Differential Diagnoses for Central Heel Pain

Primary Mechanical Causes

The American Academy of Family Physicians recommends considering calcaneal stress fracture as a differential diagnosis for central heel pain, which presents with progressively worsening pain following increased walking activity or change to a harder walking surface 1, 2
Pain on compression of the calcaneus from medial to lateral (calcaneal squeeze test) is highly suspicious for calcaneal stress fracture, according to the American Academy of Family Physicians 1, 2
The American Academy of Family Physicians notes that symptoms of calcaneal stress fracture often occur before the fracture appears on radiographs, highlighting the importance of clinical suspicion 1, 2

The American Academy of Family Physicians suggests that nerve entrapment can cause heel pain accompanied by burning, tingling, or numbness, distinguishing it from mechanical causes 1, 2
If neurologic heel pain is suspected, the American Academy of Family Physicians recommends subspecialist referral for evaluation and diagnostic testing 1, 2

The American Academy of Family Physicians states that acute calcaneal fracture is the most common osseous cause of heel pain from acute trauma, almost always resulting from a fall onto the heel from height 1
Diagnosis of acute calcaneal fracture requires history of trauma, focal pain on palpation, and radiographic confirmation, according to the American Academy of Family Physicians 1, 2

The American Academy of Family Physicians notes that tumors rarely cause heel pain but require proper diagnostic testing and appropriate referral when suspected, particularly if pain is constant at rest or progressively worsening without mechanical explanation 1, 2
Infections, such as soft tissue infections or bone osteomyelitis, rarely cause heel pain but require proper diagnostic testing, consultation, and appropriate referral when suspected, according to the American Academy of Family Physicians 1, 2

The American Academy of Family Physicians recommends initial weight-bearing radiographs for persistent heel pain, and if radiographs are negative but pain persists beyond 1 week, MRI without contrast or CT without contrast are equivalent alternatives 2
Technetium bone scanning is recommended for suspected stress fracture with negative initial radiographs, according to the American Academy of Family Physicians 1, 2