PRISCILLA TU, DO, and JEFFREY R. BYTOMSKI, DO, Duke University, Durham, North Carolina
Heel pain is a common presenting symptom in ambulatory clinics. There are many causes, but
a mechanical etiology is most common. Location of pain can be a guide to the proper diagnosis.
The most common diagnosis is plantar fasciitis, a condition that leads to medial plantar heel
pain, especially with the first weight-bearing steps in the morning and after long periods of
rest. Other causes of plantar heel pain include calcaneal stress fracture (progressively worsen-
ing pain following an increase in activity level or change to a harder walking surface), nerve
entrapment (pain accompanied by burning, tingling, or numbness), heel pad syndrome (deep,
bruise-like pain in the middle of the heel), neuromas, and plantar warts. Achilles tendinopathy
is a common condition that causes posterior heel pain. Other tendinopathies demonstrate pain
localized to the insertion site of the affected tendon. Posterior heel pain can also be attributed
to a Haglund deformity, a prominence of the calcaneus that may cause bursa inflammation
between the calcaneus and Achilles tendon, or to Sever disease, a calcaneal apophysitis in chil-
dren. Medial midfoot heel pain, particularly with continued weight bearing, may be due to tar-
sal tunnel syndrome, which is caused by compression of the posterior tibial nerve as it courses
through the flexor retinaculum, medial calcaneus, posterior talus, and medial malleolus. Sinus
tarsi syndrome occurs in the space between the calcaneus, talus, and talocalcaneonavicular and
subtalar joints. The syndrome manifests as lateral midfoot heel pain. Differentiating among
causes of heel pain can be accomplished through a patient history and physical examination,
with appropriate imaging studies, if indicated. (Am Fam Physician. 2011;84(8):909-916. Copy-
right 2011 American Academy of Family Physicians.)
T
he differential diagnosis of heel indicated, are essential to making the cor-
pain is extensive (Table 1), but rect diagnosis and initiating proper treat-
a mechanical etiology (Table 2) ment. Location of pain can be a guide to the
is most common. Obtaining a diagnosis. Figures 1 and 2 include common
patient history, performing a physical exami- causes of heel pain by anatomic location.
nation of the foot and ankle (see http://www.
youtube.com/watch?v=kdGSGofCa9I), and Plantar Heel Pain
ordering appropriate imaging studies, if PLANTAR FASCIITIS AND HEEL SPURS
Every year, as many as 2 million persons
present with plantar heel pain,1 with men
and women affected equally.2 Plantar fas-
Table 1. Differential Diagnosis of Heel Pain ciitis is the most common cause of plantar
heel pain. Historically, plantar fasciitis was
Arthritic Neuropathic
considered an inflammatory syndrome;
Gout Lumbar radiculopathy
however, recent studies have demonstrated
Rheumatoid arthritis Nerve entrapment (branches of
posterior tibial nerve)
a noninflammatory, degenerative process,3
Seronegative
spondyloarthropathies Neuroma
leading some to use the term plantar fascio-
Infectious Tarsal tunnel syndrome (posterior sis. Regardless, the condition usually stems
Diabetic ulcers tibial nerve) from multiple causes and can be debilitating
Osteomyelitis Trauma for the patient.
Plantar warts Tumor (rare) Plantar fasciitis causes throbbing medial
Mechanical Ewing sarcoma plantar heel pain that is worse with the
See Table 2 Neuroma first few steps in the morning or after long
Vascular (rare) periods of rest. The pain usually decreases
after further ambulation, but can return
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Table 2. Mechanical Etiologies of Heel Pain by Location
Plantar
Plantar fasciitis/fasciosis Pain with first steps in the morning or after Relative rest
long periods of rest Stretching/strengthening exercises
Tenderness on medial calcaneal tuberosity Anti-inflammatory/analgesic medication
and along plantar fascia
Ice
Arch support
Heel spur Radiographic findings at site of pain Decrease pressure to affected area
Calcaneal stress fracture Follows increase in weight-bearing activity Decrease in activity level, and occasionally no weight
or change to harder walking surfaces bearing
Pain with activity progressively worsens Heel pads or walking boots
to include pain at rest
Diagnosed with imaging
Posterior
Achilles tendinopathy Achy, occasionally sharp pain Eccentric exercises
Worsens with increased activity or pressure to area Decrease pressure to affected area
Tenderness along Achilles tendon Heel lifts, other orthotic devices
Occasional palpable prominence from tendon Anti-inflammatory/analgesic medication
thickening
Haglund deformity Pain caused by retrocalcaneal bursitis Decrease pressure to affected area
Positive findings on radiography Anti-inflammatory/analgesic medication
Retrocalcaneal bursitis Pain, erythema, swelling between the calcaneus Decrease pressure to affected area
and Achilles tendon Anti-inflammatory/analgesic medication
Tender to direct palpation Corticosteroid injections (preferably ultrasound-guided)
Sever disease (calcaneal Pain in children and adolescents Avoid pain-inducing activities
apophysitis) Worsens with increased activity Anti-inflammatory/analgesic medication
Tenderness at Achilles insertion Ice
Pain with passive dorsiflexion Stretching/strengthening exercises
Orthotic devices
Midfoot (medial)
Posterior tibialis Tenderness at navicular and medial cuneiform Eccentric exercises
tendinopathy Decrease pressure to affected area
Anti-inflammatory/analgesic medication
Flexor digitorum longus Tenderness posterior to medial malleolus, and Eccentric exercises
tendinopathy obliquely across sole of foot to base of distal Decrease pressure to affected area
phalanges of lateral toes
Anti-inflammatory/analgesic medication
Flexor hallucis longus Tenderness posterior to medial malleolus and on Eccentric exercises
tendinopathy plantar surface of great toe Decrease pressure to affected area
Anti-inflammatory/analgesic medication
continued
Table 2. Mechanical Etiologies of Heel Pain by Location (continued)
Midfoot (lateral)
Peroneal tendinopathy Tenderness in lateral calcaneus along path to Eccentric exercises
base of fifth metatarsal Decrease pressure to affected area
Anti-inflammatory/analgesic medication
Lateral Medial
Insertional Surrounding
With first With prolonged At rest
weight-bearing weight-bearing
steps after rest Achilles Haglund
tendinopathy deformity
Calcaneal
with or
stress
without
Plantar fracture
Heel pad Plantar wart bursitis
fasciitis
syndrome
throughout the day with continued weight achieved by passive dorsiflexion of the foot
bearing. Tenderness is noted on the medial and toes. Radiography is usually not neces-
calcaneal tuberosity and along the plantar sary, although weight-bearing radiography
fascia (Figure 2). Pain often increases with can help rule out other causes of heel pain.
stretching of the plantar fascia, which is Approximately 50 percent of patients with
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NERVE ENTRAPMENT
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Heel Pain
Evidence
Clinical recommendation rating References
October 15, 2011 Volume 84, Number 8 www.aafp.org/afp American Family Physician 915
Heel Pain
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