Heel Pain

Evaluation: Important items to consider in the history:

• etiology/onset (acute, gradual)

• duration/timing of signs and symptoms

• shoe gear (type and age)

• activity level (sedentary, novice, athlete)

Differential diagnosis:

• Trauma

  • Calcaneal fracture

  • Talar fracture

• Overuse

  • Plantar fasciitis

  • Posterior tibial dysfunction/tendonitis

  • Achilles tendonitis / bursitis

  • Tarsal tunnel syndrome

  • Calcaneal Stress Fracture

• Other

  • Arthridites

  • Infection

  • Cysts / tumors

Physical exam: 

Look for signs of emergent conditions requiring rapid treatment and referral.  

• Calcaneal or talar fractures that are intra-articular often result in dislocation and deformity and require surgical treatment.  

• Infection can rapidly progress from an open lesion, e.g. a blister, to cellulitis.  If neglected, infection of the ankle joint or bones can result.  Signs of infection include swelling, erythema, tenderness, and warmth.  

• A puncture wound may progress to osteomyelitis of the calcaneus.

The location of pain can give an indication of the cause.  

• Pain on the medial heel that is most noticeable immediately upon rising and after rest most commonly indicates plantar fasciitis.  Palpation of the medial calcaneal tubercle will elicit pain.  

• Squeezing the body of the calcaneous often indicates calcaneal stress fracture (positive squeeze test).  

• Pain just inferior to the medial malleolus may represent posterior tibial tendonitis, or, if Tinel’s sign is present, tarsal tunnel syndrome.  

• Pain on the posterior heel indicates Achilles tendonitis / bursitis.  

• To check for Achilles tendon rupture, palpate the tendon for a defect.  Then squeeze the calf and see if the foot plantar flexes (Thomas test).  Edema is nonspecific and not always present.  If ecchymosis is present consider fracture, plantar fascial tear, or Achilles tendon rupture. Inability to plantar flex indicates Achilles tendon injury.

X-rays: calcaneal axial view and rearfoot lateral

Labs: if systemic arthidities are suspected, check an erythrocyte sedimentation rate, for infection consider CBC

Treatment:

Trauma

• Fracture:

  • no displacement and no intra-articular involvement:  immobilization 4-6 wks in a short leg cast followed by partial WB to full WB over 6-8 wks

  • displacement or intra-articular involvement: surgical intervention necessary to avoid deformity and/or joint degeneration

  • Plantar fascial tear:

    • Initially rest, anti-inflammatories, ice 20 minutes tid

    • followed with aggressive stretching therapy

    • shoe inserts may be required as long-term therapy

• Achilles tendon rupture

  • Surgical correction followed by up to 12 weeks of immobilization

• Infection

  • Oral antibiotics with/without IM/IV antibiotics

  • May require surgical I&D

• Overuse

  • Plantar fasciitis:

    • anti-inflammatory therapy (NSAIDs, ice massage)

    • stretching of Achilles and plantar fascia

    • shoe inserts (functional orthotics)

    • if intractable, corticosteroid injections, night splints, possible plantar fascial release

• Posterior tibial dysfunction

  • shoe inserts to prevent excessive pronation

• Tarsal tunnel syndrome

  • shoe inserts to stabilize medial foot (prevent pronation)

  • anti-inflammatory therapy

  • surgical release may be necessary if systems persist

• Achilles tendonitis / bursitis

  • heel lifts

  • anti-inflammatory therapy / stretching

This section provided by Christopher Kardohely, DPM and Scott D. Flinn, MD

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*This web version is provided by The Brookside Associates, LLC.  It contains original contents from the official US Navy NAVMED P-5139, but has been reformatted for web access and includes advertising and links that were not present in the original version. The medical information presented was reviewed and felt to be accurate in 2001. Medical knowledge and practice methods may have changed since that time. Some links may no longer be active. This web version has not been approved by the Department of the Navy or the Department of Defense. The presence of any advertising on these pages does not constitute an endorsement of that product or service by either the US Department of Defense or the Brookside Associates. The Brookside Associates is a private organization, not affiliated with the United States Department of Defense.

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