What is the differential diagnosis of left heel pain?

Differential Diagnosis of Left Heel Pain

The differential diagnosis of left heel pain is determined primarily by the anatomic location of pain: plantar fasciitis is most common for medial plantar heel pain, Achilles tendinopathy for posterior heel pain, calcaneal stress fracture for lateral wall tenderness, and lateral ankle ligament injury or sinus tarsi syndrome for lateral heel pain. 1, 2

Anatomic Location-Based Differential

Plantar (Bottom) Heel Pain

• Plantar fasciitis is the most common diagnosis overall, characterized by medial plantar heel pain that is worst with first weight-bearing steps after rest or prolonged sitting, with tenderness at the calcaneal tuberosity 3, 4
• Calcaneal stress fracture presents with progressively worsening pain following increased walking activity or change to a harder surface, with positive calcaneal squeeze test (pain on medial-to-lateral compression) 1, 2
• Nerve entrapment or neuroma causes pain accompanied by burning, tingling, or numbness rather than purely mechanical pain 2, 3
• Heel pad syndrome produces deep, bruise-like pain in the middle of the heel, particularly in older and obese patients 3, 5
• Plantar warts can cause localized plantar pain 3

Posterior Heel Pain

• Achilles tendinopathy (both insertional and non-insertional) produces pain at or near the tendon insertion site on the posterior calcaneus 1, 3
• Haglund's deformity with retrocalcaneal bursitis presents with posterior and lateral heel pain, associated with a prominent posterior superior calcaneus visible on radiographs, typically worsened by shoe pressure 1, 3
• Sever disease (calcaneal apophysitis) is the most common cause of heel pain in children and adolescents 1

Lateral Heel Pain

• Lateral ankle ligament injury (calcaneofibular ligament sprain) occurs particularly with inversion trauma and pain with dorsiflexion 1
• Lateral process fracture of the talus ("snowboarder's fracture") causes lateral and posterior ankle pain with antalgic gait following inversion trauma 1
• Sinus tarsi syndrome manifests as lateral midfoot heel pain with a feeling of instability, particularly with increased activity or walking on uneven surfaces 3, 4

Central/Diffuse Heel Pain

• Calcaneal stress fracture with tenderness localizing to the lateral calcaneal wall, slightly posterior to the subtalar joint facet 1, 2
• Acute calcaneal fracture from fall onto heel from height causes diffuse rearfoot pain, poorly localized with intra-articular fractures 1, 2

Medial Midfoot Heel Pain

• Tarsal tunnel syndrome from compression of the posterior tibial nerve causes medial midfoot heel pain, particularly with prolonged weight bearing, often accompanied by burning, tingling, or numbness 3, 4

Key Physical Examination Findings to Differentiate

• Point tenderness location is critical: palpate the Achilles insertion, lateral malleolus, posterior superior calcaneus, lateral calcaneal wall, and over the calcaneofibular ligament course 1
• Calcaneal compression test (squeezing calcaneus medial-to-lateral) suggests stress fracture if positive 1, 2
• Rapid onset of swelling suggests acute ligamentous injury or fracture, with lateral gutter swelling indicating lateral ligament involvement 1
• Pain with passive dorsiflexion of toes increases suspicion for plantar fasciitis 5
• Burning, tingling, or numbness distinguishes neurologic causes from mechanical etiologies 2, 3

Rare but Serious Causes Requiring Consideration

• Arthritides should be considered in patients with bilateral symptoms, pain in other joints, or known inflammatory arthritis conditions 1, 5
• Infections (soft tissue or osteomyelitis) rarely cause heel pain but require proper diagnostic testing and consultation when suspected 1, 2
• Tumors (malignant and benign) are rare but require appropriate referral, particularly if pain is constant at rest or progressively worsening without mechanical explanation 1, 2
• Vascular compromise can result in heel pain and necessitates proper diagnostic evaluation 1

Imaging Recommendations

• Initial weight-bearing radiographs should be obtained 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
• MRI without contrast or CT without contrast are equivalent alternatives if radiographs are negative but pain persists >1 week 1, 2
• Technetium bone scanning is recommended for suspected stress fracture with negative initial radiographs, as symptoms often occur before the fracture is radiographically visible 1, 2

Critical Pitfalls to Avoid

• Do not rely solely on initial radiographs to exclude stress fractures, as sensitivity is only 12-56% 6
• Always reexamine 3-5 days post-injury if initial examination is limited, as excessive swelling and pain can obscure findings within the first 48 hours 1
• Avoid corticosteroid injections near the Achilles tendon due to risk of tendon rupture 1
• Consider systemic causes when symptoms are bilateral, prolonged, or unexplained by mechanical factors 1, 5