Differential Diagnosis for Pain Starting at Heel and Radiating to Hip

Primary Neurologic Considerations

Lumbar radiculopathy (L5-S1 nerve root compression) can cause pain radiating from the heel proximally through the posterior leg and hip, according to the American Academy of Family Physicians 1
If neurologic heel pain is suspected, immediate subspecialist referral for evaluation and diagnostic testing is essential, including electromyography, nerve conduction velocity studies, and MRI, as recommended by the American Academy of Family Physicians and Praxis Medical Insights 1, 2

Haglund's deformity with retrocalcaneal bursitis causes posterior and lateral heel pain from the prominent posterior superior calcaneus, as noted by the American Academy of Family Physicians and Praxis Medical Insights 1, 2
Calcaneal stress fracture presents with progressively worsening pain following increased activity, with tenderness at the lateral calcaneal wall and positive calcaneal squeeze test, according to Praxis Medical Insights 2

Point tenderness location: Palpate the Achilles insertion, lateral malleolus, posterior superior calcaneus, lateral calcaneal wall, and over the calcaneofibular ligament course, as recommended by Praxis Medical Insights 2
Neurologic symptoms: Assess for burning, tingling, numbness, or radiation patterns suggesting nerve involvement, according to the American Academy of Family Physicians 1
Calcaneal compression test: Squeeze the calcaneus medially to laterally to evaluate for stress fracture, as noted by Praxis Medical Insights 2
Lumbar spine examination: Assess for radiculopathy with straight leg raise, neurologic deficits in lower extremity, as recommended by the American Academy of Family Physicians 1
Weight-bearing radiographs of the foot and ankle should be the initial imaging study for heel pain, according to the American College of Radiology and Praxis Medical Insights 2, 3
AP pelvis and lateral hip radiographs if hip pathology is suspected, as recommended by the British Journal of Sports Medicine 4
Lumbar spine imaging (MRI preferred) if radiculopathy is suspected based on examination findings, according to the American Academy of Family Physicians 1

Electromyography and nerve conduction studies for confirmed neurologic involvement, as recommended by the American Academy of Family Physicians and Praxis Medical Insights 1, 2
MRI of the foot/ankle if radiographs are negative but pain persists >1 week, according to Praxis Medical Insights 2
Technetium bone scanning for suspected stress fracture with negative initial radiographs, as noted by the American Academy of Family Physicians and Praxis Medical Insights 1, 2

Do not assume isolated plantar fasciitis when pain radiates proximally beyond the heel—this pattern demands neurologic evaluation, according to the American Academy of Family Physicians 1
Never diagnose based on imaging alone—combine symptoms, clinical signs, and imaging findings, as recommended by the British Journal of Sports Medicine 4
Consider systemic causes (arthritides, infections, tumors, vascular compromise) when symptoms are bilateral, involve other joints, or are unexplained by mechanical causes, according to the American Academy of Family Physicians and Praxis Medical Insights 1, 2