What are the differential diagnoses and treatment options for heel pain?

Heel Pain: Differential Diagnoses and Treatment Algorithm

Primary Differential Diagnoses by Pain Location

The anatomic location of heel pain is the most critical factor in narrowing your differential diagnosis. 1

Plantar (Bottom) Heel Pain

• Plantar fasciitis is the most common cause, characterized by sharp pain with first steps in the morning or after prolonged sitting, with tenderness at the medial calcaneal tuberosity that worsens with passive toe dorsiflexion 2, 3
• Calcaneal stress fracture presents with progressively worsening diffuse heel pain following increased activity or change to harder walking surfaces; use calcaneal compression test (squeeze heel medially to laterally) to suggest diagnosis 1, 3
• Heel pad syndrome causes deep, bruise-like pain in the middle of the heel, particularly in older and obese patients 3, 4
• Tarsal tunnel syndrome manifests as medial midfoot heel pain with burning, tingling, or numbness from posterior tibial nerve compression 1, 3
• Neuromas and plantar warts can cause localized plantar pain 3

Posterior Heel Pain

• Achilles tendonitis is the most common posterior cause, with pain at the tendon insertion site 2, 1
• Haglund's deformity with retrocalcaneal bursitis presents when the prominent posterior superior calcaneus causes overlying bursa inflammation; pain is relieved when walking barefoot but worsened by shoes 2, 1
• Sever's disease (calcaneal apophysitis) occurs specifically in children 3

Lateral Heel Pain

• Lateral ankle ligament injury (calcaneofibular ligament sprain) is common with inversion trauma and pain with dorsiflexion 1
• Lateral process fracture of the talus ("snowboarder's fracture") causes lateral and posterior ankle pain with antalgic gait following inversion trauma 1
• Sinus tarsi syndrome occurs in the space between calcaneus, talus, and subtalar joints, presenting as lateral midfoot heel pain 3

Key Physical Examination Findings

Point tenderness location is essential for differentiation: palpate the Achilles insertion, lateral malleolus, posterior superior calcaneus, lateral calcaneal wall, and calcaneofibular ligament course 1

• Calcaneal compression test suggests stress fracture 1
• Rapid onset of swelling suggests acute ligamentous injury or fracture 1
• Lateral gutter swelling indicates lateral ligament involvement 1
• Always reexamine 3-5 days post-injury, as excessive swelling and pain can limit initial examination within 48 hours 1

Imaging Recommendations

• Obtain initial radiographs if patient meets Ottawa Ankle Rules criteria: inability to bear weight immediately after injury, point tenderness over malleoli/talus/calcaneus, or inability to ambulate 4 steps 1
• If radiographs are negative but pain persists >1 week, MRI without contrast or CT without contrast are equivalent alternatives 1
• For suspected stress fracture with negative initial radiographs, use technetium bone scanning, as symptoms often occur before fracture is radiographically visible 1

Treatment Algorithm

Initial Conservative Treatment (First 6-8 Weeks)

For plantar fasciitis (most common):

• Rest and activity modification to prevent ongoing damage 2
• Calf-muscle and plantar fascia stretching exercises 3-5 times daily 2
• NSAIDs (oral or topical) for pain relief and inflammation 2
• Over-the-counter heel cushions and arch supports 2
• Proper footwear with adequate arch support, cushioning, and appropriate fit/width 2
• Cryotherapy (ice application) for 10-minute periods through wet towel 2
• Weight loss if indicated 2

For Achilles tendonitis/insertional tendinopathy:

• Open-backed shoes to reduce pressure on affected area 2
• Heel lifts or orthoses to redistribute weight 2
• NSAIDs and decreased activity 1
• Stretching exercises and eccentric exercises (proven beneficial for tendinopathies) 2

For Haglund's deformity with bursitis:

• Open-backed shoes 1
• Orthoses and accommodative padding 1
• NSAIDs 1
• Corticosteroid injections (avoiding Achilles tendon area) 1
• Physical therapy 1

For lateral ankle ligament injury (inversion trauma):

• PRICE protocol (protection, rest, ice, compression, elevation) with semirigid support devices 5
• NSAIDs improve healing, reduce edema and pain, and decrease time to return to activities 5
• Functional rehabilitation is preferable to complete immobilization 5
• Semirigid or lace-up support devices are superior to elastic bandages 5

If No Improvement After 6-8 Weeks

• Consider padding and strapping, weight management, and customized orthotic devices 2
• Refer to podiatric foot and ankle surgeon 2, 1
• Advanced imaging (MRI, ultrasound) to confirm diagnosis and rule out other conditions 2
• Consider immobilization with cast or fixed-ankle walker-type device 2

If No Improvement After 2-3 Months

• Continue conservative measures 2
• Consider cast immobilization 2
• Evaluate for surgical options (plantar fasciotomy) or extracorporeal shock wave therapy 2

Special Circumstances Requiring Immediate Referral

For neurologic heel pain (burning, tingling, numbness): immediate subspecialist referral for electromyography, nerve conduction studies, and MRI 1

Critical Pitfalls to Avoid

• Never inject corticosteroids near the Achilles tendon due to risk of tendon rupture 2, 1
• Use corticosteroid injections judiciously; they provide only temporary relief 2
• Avoid complete immobilization to prevent muscular atrophy and deconditioning 2
• Don't overlook stress fractures in patients reporting increased walking activity before symptom onset, as radiographs may initially be negative 1
• Avoid overdebridement of hyperkeratotic tissue, which can increase underlying skin tenderness 2

Expected Outcomes

Most patients (nearly all) respond to conservative nonsurgical therapy within 6-8 weeks 2, 6