What imaging should be done for heel pain when standing on tiptoes (toes)?

From the Guidelines

For pain in the back of the foot, I recommend starting with a plain X-ray to evaluate for bone abnormalities, as it is usually the first imaging study in evaluating patients with chronic foot pain, with overall sensitivities ranging from 80% to 100% and specificities ranging from 97% to 98% for radiographs in the diagnosis of calcaneonavicular coalitions 1. The choice of imaging depends on the specific symptoms and clinical presentation, and X-rays are useful for identifying fractures, arthritis, or heel spurs. If necessary, an MRI can be used for soft tissue assessment, as it provides detailed images of tendons, ligaments, and soft tissues that could reveal conditions like Achilles tendinopathy or posterior tibial tendon dysfunction. Some key points to consider when evaluating foot pain include:

• The location and severity of the pain
• The presence of any underlying medical conditions, such as diabetes or arthritis
• The patient's age and activity level
• The presence of any trauma or injury to the foot Before pursuing imaging, try conservative measures like rest, ice, compression, elevation, and over-the-counter pain medications. If pain persists despite these measures, especially if you have difficulty standing on tiptoes, consult a healthcare provider who can perform a proper examination and determine the most appropriate imaging based on your specific condition. It's also important to note that ultrasound can be helpful in visualizing the plantar fascia and Achilles tendon, and can be used to guide injections or other treatments. However, the initial imaging study should be a plain X-ray, as recommended by the American College of Radiology 1. In some cases, other imaging modalities such as CT or MRI may be necessary to further evaluate the foot pain, but these should be used judiciously and only when necessary, as they may not provide additional useful information in all cases 1.

From the Research

Imaging for Foot Pain

To determine the appropriate imaging for foot pain, particularly in the back of the patient's foot, it is essential to consider the possible causes of the pain.

• The patient's symptoms, such as pain in the back of the foot, could be related to the Achilles tendon, which is a common source of foot and ankle pain 2.
• Imaging studies, such as MRI, can be useful in evaluating the Achilles tendon and surrounding structures 3, 4, 5, 6.
• MRI can help diagnose various conditions affecting the Achilles tendon, including tendinopathy, partial and full-thickness tears, and other disorders 3, 4, 5, 6.

Specific Imaging Modalities

• MRI is a sensitive imaging modality for detecting Achilles tendon pathology, including tendinosis, paratenonitis, and tendon tears 3, 4, 5, 6.
• Ultrasound can also be used to evaluate the Achilles tendon, but MRI is superior for detecting partial tears and postoperative assessment 3.
• The use of fat suppression sequences and contrast-enhanced MRI can help detect focal lesions and assess tendon healing 3, 5, 6.

Clinical Correlation

• Imaging findings should be correlated with clinical symptoms and physical examination results to determine the appropriate diagnosis and treatment plan 2, 3, 4, 5, 6.
• A thorough evaluation, including history, physical examination, and imaging, is necessary to determine the cause of foot pain and develop an effective treatment plan 2.