What is the differential diagnosis for a 51-year-old male with heel pain for 4 weeks?

Differential Diagnosis for Heel Pain in a 51-Year-Old Male (4 Weeks Duration)

Most Likely Diagnosis

Plantar fasciitis is the most probable diagnosis, presenting as medial plantar heel pain that is worst with the first weight-bearing steps in the morning and after periods of rest. 1, 2, 3

Primary Differential Diagnoses by Anatomic Location

Plantar (Bottom) Heel Pain

• Plantar fasciitis: Medial plantar heel pain, sharp with first steps after rest, point tenderness at medial tubercle of calcaneus 1, 2, 3, 4
• Calcaneal stress fracture: Progressively worsening pain following increased activity or change to harder walking surface; positive calcaneal squeeze test (compression from medial to lateral) 1, 2, 3
• Heel pad syndrome: Deep, bruise-like pain in the middle of the heel, diffuse tenderness 2, 3
• Nerve entrapment/neuroma: Pain accompanied by burning, tingling, or numbness 2, 3

Posterior Heel Pain

• Insertional Achilles tendinopathy: Pain at the Achilles tendon insertion site on the posterior calcaneus 1, 2, 3
• Haglund deformity with retrocalcaneal bursitis: Posterior and lateral heel pain with prominent posterior superior calcaneus visible on exam and radiographs 1, 2, 3

Lateral Heel Pain

• Calcaneofibular ligament sprain: History of inversion trauma, pain with dorsiflexion 1
• Sinus tarsi syndrome: Lateral midfoot heel pain with feeling of instability, particularly with increased activity or walking on uneven surfaces 2, 3

Medial Heel Pain

• Tarsal tunnel syndrome: Medial midfoot heel pain with prolonged weight bearing, burning or tingling suggesting nerve compression 2, 3

Critical Physical Examination Findings

Location-Specific Palpation

• Medial tubercle of calcaneus: Point tenderness confirms plantar fasciitis 1, 4
• Achilles insertion site: Tenderness indicates insertional tendinopathy 1
• Posterior superior calcaneus: Prominence and tenderness suggest Haglund deformity 1
• Lateral calcaneal wall (slightly posterior to subtalar joint): Tenderness indicates stress fracture 1

Provocative Tests

• Calcaneal squeeze test: Compress calcaneus from medial to lateral; pain suggests stress fracture 1
• First-step pain: Characteristic of plantar fasciitis 2, 4

Imaging Recommendations

Initial Imaging

Weight-bearing radiographs of the foot should be obtained first, with sensitivity of 85% and specificity of 95% for plantar fasciitis. 5, 6

• Radiographs are typically insensitive for fasciitis but useful to exclude other causes and identify calcaneal spurs 5
• For suspected stress fracture with negative radiographs, symptoms often precede radiographic findings 1

Advanced Imaging (If Initial Radiographs Negative and Pain Persists >1 Week)

• MRI without contrast or CT without contrast are equivalent alternatives for further evaluation 1
• Technetium bone scanning for suspected stress fracture with negative initial radiographs 1
• Ultrasound has 80% sensitivity and 88% specificity for plantar fasciitis compared to MRI 6

Red Flags Requiring Urgent Evaluation

• Constant rest pain (not mechanical) 6
• Numbness or progressive neurological symptoms 6
• Increased swelling or redness (rule out infection) 6
• History of trauma from height (acute calcaneal fracture) 1
• Bilateral symptoms with pain in other joints (consider inflammatory arthritis) 1

Common Pitfalls to Avoid

Overlooking Stress Fractures

• Patients often report increased walking activity before symptom onset 1
• Radiographs may initially be negative; maintain high clinical suspicion with positive squeeze test 1
• Tenderness localizes to lateral calcaneal wall, not plantar surface 1

Misdiagnosing Nerve Entrapment

• Burning, tingling, or numbness distinguishes nerve pathology from mechanical causes 2, 3
• Tarsal tunnel syndrome causes medial heel pain, not plantar 2, 3

Timing of Re-examination

• Always re-examine 3-5 days post-injury if trauma history exists, as excessive swelling can limit initial examination within 48 hours 1

Age-Specific Considerations

At 51 years old, this patient is in the typical age range for plantar fasciitis affecting sedentary individuals 4. Sever disease (calcaneal apophysitis) is excluded as it occurs only in children and adolescents. 1, 2