Differential Diagnosis of Calcaneal Pain
The differential diagnosis of calcaneal pain is organized by anatomic location—plantar, posterior, lateral, and diffuse—with plantar fasciitis being the most common overall cause, but mechanical trauma, neurologic conditions, inflammatory arthritides, infections, and tumors must all be systematically considered.
Plantar Heel Pain (Most Common Location)
Plantar fasciitis is the most frequent diagnosis, characterized by medial plantar heel pain that is worst with the first weight-bearing steps after rest or prolonged sitting 1, 2, 3. On examination, tenderness at the calcaneal tuberosity increases with passive dorsiflexion of the toes 3.
Calcaneal stress fracture presents with progressively worsening pain following increased activity or change to a harder walking surface 1, 2. Pain on compression of the calcaneus from medial to lateral (calcaneal squeeze test) is highly suspicious 4, 5. Tenderness localizes to the lateral calcaneal wall, slightly posterior to the subtalar joint facet 4. Symptoms often precede radiographic findings, requiring technetium bone scanning or MRI for early diagnosis 4, 5.
Nerve entrapment or neuroma causes pain accompanied by burning, tingling, or numbness 1, 2, 3. Tarsal tunnel syndrome from posterior tibial nerve compression produces medial midfoot heel pain, particularly with prolonged weight bearing 1, 2.
Heel pad syndrome manifests as deep, bruise-like pain in the middle of the heel, especially in older and obese patients 1, 2, 3.
Plantar warts can mimic other causes of plantar heel pain 1, 2.
Posterior Heel Pain
Achilles tendinopathy is the most common cause of posterior heel pain 1, 2. Insertional Achilles tendonitis produces pain at the tendon insertion site 4.
Haglund's deformity with retrocalcaneal bursitis presents with posterior and lateral heel pain, typically associated with a prominent posterior superior calcaneus visible on radiographs 4, 5, 1, 2. Pain worsens with shoe wear but improves when walking barefoot 5.
Sever disease (calcaneal apophysitis) is the most common cause of heel pain in adolescents and children 4, 1, 2.
Lateral Heel Pain
Lateral ankle ligament injury, particularly calcaneofibular ligament sprain, causes lateral heel pain following inversion trauma, with pain worsening during dorsiflexion 5.
Sinus tarsi syndrome manifests as lateral midfoot heel pain with a feeling of instability, particularly with increased activity or walking on uneven surfaces 1, 2.
Lateral process fracture of the talus ("snowboarder's fracture") causes lateral and posterior ankle pain with antalgic gait following inversion trauma 5.
Traumatic Causes
Acute calcaneal fracture from a fall onto the heel from height causes diffuse rearfoot pain, poorly localized with intra-articular fractures involving the subtalar joint 4. Diagnosis requires history of trauma, focal palpation tenderness, and radiographic confirmation 4.
Acute plantar fascia rupture is a soft tissue trauma that may show negative radiographs and bone scans 4.
Systemic and Rare Causes
Arthritides can cause heel pain, particularly in patients with bilateral symptoms, pain in other joints, or known inflammatory arthritis conditions 4, 3.
Infections (soft tissue and bone osteomyelitis) rarely cause heel pain but require proper diagnostic testing and consultation when suspected 4, 3.
Tumors (malignant and benign) are rare causes requiring appropriate referral 4, 3.
Vascular compromise can result in heel pain and necessitates proper diagnostic evaluation 4.
Key Examination Maneuvers for Differentiation
Point tenderness location is critical: palpate the Achilles insertion, lateral malleolus, posterior superior calcaneus, lateral calcaneal wall, and over the calcaneofibular ligament course 5.
The calcaneal compression test (squeezing the calcaneus medially to laterally) suggests stress fracture when positive 4, 5.
Timing of examination matters: always reexamine 3-5 days post-injury, as excessive swelling and pain within the first 48 hours can limit initial assessment 5.
Common Pitfalls
Overlooking stress fractures is common because patients often report increased walking activity before symptom onset, and radiographs may initially be negative, requiring bone scan or MRI 4, 5, 6, 7. Bilateral calcaneal stress fractures can occur even in non-athletes and may be misdiagnosed as plantar fasciitis or Achilles tendinitis for extended periods 6.
Rapid onset of swelling suggests acute ligamentous injury or fracture, with lateral gutter swelling indicating lateral ligament involvement 5.
When symptoms are prolonged, unexplained, or fail to respond to routine treatment within 6-8 weeks, consider atypical causes including stress fractures, infections, tumors, or systemic conditions 4, 5, 3, 7.