Posterior Heel Pain: Differential Diagnosis and Evaluation
The most likely causes of swelling, heat, and pain in the back of the heel are insertional Achilles tendonitis, retrocalcaneal bursitis (often associated with Haglund's deformity), or acute Achilles tendon injury—all of which present with posterior heel inflammation and localized tenderness. 1
Primary Diagnostic Considerations
The location of symptoms at the posterior heel narrows the differential significantly:
- Insertional Achilles tendonitis produces pain directly at the tendon insertion site on the calcaneus, with tenderness on palpation of the Achilles insertion 1
- Haglund's deformity with retrocalcaneal bursitis causes posterior and lateral heel pain, typically with a prominent posterior superior calcaneus that inflames the overlying bursa 1
- Acute Achilles tendon pathology (partial tear or severe tendinopathy) presents with swelling, warmth, and pain localized to the tendon itself 2
The presence of heat and swelling suggests acute inflammation, making these conditions more likely than chronic mechanical causes like plantar fasciitis (which causes plantar, not posterior, heel pain) 3, 4.
Critical Physical Examination Findings
To differentiate between these conditions, perform targeted palpation:
- Point tenderness at the Achilles insertion indicates insertional tendonitis 1
- Tenderness over the posterior superior calcaneus with a palpable bony prominence suggests Haglund's deformity 1
- Pain with passive ankle dorsiflexion can reproduce symptoms in Achilles pathology 3
- Calcaneal compression test (squeezing the calcaneus medially to laterally) helps identify stress fracture if pain is diffuse rather than localized 1
Less Common but Important Considerations
While mechanical causes dominate, don't overlook:
- Calcaneal stress fracture presents with progressively worsening pain following increased activity, with positive calcaneal squeeze test 1
- Acute calcaneal fracture requires history of trauma (fall from height) and causes diffuse rearfoot pain 1
- Septic bursitis or osteomyelitis is rare but critical to identify—look for systemic signs, fever, or risk factors for infection 1
Imaging Strategy
- Initial radiographs are indicated 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
- For suspected stress fracture with negative initial radiographs, technetium bone scanning or MRI is needed, as symptoms often precede radiographic findings 1
- If pain persists beyond 1 week with negative radiographs, MRI without contrast or CT without contrast are equivalent alternatives 1
Common Pitfalls to Avoid
- Don't examine too early: Always reexamine 3-5 days post-injury if initial examination is limited by excessive swelling and pain within the first 48 hours 1
- Don't miss stress fractures: Patients often report increased walking activity before symptom onset, and initial radiographs may be negative 1
- Never inject corticosteroids near the Achilles tendon due to high risk of tendon rupture 1, 5
- Don't assume bilateral symptoms are mechanical: Consider inflammatory arthritis or systemic illness when heel pain is bilateral or accompanied by pain in other joints 1, 4
Initial Management Approach
Once you've identified the specific diagnosis:
- For insertional Achilles tendonitis: Open-backed shoes to reduce pressure, heel lifts or orthoses, NSAIDs, decreased activity, stretching exercises, and weight loss if indicated 1
- For Haglund's deformity with bursitis: Open-backed shoes, orthoses with accommodative padding, NSAIDs, corticosteroid injections (avoiding the Achilles tendon), and physical therapy 1
- For suspected stress fracture: Protect and immobilize the foot, obtain imaging (X-ray initially, bone scan if needed) 1
When to Refer
Refer to a podiatric foot and ankle surgeon if: