conduction studies, and MRI 2, 5

Key Diagnostic Features

Pain characteristics help differentiate conditions:

• Morning pain or pain after rest that improves with activity = plantar fasciitis 3, 4
• Pain worsened by shoes but relieved barefoot = Haglund's deformity or bursitis 1, 2
• Burning/tingling = neurologic etiology requiring urgent evaluation 2

Common Pitfalls to Avoid

• Do not assume all heel pain is plantar fasciitis - plantar fasciitis is a diagnosis of exclusion after ruling out mechanical, rheumatologic, and neurologic causes 6
• Avoid corticosteroid injections near the Achilles tendon due to significant risk of tendon rupture 1, 2
• The presence of a heel spur on x-ray does not indicate the cause of symptoms but rather suggests the condition has been present for at least 6-12 months 3

When Advanced Evaluation is Needed

Refer for subspecialist evaluation or advanced imaging when:

• Neurologic symptoms (burning, tingling) are present - requires immediate referral 2, 5
• No improvement after 6-8 weeks of appropriate conservative treatment 1, 2
• Suspected stress fracture requiring bone scan or MRI 2
• Consideration of surgical intervention is necessary 2