What is the treatment for lateral heel pain that worsens with dorsiflexion of the foot?

Treatment of Lateral Heel Pain Worsening with Dorsiflexion

Start with open-backed shoes, orthotic padding, NSAIDs, and activity modification for 6-8 weeks; if no improvement, refer to a podiatric foot and ankle surgeon for advanced treatment including possible immobilization. 1

Differential Diagnosis

The location and characteristics of your pain point to specific conditions:

• Haglund's deformity with retrocalcaneal bursitis is the most common cause of lateral heel pain, presenting with a prominent posterior-lateral calcaneal bump and tenderness lateral to the Achilles tendon 1
• Pathognomonic feature: Pain relieved when walking barefoot but aggravated by shoe pressure strongly suggests Haglund's deformity or bursitis 1
• Lateral ankle ligament injury (calcaneofibular ligament sprain) should be considered if there's a history of ankle inversion trauma 1
• Calcaneal stress fracture presents with pain on medial-to-lateral compression of the heel bone (squeeze test) and lateral calcaneal wall tenderness 1

The dorsiflexion component of your pain suggests involvement of structures that are tensioned during this movement, particularly the Achilles tendon-calcaneal complex and associated bursae.

Initial Conservative Treatment (First 6-8 Weeks)

Implement all of the following simultaneously:

• Open-backed shoes to eliminate pressure on the posterior-lateral prominence—this is the single most important footwear modification 1
• Orthotic devices and accommodative padding to redistribute pressure away from the inflamed area 1
• NSAIDs (oral or topical) for pain relief and inflammation reduction 1
• Activity modification: Reduce aggravating activities while avoiding complete rest to prevent muscle weakness 1
• Ice therapy applied through a wet towel for 10-minute periods to reduce pain and inflammation 2

Most patients (89-90%) respond to conservative treatment within 6-8 weeks when appropriate measures are implemented 1, 3

Treatment Algorithm for Persistent Pain (After 6-8 Weeks)

If no improvement occurs within 6-8 weeks:

• Refer to a podiatric foot and ankle surgeon for evaluation 1
• Continue initial treatments while adding immobilization with a cast or fixed-ankle walker-type device for more severe or refractory cases 1
• Advanced imaging (MRI without contrast or CT without contrast) if diagnosis remains unclear or to rule out stress fracture 1

Critical Pitfalls to Avoid

• Never inject corticosteroids near the Achilles tendon insertion—this dramatically increases rupture risk 1, 2
• Do not overlook stress fractures in patients with increased walking activity or change to harder surfaces, even with negative initial radiographs 1
• Reexamine patients 3-5 days post-injury if trauma is involved 1

Red Flags Requiring Immediate Evaluation

Seek urgent assessment if:

• Pain becomes constant at rest without mechanical explanation 1
• Numbness, burning, or tingling suggesting nerve involvement develops 1
• Increasing swelling or redness appears 2

Expected Timeline

For Haglund's deformity with bursitis specifically, symptoms typically improve with shoe modification and padding as first-line interventions, with most patients responding within 6-8 weeks 1