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 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
Etiology
Plantar
Plantar fasciitis/fasciosis
Heel spur
Calcaneal stress fracture
Nerve entrapment
(medial or lateral
plantar nerve, nerve to
abductor digiti minimi)
Heel pad syndrome
Posterior
Achilles tendinopathy
Haglund deformity
Retrocalcaneal bursitis
Sever disease (calcaneal
apophysitis)
Midfoot (medial)
Posterior tibialis
tendinopathy
Flexor digitorum longus
tendinopathy
Flexor hallucis longus
tendinopathy
Clinical features
Pain with first steps in the morning or after
long periods of rest
Tenderness on medial calcaneal tuberosity
and along plantar fascia
Radiographic findings at site of pain
Follows increase in weight-bearing activity
or change to harder walking surfaces
Pain with activity progressively worsens
to include pain at rest
Diagnosed with imaging
Sensations of burning, tingling, or numbness
Occasionally preceded by increased activity
or trauma
Deep, bruise-like pain, usually in middle
of the heel
Achy, occasionally sharp pain
Worsens with increased activity or pressure to area
Tenderness along Achilles tendon
Occasional palpable prominence from tendon
thickening
Pain caused by retrocalcaneal bursitis
Positive findings on radiography
Pain, erythema, swelling between the calcaneus
and Achilles tendon
Tender to direct palpation
Pain in children and adolescents
Worsens with increased activity
Tenderness at Achilles insertion
Pain with passive dorsiflexion
Tenderness at navicular and medial cuneiform
Tenderness posterior to medial malleolus, and
obliquely across sole of foot to base of distal
phalanges of lateral toes
Tenderness posterior to medial malleolus and on
plantar surface of great toe
Initial treatment
Relative rest
Stretching/strengthening exercises
Anti-inflammatory/analgesic medication
Ice
Arch support
Decrease pressure to affected area
Decrease in activity level, and occasionally no weight
bearing
Heel pads or walking boots
Rest
Stretching/strengthening exercises
Decrease pressure to affected area
Anti-inflammatory/analgesic medication
Ice
Rest
Decrease pressure to affected area
Anti-inflammatory/analgesic medication
Heel cups
Taping
Eccentric exercises
Decrease pressure to affected area
Heel lifts, other orthotic devices
Anti-inflammatory/analgesic medication
Decrease pressure to affected area
Anti-inflammatory/analgesic medication
Decrease pressure to affected area
Anti-inflammatory/analgesic medication
Corticosteroid injections (preferably ultrasound-guided)
Avoid pain-inducing activities
Anti-inflammatory/analgesic medication
Ice
Stretching/strengthening exercises
Orthotic devices
Eccentric exercises
Decrease pressure to affected area
Anti-inflammatory/analgesic medication
Eccentric exercises
Decrease pressure to affected area
Anti-inflammatory/analgesic medication
Eccentric exercises
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 Avoid pain-inducing activities
heel (may extend into distal sole and toes) Orthotic devices
Worsens with standing, walking, or running Neuromodulator/anti-inflammatory medication
Examination positive for Tinel sign Corticosteroid injection
Muscle atrophy may occur if severe

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

Sinus tarsi syndrome Pain in lateral calcaneus and ankle Orthotics

Worse after exercise or when walking on uneven Physical therapy
surfaces Anti-inflammatory/analgesic medication
May have history of repeated ankle sprains or Corticosteroid injection
repeated hyperpronation of the foot

Etiologies of Heel Pain

Location of heel pain

Plantar Midfoot Posterior

Type of pain Age of patient

Lateral Medial

Burning/tingling Sharp/achy Tarsal Child/adolescent Adult

tunnel
Insertional Involving syndrome
the ankle
Timing Sever disease Location around
of pain (calcaneal Achilles tendon
Nerve Neuroma Peroneal apophysitis)
entrapment tendinopathy Sinus tarsi
syndrome

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

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
achieved by passive dorsiflexion of the foot
and toes. Radiography is usually not neces-
sary, although weight-bearing radiography
can help rule out other causes of heel pain.
Approximately 50 percent of patients with

October 15, 2011 Volume 84, Number 8 www.aafp.org/afp 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 patients 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 ini-
tial 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, cor-
ticosteroid 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, follow-
ing metatarsal stress fracture.6 A calcaneal
Posterior
tibial nerve
Flexor retinaculum
Tarsal tunnel syndrome
Haglund
deformity
Medial plantar nerve
Plantar fasciitis
ILLUSTRATION BY STEVE OH
Figure 2. Common sites of heel pain with corresponding diagnoses.
912 American Family Physician www.aafp.org/afp Volume 84, Number 8
Figure 3. Magnetic resonance image of calca-
neal stress fracture (arrow).
stress fracture is usually caused by repetitive
overload to the heel, and most commonly
occurs immediately inferior and poste-
rior to the posterior facet of the subtalar
joint.7 Patients often report onset of pain
after an increase in weight-bearing activ-
ity 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 ecchy-
mosis; point tenderness at the fracture site is
usually indicative of a calcaneal stress frac-
ture. 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 frac-
ture involves decreasing activity level and
possibly no weight bearing. Heel pads or
walking boots are also used.
NERVE ENTRAPMENT
Heel pain that is accompanied by burning,
tingling, or numbness may suggest a neuro-
pathic etiology. These symptoms most com-
monly indicate nerve entrapment caused by
overuse, trauma, or injury from previous
surgery. Affected nerves leading to plantar
heel pain are typically branches of the poste-
rior tibial nerve, including the medial plan-
tar nerve, the lateral plantar nerve, or the
nerve to the abductor digiti minimi. Neuro-
pathic heel pain is usually unilateral; there-
fore, 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 neuro-
pathic 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, muscles. The achilles tendon is formed by

