What is the differential diagnosis for pain that starts at the heel and radiates up towards the hip region?

Differential Diagnosis for Pain Starting at Heel and Radiating to Hip

The most likely diagnosis is sciatic nerve entrapment or lumbar radiculopathy causing referred pain, though you must systematically rule out local heel pathology, proximal nerve compression syndromes, and less common systemic causes.

Primary Neurologic Considerations

The radiation pattern from heel to hip strongly suggests a neurologic etiology rather than isolated mechanical heel pain:

• Lumbar radiculopathy (L5-S1 nerve root compression) can cause pain radiating from the heel proximally through the posterior leg and hip 1, 2.
• Deep gluteal syndrome with sciatic nerve entrapment presents as posterior hip pain that can radiate distally to the heel 2.
• Tarsal tunnel syndrome causes medial heel pain with burning, tingling, or numbness that may radiate proximally, though typically stays below the knee 1, 3, 4.

If neurologic heel pain is suspected, immediate subspecialist referral for evaluation and diagnostic testing is essential, including electromyography, nerve conduction velocity studies, and MRI 1, 5.

Local Heel Pathology That May Mimic Proximal Radiation

While less likely to cause true hip radiation, these conditions must be excluded:

Posterior Heel Pain

• Achilles tendinopathy produces pain at the tendon insertion site, worsening with activity 5, 3, 4.
• Haglund's deformity with retrocalcaneal bursitis causes posterior and lateral heel pain from the prominent posterior superior calcaneus 1, 5, 4.
• Calcaneal stress fracture presents with progressively worsening pain following increased activity, with tenderness at the lateral calcaneal wall and positive calcaneal squeeze test 5, 3, 4.

Plantar Heel Pain

• Plantar fasciitis causes medial plantar heel pain, especially with first weight-bearing steps in the morning, but does not typically radiate to the hip 3, 4, 6.

Diagnostic Algorithm

Step 1: Localize the Pain Origin

• Point tenderness location: Palpate the Achilles insertion, lateral malleolus, posterior superior calcaneus, lateral calcaneal wall, and over the calcaneofibular ligament course 5.
• Neurologic symptoms: Assess for burning, tingling, numbness, or radiation patterns suggesting nerve involvement 1, 3, 4.
• Calcaneal compression test: Squeeze the calcaneus medially to laterally to evaluate for stress fracture 5.

Step 2: Screen for Proximal Sources

• Lumbar spine examination: Assess for radiculopathy with straight leg raise, neurologic deficits in lower extremity 1, 2.
• Hip examination: Evaluate for intra-articular hip pathology, femoroacetabular impingement, or gluteal tendinopathy 2.
• Sciatic nerve assessment: Check for deep gluteal syndrome or piriformis involvement 2.

Step 3: Initial Imaging

• Weight-bearing radiographs of the foot and ankle should be the initial imaging study for heel pain 1, 5.
• AP pelvis and lateral hip radiographs if hip pathology is suspected 1.
• Lumbar spine imaging (MRI preferred) if radiculopathy is suspected based on examination findings 1, 2.

Step 4: Advanced Diagnostic Testing

• Electromyography and nerve conduction studies for confirmed neurologic involvement 1, 5.
• MRI of the foot/ankle if radiographs are negative but pain persists >1 week 5.
• Technetium bone scanning for suspected stress fracture with negative initial radiographs 1, 5.

Critical Pitfalls to Avoid

• Do not assume isolated plantar fasciitis when pain radiates proximally beyond the heel—this pattern demands neurologic evaluation 1, 3.
• Reexamine 3-5 days post-injury if trauma is involved, as excessive initial swelling can limit examination accuracy 5.
• Never diagnose based on imaging alone—combine symptoms, clinical signs, and imaging findings 1.
• Consider systemic causes (arthritides, infections, tumors, vascular compromise) when symptoms are bilateral, involve other joints, or are unexplained by mechanical causes 1, 5, 6.

Rare but Important Considerations

• Calcaneal osteomyelitis or bone tumor requires proper diagnostic testing and consultation when suspected 1, 5.
• Vascular compromise can result in heel pain and necessitates proper evaluation 5.
• Inflammatory arthritides should be considered with bilateral symptoms or known inflammatory conditions 5, 6.

The key distinguishing feature is the radiation pattern to the hip, which is atypical for mechanical heel pathology and mandates thorough neurologic and spinal evaluation before attributing symptoms to local heel conditions.