What are the treatment options for lateral heel pain?

Treatment of Lateral Heel Pain

For lateral heel pain, start with open-backed shoes, orthotic devices with accommodative padding, NSAIDs, and activity modification; if no improvement occurs within 6-8 weeks, refer to a podiatric foot and ankle surgeon for consideration of immobilization or advanced interventions. 1, 2

Differential Diagnosis

Lateral heel pain has several distinct causes that guide treatment:

• Haglund's deformity with retrocalcaneal bursitis is the most common cause of lateral heel pain, presenting with a prominent posterior-lateral calcaneal prominence and tenderness lateral to the Achilles tendon 1, 2, 3
• Pain is characteristically relieved when walking barefoot but aggravated by shoe pressure, which is pathognomonic for Haglund's deformity or bursitis 2, 3
• Lateral ankle ligament injury (calcaneofibular ligament sprain) should be considered, especially with history of inversion trauma 3
• Calcaneal stress fracture presents with pain on medial-to-lateral compression of the calcaneus (squeeze test) and tenderness on the lateral calcaneal wall 3, 4
• Lateral process fracture of the talus ("snowboarder's fracture") causes lateral and posterior pain following inversion trauma 3

Initial Conservative Treatment (0-6 Weeks)

Begin with these evidence-based interventions simultaneously:

• Open-backed shoes to eliminate pressure on the posterior-lateral prominence 1, 2
• Orthotic devices and accommodative padding to redistribute pressure away from the inflamed area 1, 2
• NSAIDs (oral or topical) for pain relief and inflammation reduction 1, 2
• Cryotherapy applied through a wet towel for 10-minute periods to reduce pain and swelling 2
• Activity modification by reducing aggravating activities while avoiding complete rest to prevent muscle weakness 2
• Stretching exercises for the Achilles tendon and plantar fascia, performed 3-5 times daily 2
• Weight loss if indicated to reduce pressure on the heel 2

Critical Caveat on Corticosteroid Injections

• Corticosteroid injections may be used for bursitis associated with Haglund's deformity but must be administered carefully 1
• Absolutely avoid injecting near the Achilles tendon due to significant risk of tendon rupture 2, 3

Treatment Algorithm for Persistent Pain

At 6-8 Weeks Without Improvement

Refer to a podiatric foot and ankle surgeon for evaluation and continuation of initial treatments plus: 1, 2

• Immobilization with a cast or fixed-ankle walker-type device for more severe or refractory cases 1, 2
• Advanced imaging (MRI without contrast or CT without contrast) if diagnosis remains unclear or to rule out stress fracture 2, 3
• Consider technetium bone scanning if stress fracture is suspected, as symptoms often precede radiographic findings 3, 4

Imaging Recommendations

• Initial weight-bearing radiographs to identify bony prominences, fractures, or erosions at the Achilles insertion 1, 3
• Apply Ottawa Ankle Rules: obtain radiographs if unable to bear weight immediately after injury, point tenderness over malleoli/talus/calcaneus, or inability to ambulate 4 steps 3
• If radiographs are negative but pain persists beyond 1 week, MRI or CT are equivalent alternatives 3

Common Pitfalls to Avoid

• Do not inject corticosteroids near the Achilles tendon insertion as this dramatically increases rupture risk 1, 2, 3
• Reexamine patients 3-5 days post-injury if trauma is involved, as excessive initial swelling can limit examination accuracy 3
• Do not overlook stress fractures in patients with increased walking activity or change to harder surfaces, even with negative initial radiographs 3, 4
• Avoid complete immobilization initially to prevent muscular atrophy and deconditioning 2

Red Flags Requiring Immediate Evaluation

Seek urgent assessment if: 2

• Pain becomes constant at rest without mechanical explanation
• Numbness, burning, or tingling suggesting nerve involvement
• Increasing swelling or redness suggesting infection
• Bilateral symptoms or pain in other joints suggesting systemic arthritis

Expected Outcomes

• Most patients respond to conservative treatment within 6-8 weeks when appropriate measures are implemented 2
• For Haglund's deformity with bursitis specifically, symptoms typically improve with shoe modification and padding as first-line interventions 1
• Surgical intervention is reserved for cases failing 6-8 weeks of appropriate conservative management 2