Heel Pain: Diagnosis and Management

 

Am Fam Physician. 2018 Jan 15;97(2):86-93.

Author disclosure: No relevant financial affiliations.

The differential diagnosis of heel pain is extensive, but a mechanical etiology is the most common. The specific anatomic location of the pain can help guide diagnosis. The most common diagnosis is plantar fasciitis, which leads to medial plantar heel pain, especially with the first weight-bearing steps after rest. Other causes of plantar heel pain include calcaneal stress fractures (progressively worsening pain after an increase in activity or change to a harder walking surface), nerve entrapment or neuroma (pain accompanied by burning, tingling, or numbness), heel pad syndrome (deep, bruise-like pain in the middle of the heel), and plantar warts. Achilles tendinopathy is a common cause of posterior heel pain; other tendinopathies result in pain localized to the insertion site of the affected tendon. Posterior heel pain can also be attributed to Haglund deformity (a prominence of the calcaneus that may lead to retrocalcaneal bursa inflammation) or Sever disease (calcaneal apophysitis common in children and adolescents). Medial midfoot heel pain, particularly with prolonged weight bearing, may be due to tarsal tunnel syndrome, which is caused by compression of the posterior tibial nerve. Sinus tarsi syndrome manifests as lateral midfoot heel pain and a feeling of instability, particularly with increased activity or walking on uneven surfaces.

Heel pain is a common presenting symptom to family physicians and has an extensive differential diagnosis (Table 1).1  Most diagnoses stem from a mechanical etiology (Table 2).1 A thorough patient history, physical examination of the foot and ankle,2 and appropriate imaging studies are essential in making a correct diagnosis and initiating proper management. The history should provide information about the onset and characteristics of the pain, alleviating or exacerbating factors, changes in activity, and other related conditions.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Corticosteroid and platelet-rich plasma injections can reduce pain from plantar fasciitis, especially when performed with ultrasound guidance.

A

5, 811

Extracorporeal shock wave therapy is a treatment option for chronic recalcitrant plantar fasciitis and Achilles tendinopathy.

B

5, 6, 12, 26

Bone scans, computed tomography, or magnetic resonance imaging is often needed to diagnose calcaneal stress fractures because radiography does not always reveal a fracture.

C

15, 16

Duct tape occlusion is ineffective for the treatment of plantar warts.

A

21

Radiographic findings of spurring at the Achilles tendon insertion site or intratendinous calcifications are indicative of Achilles tendinopathy.

C

13

Corticosteroid or platelet-rich plasma injections should not be used to treat Achilles tendinopathy.

A

22, 24

Radiography is typically not helpful in diagnosing Sever disease.

C

1, 30, 31


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Corticosteroid and platelet-rich plasma injections can reduce pain from plantar fasciitis, especially when performed with ultrasound guidance.

A

5, 811

Extracorporeal shock wave therapy is a treatment option for chronic recalcitrant plantar fasciitis and Achilles tendinopathy.

B

5, 6, 12, 26

Bone scans, computed tomography, or magnetic resonance imaging is often needed to diagnose calcaneal stress fractures because radiography does not always reveal a fracture.

C

15, 16

Duct tape occlusion is ineffective for the treatment of plantar warts.

A

21

Radiographic findings of spurring at the Achilles tendon insertion site or intratendinous calcifications are indicative of Achilles tendinopathy.

C

13

Corticosteroid or platelet-rich plasma injections should not be used to treat Achilles tendinopathy.

A

22, 24

Radiography is typically not helpful in diagnosing Sever disease.

C

1, 30, 31


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

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TABLE 1.

Differential Diagnosis of Heel Pain

Arthritic

Fibromyalgia

Gout

Rheumatoid arthritis

Seronegative spondyloarthropathies

Infectious

Diabetic ulcers

Osteomyelitis

Plantar warts

Mechanical (Table 2)

Neurologic

Lumbar radiculopathy (L4-S2)

Nerve entrapment (branches of posterior tibial nerve)

Neuroma

Tarsal tunnel syndrome (posterior tibial nerve)

Trauma

Tumor (rare)

Ewing sarcoma

Neuroma

The Author

PRISCILLA TU, DO, is an assistant professor of family and community medicine at Virginia Tech Carilion School of Medicine, Roanoke.

Address correspondence to Priscilla Tu, DO, Virginia Tech Carilion School of Medicine, 1314 Peters Creek Rd. NW, Roanoke, VA 24017 (e-mail: ptu@carilionclinic.org). Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.

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