Differential Diagnosis for Posterior and Lateral Heel Pain with Antalgic Gait and Pain on Dorsiflexion/Inversion
The combination of posterior and lateral heel pain worsened by dorsiflexion and inversion most strongly suggests either Achilles tendinopathy, lateral ankle ligament injury (calcaneofibular ligament), or Haglund's deformity with retrocalcaneal bursitis. 1
Primary Differential Diagnoses
Most Likely Diagnoses Based on Pain Location and Mechanism
Achilles tendinopathy/insertional Achilles tendonitis: Posterior heel pain is the hallmark of Achilles pathology, typically located 4-6 cm above the calcaneal insertion or at the insertion itself 2. Pain with dorsiflexion is characteristic as this motion stretches the Achilles tendon 1.
Lateral ankle ligament injury (calcaneofibular ligament sprain): The calcaneofibular ligament is one of the lateral stabilizing ligaments commonly injured in inversion trauma 3. Pain with inversion testing and dorsiflexion suggests involvement of this structure, which spans from the lateral malleolus to the lateral calcaneus 3.
Haglund's deformity with retrocalcaneal bursitis: This presents with posterior and lateral heel pain, particularly when the prominent posterior superior calcaneus causes inflammation of the overlying bursa 3. Pain is characteristically relieved when walking barefoot but worsened by shoes 1.
Additional Considerations
Lateral process fracture of the talus ("snowboarder's fracture"): This injury can cause lateral and posterior ankle pain with an antalgic gait, particularly following inversion trauma 3. Pain with dorsiflexion and inversion would be expected due to talar involvement 3.
Calcaneal stress fracture: Diffuse heel pain with tenderness at the lateral wall of the calcaneus, slightly posterior to the subtalar joint facet, suggests stress fracture 3. An antalgic gait is typical, and pain on compression of the calcaneus is highly suspicious 3.
Sinus tarsi syndrome: Lateral heel pain may indicate this condition, which involves the space between the talus and calcaneus laterally 1.
Peroneal tendinopathy: Often misdiagnosed, this causes chronic lateral ankle pain and should be suspected in patients with lateral symptoms 2. The peroneal tendons course along the lateral aspect of the calcaneus 2.
Anterolateral impingement syndrome: Following inadequate rehabilitation of an ankle sprain, hypertrophic scar tissue can become trapped between the talus and lateral malleolus, causing chronic lateral ankle pain 4.
Key Examination Findings to Differentiate
Point tenderness location: Palpate the Achilles insertion, lateral malleolus, posterior superior calcaneus, lateral calcaneal wall, and over the calcaneofibular ligament course 3.
Anterior drawer test: Perform this 4-5 days post-injury if acute trauma occurred, as it reliably discriminates between ankle sprain and lateral ligament rupture 5.
Calcaneal compression test: Squeeze the calcaneus from medial to lateral; pain suggests stress fracture 3.
Shoe-related pain pattern: Pain relieved barefoot but worsened by shoes strongly suggests Haglund's deformity or bursitis 1.
Swelling location and timing: Rapid onset of swelling suggests acute ligamentous injury or fracture 3. Lateral gutter swelling indicates lateral ligament involvement 3.
Imaging Recommendations
Initial radiographs are indicated if the patient meets Ottawa Ankle Rules criteria: inability to bear weight immediately after injury, point tenderness over the malleoli/talus/calcaneus, or inability to ambulate 4 steps 3.
If radiographs are negative but pain persists >1 week: MRI without contrast or CT without contrast are equivalent alternatives for further evaluation 3.
For suspected stress fracture with negative initial radiographs: Technetium bone scanning can be helpful, as symptoms often occur before the fracture is radiographically visible 3.
For suspected ligamentous injury with negative radiographs: MRI ankle without contrast is preferred over CT for soft tissue evaluation 3.
Common Pitfalls
Reexamination timing: Always reexamine 3-5 days post-injury, as excessive swelling and pain can limit the initial examination within 48 hours 3. This is critical for distinguishing partial tears from complete ruptures 3.
Missing peroneal tendinopathy: This is frequently misdiagnosed and leads to chronic lateral ankle pain and instability 2.
Corticosteroid injection near Achilles tendon: This is absolutely contraindicated due to risk of tendon rupture 1, 6.
Overlooking stress fractures: Patients often report increased walking activity before symptom onset, and radiographs may initially be negative 3.