What causes heel lumps and how are they treated?

What Causes Heel Lumps and How Are They Treated?

Heel lumps are most commonly caused by Haglund's deformity (a bony prominence on the posterior superior calcaneus), retrocalcaneal bursitis, or soft tissue swelling from insertional Achilles tendinopathy, and should be treated initially with open-backed shoes, orthotic padding, NSAIDs, and physical therapy, with surgical referral reserved for cases failing 6-8 weeks of conservative management. 1

Primary Causes of Heel Lumps

Haglund's Deformity with Retrocalcaneal Bursitis

• This is the most common structural cause of a visible heel lump, presenting as a prominent posterior superior calcaneus that causes inflammation of the overlying bursa 1
• The bony prominence is typically visible on radiographs and creates both posterior and lateral heel pain 1
• Pain is characteristically relieved when walking barefoot but worsened by shoes, which is a key diagnostic clue 1, 2

Insertional Achilles Tendinopathy

• Produces pain and swelling at the tendon insertion site on the calcaneus 1
• Can present with a palpable lump or thickening at the Achilles insertion 3
• May coexist with Haglund's deformity and retrocalcaneal bursitis as part of "Haglund syndrome" 3

Other Causes to Consider

• Calcaneal stress fracture: Progressive pain with activity, positive calcaneal squeeze test (medial-to-lateral compression), tenderness on the lateral calcaneal wall 1
• Acute calcaneal fracture: History of fall from height, diffuse rearfoot pain, requires radiographic confirmation 1
• Soft tissue masses: Plantar fibromatosis (benign but locally aggressive), tumors (rare), or infections requiring subspecialist evaluation 1, 3

Physical Examination Approach

Key Examination Maneuvers

• Palpate specific anatomic landmarks: Achilles insertion, posterior superior calcaneus, lateral calcaneal wall, and retrocalcaneal bursa 1
• Calcaneal compression test: Squeeze the calcaneus medially to laterally—pain suggests stress fracture 1
• Assess swelling pattern: Rapid onset suggests acute injury or fracture; localized posterior swelling indicates Haglund's deformity or bursitis 1
• Always reexamine 3-5 days post-injury if trauma is involved, as excessive initial swelling can limit accurate assessment 1

Treatment Algorithm

Initial Conservative Management (First 6-8 Weeks)

For Haglund's Deformity with Bursitis:

• Open-backed shoes to eliminate pressure on the posterior heel 1, 2
• Orthoses and accommodative padding to redistribute pressure 1, 2
• NSAIDs (oral or topical) for pain and inflammation 1, 2
• Ice therapy applied through a wet towel for 10-minute periods 2
• Physical therapy including stretching exercises for the Achilles tendon and plantar fascia 1, 2
• Corticosteroid injections may be considered for the bursa, but absolutely avoid injecting near the Achilles tendon due to rupture risk 1, 2

For Insertional Achilles Tendinopathy:

• Open-backed shoes to reduce pressure 1
• Heel lifts or orthoses to decrease tension on the insertion 1, 2
• NSAIDs and decreased activity 1
• Stretching and eccentric exercises for the Achilles tendon 2
• Weight loss if indicated to reduce mechanical stress 1, 2

For Suspected Stress Fracture:

• Protect and immobilize the foot with a cast or fixed-ankle walker 2
• Initial radiographs, but recognize that symptoms often precede radiographic findings 1
• Technetium bone scan or MRI if radiographs are negative but clinical suspicion remains high 1

When Conservative Treatment Fails

• Refer to podiatric foot and ankle surgeon if no improvement after 6-8 weeks of appropriate conservative treatment 1, 2
• Consider advanced imaging (MRI or ultrasound) to confirm diagnosis and rule out other pathology 2
• Surgical options include excision of the bony prominence, bursa debridement, or Achilles tendon repair/reconstruction 3
• Extracorporeal shock wave therapy may be considered as a non-invasive option for persistent pain 2

Critical Pitfalls to Avoid

• Never inject corticosteroids near the Achilles tendon—this significantly increases rupture risk 1, 2
• Don't overlook stress fractures—patients often report increased walking activity before symptom onset, and initial radiographs may be falsely negative 1
• Avoid complete immobilization unless absolutely necessary, as this leads to muscular atrophy and deconditioning 2
• Consider systemic causes (arthritides, infections, tumors, vascular compromise) if pain is bilateral, involves other joints, or fails to respond to standard treatment 1, 4
• Reexamine 3-5 days post-injury rather than relying solely on initial assessment when swelling limits examination 1

Red Flags Requiring Immediate Evaluation

• Constant pain at rest or pain that awakens the patient from sleep 2
• Numbness, increasing swelling, or redness suggesting infection or nerve compression 2
• Inability to bear weight immediately after injury or inability to ambulate 4 steps (Ottawa Ankle Rules criteria) 1
• Suspected infection or tumor—requires immediate subspecialist referral with appropriate diagnostic testing including MRI, electromyography, and nerve conduction studies 1