What are the differential diagnoses and treatment options for a patient presenting with heel pain?

Differential Diagnoses for Heel Pain

Location-Based Diagnostic Approach

The anatomic location of heel pain is the most critical factor in narrowing your differential diagnosis, with plantar heel pain most commonly indicating plantar fasciitis, posterior pain suggesting Achilles tendinopathy, and lateral pain pointing toward Haglund's deformity or lateral ligament injury. 1

Plantar (Bottom) Heel Pain

• Plantar fasciitis is the most common cause, characterized by sharp pain with first steps in the morning or after prolonged sitting, with tenderness at the calcaneal tuberosity that worsens with passive toe dorsiflexion 2, 3
• Calcaneal stress fracture presents with progressively worsening pain following increased walking activity or change to harder surfaces, with positive calcaneal squeeze test (medial-to-lateral compression) 1, 4
• Nerve entrapment (tarsal tunnel syndrome) causes burning, tingling, or numbness accompanying the heel pain, distinguishing it from mechanical causes 1, 4
• Heel pad syndrome produces deep, bruise-like pain in the middle of the heel, particularly in older and obese patients 2, 3

Posterior Heel Pain

• Achilles tendinopathy (insertional or non-insertional) causes pain at or near the tendon insertion site 1, 5
• Haglund's deformity with retrocalcaneal bursitis presents with posterior and lateral heel pain, associated with a prominent posterior superior calcaneus visible on radiographs 1, 5
• Sever disease (calcaneal apophysitis) is the most common cause in children and adolescents 1

Lateral Heel Pain

• Lateral ankle ligament injury (calcaneofibular ligament sprain) occurs with inversion trauma and pain with dorsiflexion 1
• Lateral process fracture of 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 in the space between calcaneus, talus, and subtalar joints 2

Diffuse Heel Pain

• Acute calcaneal fracture from fall onto heel from height causes poorly localized rearfoot pain, requiring history of trauma and radiographic confirmation 1, 4

Critical Physical Examination Findings

• Point tenderness location is essential: palpate the Achilles insertion, lateral malleolus, posterior superior calcaneus, lateral calcaneal wall, and calcaneofibular ligament course 1
• Calcaneal compression test (medial-to-lateral squeeze) strongly suggests stress fracture when positive 1, 4
• Timing of examination matters: always reexamine 3-5 days post-injury, as excessive swelling within 48 hours can limit initial assessment 1
• Rapid onset swelling suggests acute ligamentous injury or fracture, with lateral gutter swelling indicating lateral ligament involvement 1

Red Flags Requiring Urgent Evaluation

• Constant pain at rest or progressively worsening pain without mechanical explanation suggests tumor 4
• Fever, increasing swelling, or redness raises concern for infection (soft tissue or osteomyelitis) 1, 4
• Bilateral heel pain with other joint involvement suggests systemic inflammatory arthritis 1, 3
• Neurologic symptoms (burning, tingling, numbness) require subspecialist referral for electromyography, nerve conduction studies, and MRI 1, 5

Imaging Algorithm

• Initial radiographs are indicated if patient meets Ottawa Ankle Rules: inability to bear weight immediately after injury, point tenderness over malleoli/talus/calcaneus, or inability to ambulate 4 steps 1
• If radiographs negative but pain persists >1 week: MRI without contrast or CT without contrast are equivalent alternatives 1, 4
• For suspected stress fracture with negative radiographs: technetium bone scanning is recommended, as symptoms often precede radiographic findings 1, 4

Treatment Framework by Diagnosis

For Plantar Fasciitis

• Initial 6-week treatment period includes: calf muscle and plantar fascia stretching exercises (3-5 times daily), over-the-counter heel cushions and arch supports, activity modification, proper footwear with adequate arch support, and NSAIDs for pain 5
• If no improvement after 6 weeks: add padding and strapping, weight management, and customized orthotic devices 5
• If no improvement after 2-3 months: consider cast immobilization, extracorporeal shock wave therapy, or surgical plantar fasciotomy 5
• Most patients respond within 6-8 weeks to conservative treatment 5

For Achilles Tendinopathy

• Open-backed shoes to reduce pressure, heel lifts or orthoses, NSAIDs, decreased activity, stretching exercises, and weight loss if indicated 5
• Eccentric exercises have proven beneficial for tendinopathies 5

For Haglund's Deformity with Bursitis

• Open-backed shoes, orthoses with accommodative padding, NSAIDs, physical therapy, and corticosteroid injections (avoiding the Achilles tendon) 5

For Calcaneal Stress Fracture

• Protect and immobilize the foot with cast or fixed-ankle walker-type device 5
• Avoid complete immobilization to prevent muscular atrophy 5

Critical Pitfalls to Avoid

• Never inject corticosteroids near the Achilles tendon due to high risk of tendon rupture 5
• Do not overlook stress fractures: patients often report increased walking activity before symptom onset, and radiographs may initially be negative 1
• Avoid complete rest: activity modification is preferred over complete immobilization to prevent muscle weakness 5
• Corticosteroid injections provide only temporary relief (short-term benefit) and should be used judiciously 5, 6

Referral Indications

• No improvement after 6-8 weeks of appropriate conservative treatment 5
• Neurologic heel pain requires immediate subspecialist referral 1, 5
• Need for advanced imaging or consideration of surgical intervention 5