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Diagnosis of Heel Pain
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 worsening 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 children. Medial midfoot heel pain, particularly with continued weight bearing, may be due to tarsal 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. Copyright © 2011 American Academy of Family Physicians.)
T
he differential diagnosis of heel
pain is extensive (Table 1), but
a mechanical etiology (Table 2)
is most common. Obtaining a
patient history, performing a physical examination of the foot and ankle (see http://www.
youtube.com/watch?v=kdGSGofCa9I), and
ordering appropriate imaging studies, if
Table 1. Differential Diagnosis of Heel Pain
Arthritic
Neuropathic
Gout
Lumbar radiculopathy
Rheumatoid arthritis
Nerve entrapment (branches of
posterior tibial nerve)
Seronegative
spondyloarthropathies
Infectious
Diabetic ulcers
Neuroma
Tarsal tunnel syndrome (posterior
tibial nerve)
Osteomyelitis
Trauma
Plantar warts
Tumor (rare)
Mechanical
See Table 2
Ewing sarcoma
Neuroma
Vascular (rare)
indicated, are essential to making the correct diagnosis and initiating proper treatment. Location of pain can be a guide to the
diagnosis. Figures 1 and 2 include common
causes of heel pain by anatomic location.
Plantar Heel Pain
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 fasciitis is the most common cause of plantar
heel pain. Historically, plantar fasciitis was
considered an inflammatory syndrome;
however, recent studies have demonstrated
a noninflammatory, degenerative process,3
leading some to use the term plantar fasciosis. Regardless, the condition usually stems
from multiple causes and can be debilitating
for the patient.
Plantar fasciitis causes throbbing medial
plantar heel pain that is worse with the
first few steps in the morning or after long
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
Etiology
Clinical features
Initial treatment
Pain with first steps in the morning or after
long periods of rest
Relative rest
Tenderness on medial calcaneal tuberosity
and along plantar fascia
Anti-inflammatory/analgesic medication
Plantar
Plantar fasciitis/fasciosis
Stretching/strengthening exercises
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
or change to harder walking surfaces
Decrease in activity level, and occasionally no weight
bearing
Pain with activity progressively worsens
to include pain at rest
Heel pads or walking boots
Diagnosed with imaging
Nerve entrapment
(medial or lateral
plantar nerve, nerve to
abductor digiti minimi)
Sensations of burning, tingling, or numbness
Rest
Occasionally preceded by increased activity
or trauma
Stretching/strengthening exercises
Decrease pressure to affected area
Anti-inflammatory/analgesic medication
Ice
Heel pad syndrome
Deep, bruise-like pain, usually in middle
of the heel
Rest
Decrease pressure to affected area
Anti-inflammatory/analgesic medication
Heel cups
Taping
Posterior
Achilles tendinopathy
Haglund deformity
Retrocalcaneal bursitis
Sever disease (calcaneal
apophysitis)
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
thickening
Anti-inflammatory/analgesic medication
Pain caused by retrocalcaneal bursitis
Decrease pressure to affected area
Positive findings on radiography
Anti-inflammatory/analgesic medication
Pain, erythema, swelling between the calcaneus
and Achilles tendon
Decrease pressure to affected area
Tender to direct palpation
Corticosteroid injections (preferably ultrasound-guided)
Pain in children and adolescents
Avoid pain-inducing activities
Worsens with increased activity
Anti-inflammatory/analgesic medication
Tenderness at Achilles insertion
Ice
Pain with passive dorsiflexion
Stretching/strengthening exercises
Anti-inflammatory/analgesic medication
Orthotic devices
Midfoot (medial)
Posterior tibialis
tendinopathy
Tenderness at navicular and medial cuneiform
Eccentric exercises
Decrease pressure to affected area
Anti-inflammatory/analgesic medication
Flexor digitorum longus
tendinopathy
Flexor hallucis longus
