What is the diagnostic workup and treatment for a 65-year-old female with a knot on her heel?

Diagnostic Workup and Treatment for a Knot on the Heel in a 65-Year-Old Female

The most likely diagnosis is Haglund's deformity with retrocalcaneal bursitis, which requires clinical examination focusing on posterior superior calcaneal prominence, followed by conservative treatment with open-backed shoes, NSAIDs, and physical therapy. 1

Initial Clinical Assessment

Key Physical Examination Findings

Palpate specific anatomical landmarks to differentiate the diagnosis:

• Posterior superior calcaneus for Haglund's deformity (prominent bony knot) 1
• Achilles tendon insertion site for insertional tendonitis 1
• Lateral calcaneal wall for stress fracture 1
• Perform calcaneal compression test (medial-to-lateral squeeze) to assess for stress fracture 1

Pain characteristics that guide diagnosis:

• Pain relieved when walking barefoot but worsened by shoes strongly suggests Haglund's deformity or bursitis 1
• Posterior heel pain indicates Achilles tendonitis or bursitis 1
• Progressively worsening pain following increased activity suggests calcaneal stress fracture 1

Imaging Strategy

Obtain plain radiographs initially 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
• Haglund's deformity is suspected—radiographs will show prominent posterior superior calcaneus 1

Advanced imaging 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, technetium bone scanning is recommended, as symptoms often precede radiographic findings 1

Treatment Algorithm

First-Line Conservative Management (Initial 6-8 Weeks)

For Haglund's deformity with retrocalcaneal bursitis:

• Open-backed shoes to eliminate pressure on the posterior heel 1, 2
• Orthoses and accommodative padding to redistribute weight 1, 2
• NSAIDs (oral or topical) for pain relief and inflammation reduction 1, 2
• Physical therapy including stretching exercises for plantar fascia and Achilles tendon 2
• Cryotherapy (ice application) for 10-minute periods through a wet towel 2
• Weight loss if indicated to reduce pressure 2

Critical caveat: Corticosteroid injections should be used judiciously and are absolutely contraindicated near the Achilles tendon due to rupture risk 1, 2

If Insertional Achilles Tendonitis is the Diagnosis

• Open-backed shoes 1
• Heel lifts or orthoses 1
• NSAIDs and decreased activity 1
• Stretching exercises (eccentric exercises have proven beneficial for tendinopathies) 2

If Calcaneal Stress Fracture is Confirmed

• Protect and immobilize the foot 1
• Consider cast or fixed-ankle walker-type device 2
• Avoid complete immobilization to prevent muscular atrophy 2

When to Refer

Refer to podiatric foot and ankle surgeon if:

• No improvement after 6-8 weeks of appropriate conservative treatment 1, 2
• Need for advanced imaging or diagnostic testing beyond plain radiographs 1
• Consideration of surgical intervention (plantar fasciotomy, excision of Haglund's deformity) 2

Common Pitfalls to Avoid

• Never inject corticosteroids near the Achilles tendon—this significantly increases rupture risk 1, 2
• Reexamine 3-5 days post-initial evaluation, as excessive swelling and pain can limit the initial examination within 48 hours 1
• Do not overlook stress fractures—patients often report increased walking activity before symptom onset, and radiographs may initially be negative requiring bone scan 1
• Avoid overdebridement of any hyperkeratotic tissue, as this can make underlying skin more tender 2