What are the treatment options for hindfoot pain that occurs with weightbearing?

Treatment of Hindfoot Pain with Weightbearing

For hindfoot pain with weightbearing, the treatment approach depends critically on identifying the specific underlying cause through targeted physical examination and selective imaging, with initial management focusing on offloading interventions, activity modification, and NSAIDs for most mechanical etiologies.

Diagnostic Approach to Localize the Pain Source

The location and character of hindfoot pain guides the differential diagnosis and subsequent treatment:

• Posterior heel pain suggests Achilles tendonitis, retrocalcaneal bursitis, or insertional tendinopathy 1
• Lateral heel pain indicates potential calcaneofibular ligament injury, Haglund's deformity, sinus tarsi syndrome, or calcaneal stress fracture 1
• Diffuse hindfoot pain with progressive worsening after increased activity is highly suspicious for calcaneal stress fracture, particularly if the calcaneal squeeze test (medial-to-lateral compression) reproduces pain 1
• Pain at the Achilles insertion site specifically indicates insertional Achilles tendonitis 1
• Prominent posterior superior calcaneus with overlying tenderness suggests Haglund's deformity with retrocalcaneal bursitis 1

Key Physical Examination Maneuvers

• Palpate specific anatomic landmarks: Achilles insertion, lateral malleolus, posterior superior calcaneus, lateral calcaneal wall, and the course of the calcaneofibular ligament 1
• Perform the calcaneal compression test by squeezing the calcaneus from medial to lateral—positive test suggests stress fracture 1
• Always reexamine 3-5 days post-injury if trauma is involved, as excessive initial swelling can limit examination accuracy 1

Initial Imaging Strategy

• Obtain radiographs if the 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, obtain MRI without contrast or CT without contrast as equivalent alternatives 1
• For suspected stress fracture with negative initial radiographs, order technetium bone scanning, as symptoms often precede radiographic findings 1

Treatment Algorithm Based on Specific Diagnosis

For Insertional Achilles Tendonitis

• Use open-backed shoes to reduce pressure on the posterior heel 1
• Provide heel lifts or orthoses to decrease tension on the Achilles insertion 1
• Prescribe NSAIDs for pain and inflammation 1
• Implement decreased activity and stretching exercises for the Achilles tendon 1
• Recommend weight loss if indicated 1

For Haglund's Deformity with Retrocalcaneal Bursitis

• Prescribe open-backed shoes to avoid pressure on the prominent posterior calcaneus 1
• Provide orthoses and accommodative padding to redistribute pressure 1
• Use NSAIDs for inflammation 1
• Consider corticosteroid injections into the bursa, but never inject near the Achilles tendon itself due to rupture risk 1
• Refer to physical therapy 1

For Calcaneal Stress Fracture

• Protect and immobilize the foot immediately 1
• Obtain initial radiographs, followed by bone scan or MRI if radiographs are negative but clinical suspicion remains high 1
• Restrict weightbearing activity until healing is confirmed 1

For Lateral Ligament Injury (Calcaneofibular Ligament Sprain)

• Look for rapid onset of swelling suggesting acute ligamentous injury, with lateral gutter swelling indicating lateral ligament involvement 1
• Initiate standard ankle sprain protocol with rest, ice, compression, elevation, and progressive rehabilitation 1

Advanced Treatment Options for Refractory Cases

For patients with persistent hindfoot pain despite 6-8 weeks of conservative treatment:

• Hindfoot endoscopy can diagnose and treat multiple pathologies including posterior tibial tenosynovectomy, peroneal tendon adhesiolysis, flexor hallucis longus release, os trigonum removal, and endoscopic calcaneoplasty for retrocalcaneal bursitis 2, 3
• Endoscopic approaches offer advantages of less morbidity, reduced postoperative pain, outpatient treatment, and functional postoperative rehabilitation compared to open surgery 2, 3
• Weightbearing multiplanar imaging (CT or MRI) can reliably assess lateral hindfoot arthrosis, subtalar joint pathology, and calcaneofibular impingement in complex cases 4

Critical Pitfalls to Avoid

• Never inject corticosteroids near the Achilles tendon—this is contraindicated due to high rupture risk 1
• Do not overlook stress fractures in patients reporting increased walking activity before symptom onset, even with negative initial radiographs 1
• Avoid examining patients within 48 hours of acute injury as the sole assessment—always reexamine at 3-5 days when swelling has decreased 1
• Do not dismiss bilateral heel pain or pain in multiple joints—consider systemic arthritides in these presentations 1

When to Refer to Subspecialist

Refer when:

• No improvement after 6-8 weeks of appropriate conservative treatment 1
• Need for advanced imaging or diagnostic testing beyond initial radiographs 1
• Consideration of surgical intervention is warranted 1
• Neurologic symptoms (burning, tingling) are present—these require immediate subspecialist referral for electromyography, nerve conduction studies, and MRI 1