tendinopathy
Tenderness posterior to medial malleolus, and
obliquely across sole of foot to base of distal
phalanges of lateral toes
Eccentric exercises
Tenderness posterior to medial malleolus and on
plantar surface of great toe
Eccentric exercises
Decrease pressure to affected area
Anti-inflammatory/analgesic medication
Decrease pressure to affected area
Anti-inflammatory/analgesic medication
continued
Table 2. Mechanical Etiologies of Heel Pain by Location (continued)
Etiology
Clinical features
Initial treatment
Midfoot (medial) (continued)
Tarsal tunnel syndrome
Pain and numbness in posteromedial ankle and
heel (may extend into distal sole and toes)
Avoid pain-inducing activities
Worsens with standing, walking, or running
Neuromodulator/anti-inflammatory medication
Examination positive for Tinel sign
Corticosteroid injection
Orthotic devices
Muscle atrophy may occur if severe
Midfoot (lateral)
Peroneal tendinopathy
Tenderness in lateral calcaneus along path to
base of fifth metatarsal
Eccentric exercises
Decrease pressure to affected area
Anti-inflammatory/analgesic medication
Sinus tarsi syndrome
Pain in lateral calcaneus and ankle
Orthotics
Worse after exercise or when walking on uneven
surfaces
Physical therapy
May have history of repeated ankle sprains or
repeated hyperpronation of the foot
Corticosteroid injection
Anti-inflammatory/analgesic medication
Etiologies of Heel Pain
Location of heel pain
Plantar
Midfoot
Posterior
Type of pain
Age of patient
Lateral
Burning/tingling
Sharp/achy
Insertional
Nerve
entrapment
Timing
of pain
Neuroma
With first
weight-bearing
steps after rest
Plantar
fasciitis
Medial
Peroneal
tendinopathy
With prolonged
weight-bearing
Heel pad
syndrome
Involving
the ankle
Plantar wart
Sinus tarsi
syndrome
Tarsal
tunnel
syndrome
Child/adolescent
Adult
Sever disease
(calcaneal
apophysitis)
Location around
Achilles tendon
Insertional
Surrounding
Achilles
tendinopathy
Haglund
deformity
with or
without
bursitis
At rest
Calcaneal
stress
fracture
Figure 1. Algorithm for diagnosing etiologies of heel pain.
throughout the day with continued weight
bearing. Tenderness is noted on the medial
calcaneal tuberosity and along the plantar
fascia (Figure 2). Pain often increases with
stretching of the plantar fascia, which is
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achieved by passive dorsiflexion of the foot
and toes. Radiography is usually not necessary, although weight-bearing radiography
can help rule out other causes of heel pain.
Approximately 50 percent of patients with
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American Family Physician 911
Heel Pain
plantar fasciitis have heel spurs,4,5 but they are
most often an incidental finding and do not
correlate well with the patient’s symptoms.
Ultrasonography can demonstrate a thicker
heel aponeurosis of greater than 5 mm.4,5
Treatment of plantar fasciitis is typically
conservative, although resolution can take
months to years.4,6,7 First-line therapies
include relative rest, stretching before initial weight bearing, strengthening exercises,
anti-inflammatory or analgesic medications,
and ice. Arch taping, over-the-counter shoe
inserts, custom orthotics, or supportive
shoes may be helpful.4,8 Night splints, corticosteroid injections, and formal physical
therapy have been used for more recalcitrant
cases.2,4,8 Extracorporeal shock wave therapy
may also be of benefit.9,10 Surgery to transect
the plantar aponeurosis is used only when
other treatments have been ineffective.4,6,8
CALCANEAL STRESS FRACTURE
Calcaneal stress fracture is the second most
common stress fracture in the foot, following metatarsal stress fracture.6 A calcaneal
Figure 3. Magnetic resonance image of calcaneal stress fracture (arrow).
stress fracture is usually caused by repetitive
overload to the heel, and most commonly
occurs immediately inferior and posterior to the posterior facet of the subtalar
joint.7 Patients often report onset of pain
after an increase in weight-bearing activity or change to a harder walking surface.
