Plantar Heel Pain Differential Diagnoses

Updated: Mar 28, 2022
  • Author: Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS; Chief Editor: Thomas M DeBerardino, MD, FAAOS, FAOA  more...
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Diagnostic Considerations

Conditions that can be associated with pain under the arch include the following:

  • Distal plantar fasciitis - The tenderness is under the midfoot, and, as opposed to proximal plantar fasciitis, dorsiflexion of the toes aggravates pain
  • Plantar fibromatosis - Painful nodules or lumps are palpable in the plantar fascia [10]

Conditions that can be associated with pain on the posterior aspect of the hindfoot include the following:

  • Insertional Achilles tendinitis - Pain, tenderness, and a bony prominence are mainly located at the back of the heel; plain radiographs may show calcification at the insertion of the Achilles tendon
  • Haglund syndrome - This is a term given to the prominent posterosuperior corner of the calcaneus that is thought to impinge on the Achilles tendon and give rise to pain, swelling, and tenderness in the posterior aspect of the heel; the diagnosis is made on the basis of plain radiographic findings
  • Pump bump - This is a term used to describe a prominent posterolateral protuberance in the calcaneus near the attachment of the Achilles tendon; the pain is usually caused by friction from footwear and can coexist with Haglund syndrome
  • Flexor hallucis longus tenosynovitis - The pain and tenderness are posteromedial at the level of the subtalar joint and can be aggravated by dorsiflexion of the great toe with the ankle held in full plantarflexion
  • Posterior impingement of the os trigonal or Stieda process or fracture - Usually, activities that require acute plantar flexion, such as a pointe in ballet, can aggravate the pain, and the tenderness is posterolateral at the level of the subtalar joint

Conditions that can be associated with pain on the medial aspect of the ankle include the following:

  • Posterior tibial tendon dysfunction - This is associated with pain on the medial side of the ankle, which radiates proximally along the leg and distally into the midfoot; swelling and pitting edema often occur over the region of the tendon; the patient has weakness in active inversion of the hindfoot and difficulty performing a single or double raise on the toes [21]
  • Medial ankle instability - The patient history includes an ankle sprain, followed later by the ankle giving way; the pain and tenderness are in the medial gutter of the ankle; the heel is in valgus, but unlike the situation with posterior tibial tendon dysfunction, the heel valgus is corrected when the person raises up on the toes

Conditions that can be associated with pain on the lateral aspect of the ankle include the following:

  • Peroneal tendon dysfunction - The pain is on the lateral aspect of the heel over the peroneal tendons and behind the lateral malleolus; this may be associated with swelling, tenderness, and pes cavus
  • Chronic lateral ankle sprain - The pain is on the lateral aspect of the ankle; the condition is associated with a history of repeated sprains of the ankle and symptoms of instability; the patient has swelling and tenderness at the points of attachment of the anterior talofibular and calcaneofibular ligaments; a positive drawer sign signifies ligament laxity; a pes cavus and heel varus may be contributory factors
  • Sinus tarsi syndrome - This condition often follows a lateral ligament sprain of the ankle, and patients have pain and tenderness in the sinus tarsi region and lateral aspect of the hindfoot; the diagnosis is confirmed if symptoms improve with local injection of an anesthetic or a steroid; magnetic resonance imaging (MRI) shows an obliteration of the fat plane, with or without interruption of the ligaments; a high index of suspicion and a solid familiarity with the complex ligamentous anatomy of the hindfoot and midfoot are necessary [22]

Differential Diagnoses