What causes tingling in the heels?

Tingling in the Heels: Causes and Diagnostic Approach

Tingling in the heels is most commonly caused by diabetic peripheral neuropathy, which characteristically begins distally in the toes and forefoot with burning, tingling, and painful dysesthesias that worsen at night. 1

Primary Causes of Heel Tingling

Diabetic Peripheral Neuropathy (Most Common)

• Diabetes is the most common cause of peripheral neuropathy in adults, affecting up to 50% of diabetic patients, and should be screened for even in young adults presenting with bilateral tingling. 1
• Small fiber involvement produces burning sensations, tingling, and painful dysesthesias in the feet and toes, characteristically worse at night. 1
• Symptoms follow a typical distal-to-proximal pattern, starting in the toes before progressing proximally. 2, 1

Nerve Entrapment or Compression

• Tarsal tunnel syndrome causes medial heel pain with tingling, burning, or numbness due to compression of the posterior tibial nerve as it courses through the flexor retinaculum. 3, 4
• More proximal nerve impingement syndromes (lumbar radiculopathy at L5-S1) can cause tingling radiating from the heel through the posterior leg. 5
• Neurologic heel pain from irritation or entrapment of nerves innervating the heel requires subspecialist referral for electromyography and nerve conduction studies. 2, 5

Vitamin and Metabolic Deficiencies

• Vitamin B12 deficiency can cause sensory neuropathy with tingling in the feet. 2, 1
• Hypothyroidism can produce neuropathy with sensory symptoms. 1
• Renal disease may contribute to peripheral neuropathy. 2

Other Systemic Causes

• Heavy metal poisoning, alcohol abuse, neurotoxic medications, chronic inflammatory demyelinating neuropathy, inherited neuropathies, and vasculitis should be considered in atypical presentations. 2

Diagnostic Algorithm

Initial Clinical Assessment

• Determine duration, pattern, and specific characteristics of symptoms (burning, sharp pain, purely sensory changes). 1
• Screen for diabetes history, alcohol use, vitamin deficiencies, family history of neuropathy, medications, and autoimmune conditions. 1
• A bilateral presentation suggests systemic disease rather than focal compression. 1

Physical Examination

Perform a comprehensive neurological foot examination: 1

Small fiber function:

• Pinprick sensation testing in both feet, particularly the toes. 2, 1
• Temperature sensation testing. 1

Large fiber function:

• Vibration testing with a 128-Hz tuning fork, starting distally at the dorsal aspect of the hallux and moving proximally. 2, 1
• Assessment of ankle reflexes. 2, 1

Protective sensation:

• 10-g monofilament testing at multiple plantar sites. 2, 1

Laboratory Workup

Order the following tests to identify treatable causes: 1

• Hemoglobin A1c or fasting glucose (most important—diabetes is the leading cause)
• Vitamin B12 level
• Thyroid function tests
• Complete blood count
• Comprehensive metabolic panel (renal function and electrolytes)

Electrodiagnostic Testing

• Electrophysiological testing (EMG/nerve conduction studies) is rarely needed except when clinical features are atypical or diagnosis remains unclear after initial workup. 2, 1
• If neurologic heel pain is suspected, immediate referral for EMG, nerve conduction velocity studies, and MRI is essential. 2, 5

Management Based on Findings

If Laboratory Abnormalities Are Found

• Treat underlying conditions: optimize diabetes management, vitamin B12 supplementation, thyroid replacement. 1
• Tight glycemic control is the only strategy convincingly shown to prevent or delay diabetic peripheral neuropathy development. 2

If Symptoms Persist Beyond 6-8 Weeks

• Refer to neurology for electrodiagnostic studies. 1
• Consider podiatry referral for custom orthotics and biomechanical assessment. 1

Symptomatic Treatment

• Assess and treat patients to reduce pain related to neuropathy and improve quality of life. 2

Critical Pitfalls to Avoid

• Never assume symptoms are purely mechanical without screening for diabetes, even in young adults. 1
• Bilateral presentation demands consideration of systemic disease rather than focal compression. 1
• Do not order extensive imaging initially—this is a clinical diagnosis and imaging is low-yield unless red flags are present (trauma, inability to bear weight, point tenderness over bone). 1
• When symptoms are bilateral, involve other joints, or are unexplained by mechanical causes, consider systemic causes including arthritides, infections, tumors, and vascular compromise. 2, 5