The pain initially occurs only with activity,
but often progresses to include pain at rest.
Examination may reveal swelling or ecchymosis; point tenderness at the fracture site is
usually indicative of a calcaneal stress fracture. Because radiography often does not
initially reveal the fracture, bone scans or
magnetic resonance imaging (Figure 3) may
be needed.6,7
Early treatment of a calcaneal stress fracture involves decreasing activity level and
possibly no weight bearing. Heel pads or
walking boots are also used.
NERVE ENTRAPMENT
Posterior
tibial nerve
Flexor retinaculum
Tarsal tunnel syndrome
Haglund
deformity
Medial plantar nerve
ILLUSTRATION BY STEVE OH
Plantar fasciitis
Figure 2. Common sites of heel pain with corresponding diagnoses.
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Heel pain that is accompanied by burning,
tingling, or numbness may suggest a neuropathic etiology. These symptoms most commonly indicate nerve entrapment caused by
overuse, trauma, or injury from previous
surgery. Affected nerves leading to plantar
heel pain are typically branches of the posterior tibial nerve, including the medial plantar nerve, the lateral plantar nerve, or the
nerve to the abductor digiti minimi. Neuropathic heel pain is usually unilateral; therefore, underlying systemic illnesses should
be ruled out in those with bilateral pain.7,11
Lumbar radiculopathy of L4-S2 must also
be considered in the diagnosis of neuropathic heel pain.
Initial treatment of heel pain caused
by nerve entrapment includes rest, ice,
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Heel Pain
anti-inflammatory or analgesic medications,
relief of pressure at the site of pain, and
stretching exercises. If conservative measures
are ineffective after six to 12 months, surgical decompression should be considered.
HEEL PAD SYNDROME
Pain from heel pad syndrome is often
erroneously attributed to plantar fasciitis.
Patients with heel pad syndrome present
with deep, bruise-like pain, usually in the
middle of the heel, that can be reproduced
with firm palpation. Walking barefoot or on
hard surfaces exacerbates the pain. The syndrome is usually caused by inflammation,
but damage to or atrophy of the heel pad can
also elicit pain. Decreased heel pad elasticity
with aging and increasing body weight can
also contribute to the condition.12 Treatment
is aimed at decreasing pain with rest, ice, and
anti-inflammatory or analgesic medications.
Heel cups, proper footwear, and taping can
also be used.
muscles. The achilles tendon is formed by
the union of the gastrocnemius and soleus
muscle tendons.6 The condition can be
insertional or within the midsubstance of
the tendon, leading to posterior heel pain
that is achy, is occasionally sharp, and worsens with increased activity or pressure to the
area, such as from contact with shoe backing.7 Fluoroquinolone use has also been
shown to precipitate Achilles tendinopathy,
particularly in older persons.14,15 Palpation
reveals tenderness along the Achilles tendon
and sometimes a palpable prominence from
tendon thickening. Passive dorsiflexion of
the foot increases the pain. Radiography may
demonstrate spurring at the Achilles tendon
insertion site or intratendinous calcifications,7 whereas ultrasonography may show
thickening of the tendon (Figure 4).
SOFT TISSUE ETIOLOGIES
Neuromas may develop on the branches of
the tibial nerve, causing plantar heel pain.
Patients often present with symptoms similar to plantar fasciitis, although pain can
sometimes be a more burning or tingling
sensation. Palpation may reveal a painful
lump at the neuroma site. Neuromas should
be considered when treatment for plantar
fasciitis is ineffective.6,11,13
Plantar warts are sometimes a source
of heel pain. They are raised skin lesions
arising from direct contact with human
papillomavirus. The lesion is noted on
inspection of the heel and is tender to palpation. Plantar warts are usually self-limited;
however, patients often need quicker resolution to return to activity. Over-the-counter
topical medications, cryotherapy, laser therapy, and shaving the wart have been shown
to be beneficial, but may worsen pain.
