Differential Diagnosis and Management of Heel Pad Pain

Clinical Presentation and Diagnosis

Tenderness at medial calcaneal tubercle on examination is a characteristic finding in plantar fasciitis, according to the American Academy of Family Physicians 1
Pain on compression of lateral calcaneus wall, slightly posterior to subtalar joint facet, is indicative of calcaneal stress fracture, as noted by the American Academy of Family Physicians 2
Swelling and warmth may be present in calcaneal stress fracture, as reported by the American Academy of Family Physicians 2
Radiographs may be initially negative in calcaneal stress fracture, but bone scan can confirm the diagnosis, according to the American Academy of Family Physicians 2
EMG and nerve conduction studies are required for confirmation of nerve entrapment, such as Baxter's nerve or tarsal tunnel syndrome, as stated by the American Academy of Family Physicians 3

The American Academy of Family Physicians recommends starting conservative treatment immediately for all mechanical causes of heel pad pain, including stretching, cryotherapy, footwear modifications, NSAIDs, activity modification, weight loss, and padding and strapping 1, 4
For insertional Achilles tendinopathy, the American Academy of Family Physicians suggests using open-backed shoes, heel lifts, and avoiding corticosteroid injections near the Achilles tendon to prevent rupture 3, 2, 4
If no improvement is seen after 6 weeks, referral to a podiatric foot and ankle surgeon is recommended, along with continued initial treatments, as advised by the American Academy of Family Physicians 1, 4
Customized orthotic devices, night splinting, limited corticosteroid injections, and casting or fixed-ankle walker devices may be considered if no improvement is seen after 2-3 months, according to the American Academy of Family Physicians 1, 4

Radiographs are the first-line imaging modality for all heel pain to identify fractures, spurs, and Haglund deformity, as recommended by the American Academy of Family Physicians 1, 3
MRI or ultrasound may be used when the diagnosis is unclear, to evaluate heel fat pad pathology, stress fractures not visible on x-ray, or soft tissue pathology, as suggested by the American Academy of Family Physicians 3
Bone scan is recommended for suspected stress fracture with negative radiographs, according to the American Academy of Family Physicians 2
EMG and nerve conduction studies are necessary for suspected nerve entrapment, as stated by the American Academy of Family Physicians 3