Heel Pain Management

Clinical History and Examination

The American Academy of Family Physicians recommends a focused history and physical examination to localize pain and identify the specific diagnosis, as the anatomic location of heel pain guides both diagnosis and treatment 1
Pain location is crucial in diagnosis: plantar heel pain suggests plantar fasciitis, posterior heel pain indicates Achilles tendonitis or bursitis, lateral heel pain points to Haglund's deformity or sinus tarsi syndrome, and diffuse heel pain suggests stress fracture or heel pad syndrome 1, 2
The American College of Foot and Ankle Surgeons suggests that pain relieved when walking barefoot but worsened by shoes indicates Haglund's deformity or bursitis 3, 1
Neurologic symptoms such as burning, tingling, or numbness indicate nerve entrapment rather than mechanical causes 1, 2
A recent trauma history, such as a fall from height or inversion injury, requires consideration of acute fracture 1

Palpation can confirm plantar fasciitis (point tenderness at the medial plantar calcaneal region), Haglund's deformity (tenderness lateral to the Achilles tendon), or stress fracture (tenderness at the lateral calcaneal wall) 3, 1
The calcaneal squeeze test can indicate calcaneal stress fracture 1, 2
Examination of the Achilles tendon should include palpation for prominence medially and laterally to the insertion and assessment for spurring, with avoidance of corticosteroid injections in this area due to rupture risk 3, 4

Initial radiographs should be ordered if the patient meets Ottawa Ankle Rules criteria 1
For persistent pain, MRI without contrast or CT without contrast are equivalent alternatives if radiographs are negative 1, 2
Technetium bone scanning is recommended for suspected stress fracture when initial radiographs are negative 1, 2

The American Academy of Family Physicians recommends implementing patient-directed measures simultaneously, including stretching exercises, footwear modifications, over-the-counter supports, activity modification, cryotherapy, NSAIDs, and weight loss if indicated 3, 5
Customized orthotic devices, night splinting, and corticosteroid injections may be added as second-line treatment if no improvement occurs after 6 weeks of conservative treatment 3, 5, 4
Surgical consultation may be necessary for chronic recalcitrant cases lasting 6 months or longer 3

For insertional Achilles tendonitis, open-backed shoes, heel lifts or orthoses, and avoidance of corticosteroid injections near the tendon insertion are recommended 3, 5
For Haglund's deformity with bursitis, open-backed shoes, accommodative padding, and corticosteroid injections into the bursa (avoiding the Achilles tendon) may be used 3, 5
For neurologic heel pain, immediate subspecialist referral for evaluation and diagnostic testing is necessary 3, 1

Corticosteroid injection placement should avoid the Achilles tendon to prevent rupture risk 3, 4
Delayed reexamination can lead to overlooked diagnoses, and patients should be reexamined 3-5 days post-injury 1
Overlooking stress fractures can occur if clinical suspicion is low, despite negative initial radiographs 1, 2
Complete immobilization should be avoided to prevent muscular atrophy and deconditioning 4