Heel Pain: Diagnosis and Management

Heel pain accounts for 2 million office visits annually and is associated with higher body mass index, manual jobs, and a sedentary lifestyle. Retrocalcaneal bursitis is more common in women 40 to 60 years of age with Haglund deformity and a thickened Achilles tendon. Calcaneal apophysitis (Sever disease) is the most common cause of heel pain in active children and adolescents; in the outpatient setting, it accounts for up to 16% of musculoskeletal conditions in children. In os trigonum syndrome, athletes such as soccer players, gymnasts, and dancers who are engaged in repetitive plantar flexion commonly present with worsening posterior ankle pain and an antalgic gait. Risk factors for peroneal tendon injuries include corticosteroid injections into the peroneal sheath, use of fluoroquinolones, rheumatoid arthritis, hyperparathyroidism, and diabetes. Magnetic resonance imaging is the most accurate test for the diagnosis of most causes of heel pain, but ultrasonography is being used more often as it becomes more readily available at the point of care. Most patients with heel pain improve with conservative treatment, and surgical management should be reserved for recalcitrant cases. Pain catastrophizing and kinesiophobia are associated with diminished foot function and poorer prognosis.