A
Posterior Heel Pain
ACHILLES TENDINOPATHY
Achilles tendinopathy is usually caused
by running, wearing high heels, and other
activities associated with overuse of the calf
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B
Figure 4. Ultrasound image showing (A) normal
Achilles tendon (arrow) and (B) thickened Achilles tendon (arrow) from Achilles tendinopathy.
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American Family Physician 913
Heel Pain
The most beneficial treatment of Achilles
tendinopathy is eccentric exercises, which
involve lengthening a muscle in response
to external resistance.16 Initial treatment
should also include reduction of pressure to
the area, heel lifts or other orthotic devices,
and anti-inflammatory or analgesic medications. Nitroglycerin patches and plateletrich plasma injections have shown benefit in
some studies.17-20 Surgical debridement may
be needed for severe cases.
HAGLUND DEFORMITY
A Haglund deformity is a prominence of the
superior aspect of the posterior calcaneus
(Figures 2 and 5). The condition can occur
in anyone, but is most common in women
who are in their twenties.21 Repeated pressure, from this deformity or from ill-fitting
footwear, can cause inflammation and swelling between the calcaneus and Achilles tendon, leading to retrocalcaneal bursitis.6,7,21,22
Patients with bursitis have erythema and
swelling over the bursa and tenderness to
direct palpation.
Treatment of Haglund deformity, with
or without bursitis, targets decreasing the
pressure and inflammation with openheeled shoes, anti-inflammatory or analgesic
medications, and corticosteroid injections
(ultrasound-guided injections are preferable
to avoid disruption of the Achilles tendon).
Physical therapy may also help reduce pain.
In recalcitrant cases, surgery to remove the
Haglund deformity may be necessary.7,22
SEVER DISEASE
Sever disease (calcaneal apophysitis) is the
most common etiology of heel pain in children and adolescents, usually occurring
between five and 11 years of age.23 Bones
grow quicker than the muscles and tendons
in these patients. The tight Achilles tendon
begins to pull on its insertion site with repetitive running or jumping activities, causing microtrauma to the area. There may be
swelling and tenderness around the Achilles
tendon insertion site, and passive dorsiflexion may increase pain. Radiography is usually normal and therefore does not aid in
the diagnosis, but may reveal a fragmented
or sclerotic calcaneal apophysis.23 Treatment
involves decreasing pain-inducing activities,
anti-inflammatory or analgesic medication
if needed, ice, stretching and strengthening
of the gastrocnemius-soleus complex, and
some orthotic devices.
Midfoot Heel Pain
TENDINOPATHIES
Although less common, other tendinopathies
can cause heel pain localized to the insertion
site of the affected tendon. Medial heel pain
may be triggered by the posterior tibialis,
flexor digitorum longus, or flexor hallucis
longus tendons.6 Lateral heel pain can originate from the peroneal tendon. Musculo­
skeletal ultrasonography of these tendons
may aid in the diagnosis.24 Treatment is similar to that of Achilles tendinopathy.
TARSAL TUNNEL SYNDROME
Figure 5. Radiograph of Haglund deformity
(arrow).
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The tarsal tunnel is a fibro-osseous space
formed by the flexor retinaculum, medial
calcaneus, posterior talus, and medial malleolus.25 Compression of the posterior tibial
nerve most commonly occurs as it courses
through this tunnel, causing neuropathic
pain and numbness in the posteromedial
ankle and heel (Figure 2), which may extend
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Heel Pain
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Clinical recommendation
Evidence
rating
References
Plain radiography is not helpful in diagnosing plantar fasciitis.
C
4-8
A thickened heel aponeurosis of greater than 5 mm on ultrasonography
is suggestive of plantar fasciitis.
C
4, 5
Bone scans or magnetic resonance imaging is often needed to diagnose
a calcaneal stress fracture because plain radiography does not always
reveal a fracture.
