Heel Pain

Aka: Heel Pain, Hindfoot Pain

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II. Causes: Heel Pain by location

  1. Midfoot pain
    1. Lateral pain
      1. Peroneus longus or peroneus brevis Tendonitis (peoneal Tendinopathy)
      2. Sinus Tarsi Syndrome
    2. Medial pain
      1. Flexor digitorum or hallucis longus Tendonitis or Tendinopathy
      2. Tibialis posterior Tendonitis or Tendinopathy (at navicular or medial Cuneiform)
  2. Posterior plantar Foot Pain
    1. Plantar Fasciitis
    2. Plantar fascia rupture
    3. Heel pad dysfunction or Heel Fat Pad Syndrome
      1. Heel pad atrophy: Elderly or obese patients
      2. Heel pad inflammation: Athletes
    4. Nerve Entrapment or other neurologic causes (Paresthesias or numbness)
      1. Tarsal Tunnel Syndrome
      2. Baxter Nerve Entrapment
      3. Calcaneal neuroma (rare)
    5. Bone cyst
    6. Calcaneal Osteomyelitis (from contiguous Cellulitis)
    7. Calcaneal Stress Fracture
    8. Ewing's Sarcoma of Calcaneus
    9. Medial Heel Pain
    10. Achilles Tendinopathy
    11. Master knot of Henry Intersection Syndrome (posterior medial ankle)
      1. Friction between the flexor hallucis longus (FHL) and the flexor digitorum longus (FDL)
  3. Posterior Heel Pain
    1. Achilles Tendonitis or Achilles Tendinopathy
    2. Retroachilles Bursitis (Pump-Bump)
    3. Retrocalcaneal Bursitis
    4. Haglund Deformity (pain at posterior-superior calcaneous)
    5. Severe Disease (Calcaneal Apophysitis in children)

III. Causes: Entrapment Neuropathy

  1. Lumbar back pain
    1. Lumbar Radiculopathy (L4-S2)
  2. Paresthesias of plantar surface, walking and at night
    1. Tarsal Tunnel Syndrome (posterior tibial nerve)
  3. Burning pain at heel pad
    1. Abductor digiti quinti nerve entrapment
  4. Medial and plantar Heel Pain
    1. Medial calcaneal branch of posterior tibial nerve (Tarsal Tunnel Syndrome)
    2. First branch of Lateral Plantar Nerve (Baxter Nerve Entrapment)
      1. Mimics refractory Plantar Fasciitis

IV. Causes: Inflammatory conditions with bilateral involvement

  1. Ankylosing Spondylitis
  2. Psoriatic Arthritis
  3. Reactive Arthritis
  4. Reiter's Syndrome
  5. Rheumatoid Arthritis
  6. Gouty Arthritis
  7. Systemic Lupus Erythematosus (SLE)

V. Causes: Infectious Disease

  1. Diabetic Foot Ulcer
  2. Osteomyelitis
  3. Plantar Wart

VI. Causes: Skeletal Conditions

  1. Calcaneal Stress Fracture
  2. Paget's Disease
  3. Bony Tumor (e.g. Ewing Sarcoma)
  4. Calcaneal Apophysitis (Sever's Disease) in Adolescent
  5. Os Trigonum Syndrome

VII. Causes: Soft Tissue Conditions

  1. Fat pad syndrome (fat pad atrophy)
  2. Plantar fascia rupture
  3. Black Dot Heel
  4. Heel Bruise
  5. Plantar Fasciitis
  6. Retroachilles Bursitis (Pump-Bump)
  7. Retrocalcaneal Bursitis
  8. Flexor Hallucis Longus Tendonitis
  9. Posterior Tibial Tendonitis

VIII. References

  1. Aldridge (2004) Am Fam Physician 70:332-8 [PubMed]
  2. Barrett (1999) Am Fam Physician 59(8):2200-6 [PubMed]
  3. Madden (1996) Am Fam Physician 54(6):1995-2000 [PubMed]
  4. Van Wyngarden (1997) Am Fam Physician 2207-12 [PubMed]
  5. Tu (2011) Am Fam Physician 84(8):909-16 [PubMed]
  6. Tu (2018) Am Fam Physician 97(2):86-93 [PubMed]

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