What are the differential diagnoses for heel pain?

Differential Diagnoses for Heel Pain

Anatomic Location-Based Approach

The anatomic location of heel pain is the most critical factor in narrowing the differential diagnosis, with plantar fasciitis being the most common cause overall, followed by insertional Achilles tendinopathy for posterior heel pain. 1

Plantar (Bottom) Heel Pain

• Plantar fasciitis is the most common cause of heel pain in adults, presenting with sharp medial plantar heel pain that is worst with the first steps in the morning or after prolonged sitting 2, 3

• Point tenderness localizes to the medial calcaneal tuberosity and is worsened by passive dorsiflexion of the toes 2, 4

• Risk factors include obesity, excessive foot pronation, excessive running, and prolonged standing 2

• Calcaneal stress fracture presents with progressively worsening pain following increased activity or change to a harder walking surface 1, 3

• The calcaneal squeeze test (compressing the calcaneus from medial to lateral) is highly suspicious for stress fracture 1

• Tenderness localizes to the lateral calcaneal wall, slightly posterior to the subtalar joint facet 1

• Critical pitfall: Symptoms often precede radiographic findings (radiographs only 12-56% sensitive initially), requiring technetium bone scanning or MRI for early diagnosis 1, 5

• Heel pad syndrome causes deep, bruise-like diffuse plantar heel pain, particularly in older and obese patients 4, 3

• Tarsal tunnel syndrome presents with plantar heel pain accompanied by burning, tingling, or numbness due to posterior tibial nerve compression 1, 4, 3

Posterior Heel Pain

• Insertional Achilles tendinopathy is the most likely diagnosis for posterior-superior heel pain with tenderness at the Achilles insertion site 6

• Pain is worsened by increased activity and pressure from footwear, but relieved when walking barefoot (differentiating it from plantar fasciitis) 6

• Physical examination reveals central or global tenderness at the Achilles insertion with palpable medial and lateral prominence 6

• Weight-bearing radiographs commonly show spurring or erosion at the Achilles insertion 6

• Haglund's deformity with retrocalcaneal bursitis presents with posterior and lateral heel pain, more frequent in younger adults (20-30 years) 1, 6

• A prominent posterior-superior calcaneus is visible on radiographs and palpable on examination 1, 6

• Lateral tenderness and visible posterior-lateral calcaneal prominence help differentiate from insertional tendinopathy 6

• Sever disease (calcaneal apophysitis) is the most common cause of heel pain in adolescents and children 1

Lateral Heel Pain

• Lateral ankle ligament injury (calcaneofibular ligament sprain) is common with inversion trauma and pain with dorsiflexion 1

• Lateral gutter swelling indicates lateral ligament involvement 1

• Lateral process fracture of the 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 the calcaneus, talus, and subtalar joints 1, 3

Key Physical Examination Maneuvers

• Point tenderness location is critical: palpate the Achilles insertion, lateral malleolus, posterior superior calcaneus, lateral calcaneal wall, and over the calcaneofibular ligament course 1
• Calcaneal compression test (medial-to-lateral squeeze) suggests stress fracture 1
• Passive ankle/first toe dorsiflexion elicits discomfort in plantar fasciitis 2
• Reexamination timing: Always reexamine 3-5 days post-injury, as excessive swelling and pain can limit the initial examination within 48 hours 1

Imaging Algorithm

• 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
• Weight-bearing radiographs of the foot have 85% sensitivity and 95% specificity for plantar fasciitis, though typically insensitive for fasciitis itself but useful to exclude other causes 1
• If radiographs are negative but pain persists >1 week: MRI without contrast or CT without contrast are equivalent alternatives 1, 6
• For suspected stress fracture with negative initial radiographs: Technetium bone scanning is recommended 1

Less Common but Important Causes

• Acute calcaneal fracture from fall onto heel from height causes diffuse rearfoot pain, poorly localized with intra-articular fractures 1
• Arthritides should be considered in patients with bilateral symptoms, pain in other joints, or known inflammatory arthritis conditions 1, 4
• Infections (soft tissue and bone osteomyelitis) rarely cause heel pain but require proper diagnostic testing and consultation when suspected 1
• Tumors (malignant and benign) are rare causes requiring appropriate referral 1
• Vascular compromise can result in heel pain and necessitates proper diagnostic evaluation 1

Critical Treatment Pitfall

• Corticosteroid injections should NEVER be placed near or into the Achilles tendon insertion due to high risk of tendon rupture 6, 5
• When injection therapy is indicated for retrocalcaneal bursitis, it must be directed exclusively into the bursa, carefully avoiding the tendon itself 6, 5