C
6, 7
Spurring at the Achilles tendon insertion site or intratendinous
calcifications on plain radiography indicate Achilles tendinopathy.
C
7
Plain radiographs are usually not helpful in diagnosing Sever disease.
C
23
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.xml.
into the distal sole and toes.6 Patients often
report worsening of pain with standing,
walking, or running, and alleviation of pain
with rest or loose-fitting footwear. Physical examination may reveal a pes planus
deformity, which increases tension of the
nerve with weight bearing,6,25 or muscle
atrophy in more severe cases.13 Pain can be
reproduced by tapping along the course of
the nerve (Tinel sign) and with provocative
maneuvers to stretch or compress the nerve
(dorsiflexion-eversion test, plantar flexioninversion test).6 Electromyography and
nerve conduction studies may be useful to
confirm the diagnosis.6,11,13
Treatment is mostly conservative, with
activity modification, orthotic devices,
neuromodulator medications (tricyclics or
antiepileptics), or anti-inflammatory medications. Corticosteroid injections into the
tarsal tunnel may also be beneficial. Surgery is available if conservative measures are
ineffective.13
SINUS TARSI SYNDROME
The sinus tarsi, or talocalcaneal sulcus, is
an anatomic space bound by the calcaneus,
talus, talocalcaneonavicular joint, and posterior facet of the subtalar joint. Pain from
this location is usually felt in the lateral calcaneus and ankle, and is worse immediately
following exercise and when walking on an
uneven surface.24 It can arise from repeated
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Figure 6. Corticosteroid injection site in the
treatment of sinus tarsi syndrome.
lateral ankle sprains or from repeated hyperpronation of the foot.24 Initial treatment
includes managing the underlying causes
with orthotics or physical therapy, although
anti-inflammatory or analgesic medications
and corticosteroid injections (Figure 6) may
also be beneficial.
Data Sources: We searched Medline for heel pain and
for each etiology discussed in the article, with occasional
use of the keywords diagnosis, treatment, and management. We also searched Essential Evidence Plus, Cochrane
Database of Systematic Reviews, and the Clinical Journal
of Sports Medicine. Search dates: August and September
2010, February and May 2011.
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American Family Physician 915
Heel Pain
The Authors
PRISCILLA TU, DO, CAQSM, is a team physician and medical instructor in the Department of Community and Family
Medicine at Duke University in Durham, N.C.
JEFFREY R. BYTOMSKI, DO, FAOASM, is head medical
team physician and associate professor in the Department
of Community and Family Medicine at Duke University.
Address correspondence to Priscilla Tu, DO, Duke University, 2100 Erwin Rd., DUMC 3886, Durham, NC 27710
(e-mail: [email protected]). Reprints are not available from the authors.
10.Othman AM, Ragab EM. Endoscopic plantar fasciotomy
versus extracorporeal shock wave therapy for treatment
of chronic plantar fasciitis. Arch Orthop Trauma Surg.
2010;​130(11):​1343-1347.
11. Alshami AM, Souvlis T, Coppieters MW. A review of
plantar heel pain of neural origin:​differential diagnosis
and management. Man Ther. 2008;​13(2):​103-111.
12. Prichasuk S. The heel pad in plantar heel pain. J Bone
Joint Surg Br. 1994;​76(1):​140-142.
13.Peck E, Finnoff JT, Smith J. Neuropathies in runners. Clin
Sports Med. 2010;​29(3):​437-457.
14.Corrao G, Zambon A, Bertù L, et al. Evidence of tendinitis provoked by fluoroquinolone treatment:​ a casecontrol study. Drug Saf. 2006;​29(10):​8 89-896.
Author disclosure: No relevant financial affiliations to
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15.Yu C, Giuffre B. Achilles tendinopathy after treatment
with fluoroquinolone. Australas Radiol. 2005;​49(5):​
407-410.
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