What are the possible diagnoses for an 80‑year‑old woman with several months of heel pain that is worst after rest (especially in the morning), worsens with weight‑bearing and movement, improves briefly with stretching, and is absent when not walking?

Differential Diagnosis for Heel Pain in an 80-Year-Old Woman

Plantar fasciitis is the most likely diagnosis given the classic presentation of heel pain that is worst with the first steps in the morning after rest, improves temporarily with stretching, and worsens with weight-bearing activity. 1, 2

Most Likely Diagnosis: Plantar Fasciitis

The clinical presentation is pathognomonic for plantar fasciitis:

• Morning pain with first weight-bearing steps after rest is the hallmark symptom that distinguishes plantar fasciitis from other causes of heel pain 2, 3, 4
• Pain that temporarily improves with stretching but returns with continued activity is characteristic of plantar fascia pathology 3, 4
• Absence of pain when not moving (non-weight-bearing) further supports a mechanical etiology rather than inflammatory or neuropathic causes 2, 5

Key Physical Examination Finding to Confirm

• Tenderness at the medial calcaneal tubercle on palpation is the diagnostic finding that confirms plantar fasciitis 1, 4
• Pain can be elicited by passive dorsiflexion of the ankle and first toe, which stretches the plantar fascia 3

Alternative Diagnoses to Consider

Calcaneal Stress Fracture

• Presents with progressively worsening pain following increased activity or change to harder walking surface, not intermittent pain that improves with stretching 1, 2
• Pain on compression of the lateral calcaneus wall with possible swelling and warmth distinguishes this from plantar fasciitis 1
• Less likely given the several-month duration without progression and the relief with stretching 2

Heel Pad Syndrome

• Characterized by deep, bruise-like pain in the middle of the heel rather than medial plantar pain 2, 5
• More common in older patients but lacks the characteristic morning pain pattern 6

Tarsal Tunnel Syndrome or Nerve Entrapment

• Would present with burning, tingling, or numbness accompanying the pain, not pure mechanical pain 1, 2
• Requires EMG and nerve conduction studies for confirmation 1

Achilles Tendinopathy

• Causes posterior heel pain proximal to the tendon insertion, not plantar heel pain 7
• Would have palpable nodules and thickening on examination 7

Diagnostic Workup

Initial Imaging

• Radiographs are the first-line imaging modality for all heel pain to identify fractures, spurs, and Haglund deformity 8, 1
• The American College of Radiology recommends conventional radiography as the initial study, as it is usually sufficient to distinguish among different causes of chronic foot pain 8
• MRI or ultrasound should be reserved for cases where the diagnosis remains unclear after clinical examination and plain films 7, 1

When Advanced Imaging Is Needed

• If radiographs are negative but stress fracture is suspected, bone scan can confirm the diagnosis 1
• MRI findings of increased plantar fascia thickness and abnormal tissue signal confirm plantar fasciitis in recalcitrant cases 3

Treatment Algorithm

Initial Conservative Management (0-6 Weeks)

Begin immediately with the following regimen 1, 9:

• Regular calf and plantar fascia stretching exercises 3-5 times daily 9
• Ice massage through a wet towel for 10-minute periods 9
• Over-the-counter arch supports or heel cushions 9
• NSAIDs (such as naproxen) for pain relief 9
• Activity modification and avoiding barefoot walking 9
• Proper footwear with adequate arch support 9

If No Improvement After 6 Weeks

Refer to a podiatric foot and ankle surgeon while continuing initial treatments and adding 1, 9:

• Customized orthotic devices (moderate benefit in 7-12 weeks) 9
• Night splinting 1, 9
• Limited corticosteroid injections 1, 9
• Consider casting or fixed-ankle walker device 1, 9

If No Improvement After 2-3 Months

• Continue conservative measures 9
• Consider extracorporeal shock wave therapy 9
• Surgical options (plantar fasciotomy) for chronic recalcitrant cases lasting 6 months or longer 3, 4

Critical Caveats

• Avoid corticosteroid injections near the Achilles tendon due to risk of rupture 9
• Corticosteroid injections may temporarily relieve pain but increase risk of plantar fascia rupture and fat pad atrophy 4
• Approximately 90% of patients respond to conservative treatment within 3-6 months, so patience with non-operative management is warranted 7, 3, 4
• In an 80-year-old woman, consider heel pad atrophy as a contributing factor, especially if she is obese, though this typically presents with diffuse plantar heel pain rather than the classic morning pain pattern 6