Tools to speed your heel pain diagnosis

3 less common causes of posterior heel pain

Haglund’s deformity is an overgrowth of the calcaneus at the insertion of the Achilles tendon.³ Caused by overuse and poorly fitted shoes, this condition commonly requires surgical intervention.

Pump bump is an inflamed superficial bursa commonly associated with a Haglund’s deformity, and it may respond to NSAIDs, shoe-fit modification, ice massage, or steroid injection.

Peroneal tendonitis is a tendinopathy of evertors and external rotators of the foot. The pain will follow the tendons posterior to the lateral malleolus and extend to the lateral midfoot. It is also treated with rest, NSAIDs, icing, and physical therapy.

Plantar-surface heel pain

The problems most likely to cause plantar-surface pain (FIGURE 1B) are plantar fasciitis, stress fracture of the calcaneus, and fat pad syndrome.

Plantar fasciitis: Pain is worst in the morning

This is by far the most common cause of heel pain primary care physicians will see. Rarely, infection and neoplasia will cause unilateral plantar heel pain.⁴

Evaluation. Tenderness localized to the plantar surface of the heel in adults usually indicates plantar fasciitis.

Pain is worst with the first step of the morning, and lessens with activity. The tender spot is the medial calcaneal tubercle, with pain radiating through the arch.^1,28-30

Treatment. The many therapeutic modalities—NSAIDs, stretching exercises, gel cups, arch supports, night splints, steroid injections, ESWT, and surgery—have been extensively reviewed elsewhere, including in a Cochrane review from 2005.^31-33

Calcaneal stress fracture: Suspect it in runners

Calcaneal stress fractures are relatively rare, but may occur in those who put significant stressors on their feet, such as avid runners or military recruits.

Evaluation. Most patients report a recent increase in frequency or intensity of activity, and runners can tell you when it is during their run that the pain begins. As the stress fracture worsens, the pain begins earlier in the activity and eventually is present with even minimal activity. A key distinction from plantar fasciitis, in which pain lessens with activity, is that the pain of a stress fracture typically worsens with activity and diminishes with rest.³⁴

Physical exam provides few clues except for the “squeeze test” (FIGURE 1A) Putting pressure on both the medial and lateral calcaneal tuberosities will cause discomfort. Pain will be absent in the posterior structures of the heel. Placing a vibrating 128-cps tuning fork on the calcaneus should also increase discomfort.

Plain x-ray films may be falsely negative, especially during the first 2 to 3 weeks of pain. Three-phase bone scans are nearly 100% sensitive for detecting stress fractures, with changes evident in as little as 1 to 2 days after injury. The specificity of MRI scans is superior to that of bone scans and can reveal alternate problems.³⁵

Treatment. Activity modification reduces trauma to the heel. Encourage patients to walk if they are pain free and to increase activity as comfort allows. Tell patients to stop activity if the fracture becomes symptomatic. Advanced fractures demand an absolute absence of weight bearing.

Pain can be controlled with NSAIDs TABLE 2 and ice. Lab and animal data have suggested that NSAIDs may impede fracture healing rates, but no similar data exist regarding their effect on stress fractures.³⁶ Symptoms abate within 2 or 3 weeks. Advise athletes to resume activity slowly in a stepwise progression, letting them know that a return to full activity is likely within 6 to 8 weeks. Have runners restart their routine at half their customary distance, increasing it by no more than 10% to 15% per week.

Any medical condition that weakens the bone may predispose a patient to stress fracture. To prevent primary and secondary stress fractures, correct the patient’s underlying medical problems. Evaluate young, thin women with a stress fracture for the “female athlete triad” (osteopenia, disordered eating, menstrual irregularity). The elderly are also at risk for stress fractures due to osteopenia or osteoporosis.

TABLE 2
Heel pain treatment options: A look at the evidence