relief of pressure at the site of pain, and
stretching exercises. If conservative measures
are ineffective after six to 12 months, surgi-
cal 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 syn-
drome 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.
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 wors-
ens with increased activity or pressure to the
area, such as from contact with shoe back-
ing.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 calcifica-
tions,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 simi-
lar to plantar fasciitis, although pain can
sometimes be a more burning or tingling
sensation. Palpation may reveal a painful A
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 palpa-
tion. Plantar warts are usually self-limited;
however, patients often need quicker resolu-
tion to return to activity. Over-the-counter
topical medications, cryotherapy, laser ther-
apy, and shaving the wart have been shown
to be beneficial, but may worsen pain.

Posterior Heel Pain

ACHILLES TENDINOPATHY B
Achilles tendinopathy is usually caused Figure 4. Ultrasound image showing (A) normal
by running, wearing high heels, and other Achilles tendon (arrow) and (B) thickened Achil-
activities associated with overuse of the calf les tendon (arrow) from Achilles tendinopathy.

October 15, 2011 Volume 84, Number 8 www.aafp.org/afp 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 medi-
cations. Nitroglycerin patches and platelet-
rich 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 pres-
sure, from this deformity or from ill-fitting
footwear, can cause inflammation and swell-
ing between the calcaneus and Achilles ten-
don, 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 open-
heeled shoes, anti-inflammatory or analgesic
Figure 5. Radiograph of Haglund deformity
(arrow).
914 American Family Physician www.aafp.org/afp Volume 84, Number 8
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 chil-
dren 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 repet-
itive running or jumping activities, caus-
ing microtrauma to the area. There may be
swelling and tenderness around the Achilles
tendon insertion site, and passive dorsiflex-
ion may increase pain. Radiography is usu-
ally 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 origi-
nate from the peroneal tendon. Musculo
skeletal ultrasonography of these tendons
may aid in the diagnosis.24 Treatment is sim-
ilar to that of Achilles tendinopathy.
TARSAL TUNNEL SYNDROME
The tarsal tunnel is a fibro-osseous space
formed by the flexor retinaculum, medial
calcaneus, posterior talus, and medial mal-
leolus.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
October 15, 2011
 Heel Pain

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation 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 C 4, 5
is suggestive of plantar fasciitis.
Bone scans or magnetic resonance imaging is often needed to diagnose C 6, 7
a calcaneal stress fracture because plain radiography does not always
reveal a fracture.
Spurring at the Achilles tendon insertion site or intratendinous C 7
calcifications on plain radiography indicate Achilles tendinopathy.
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 evi-

dence; 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. Physi-
cal 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 flexion-
inversion 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 Figure 6. Corticosteroid injection site in the
antiepileptics), or anti-inflammatory medi- treatment of sinus tarsi syndrome.
cations. Corticosteroid injections into the
tarsal tunnel may also be beneficial. Sur- lateral ankle sprains or from repeated hyper-
gery is available if conservative measures are pronation of the foot.24 Initial treatment
ineffective.13 includes managing the underlying causes
with orthotics or physical therapy, although
SINUS TARSI SYNDROME anti-inflammatory or analgesic medications
The sinus tarsi, or talocalcaneal sulcus, is and corticosteroid injections (Figure 6) may
an anatomic space bound by the calcaneus, also be beneficial.
talus, talocalcaneonavicular joint, and pos- Data Sources: We searched Medline for heel pain and
terior facet of the subtalar joint. Pain from for each etiology discussed in the article, with occasional
this location is usually felt in the lateral cal- use of the keywords diagnosis, treatment, and manage-
ment. We also searched Essential Evidence Plus, Cochrane
caneus and ankle, and is worse immediately Database of Systematic Reviews, and the Clinical Journal
following exercise and when walking on an of Sports Medicine. Search dates: August and September
uneven surface.24 It can arise from repeated 2010, February and May 2011.

October 15, 2011 Volume 84, Number 8 www.aafp.org/afp American Family Physician 915
Heel Pain
The Authors
PRISCILLA TU, DO, CAQSM, is a team physician and medi-
cal 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 Uni-
versity, 2100 Erwin Rd., DUMC 3886, Durham, NC 27710
(e-mail: priscilla.tu@duke.edu). Reprints are not avail-
able from the authors.
Author disclosure: No relevant financial affiliations to
disclose.
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