History may be of a pain that is initially migratory or diffuse. With time the pain localises to the area of the medial calcaneal tuberosity. The pain is usually of gradual onset and is worst on first weight bearing in the morning. The heel pain generally decreases during the day but may worsen with increased activity e.g. jogging (1).
A pain that worsens during the day is more typical of calcaneal stress fractures or nerve entrapment. A nocturnal heel pain may be due to infections, tumours and neuropathic pain e.g., tarsal tunnel syndrome.
- On examination of the foot, there is focal, pinpoint tenderness on palpation of the plantar medial calcaneum or the plantar central calcaneum. In addition, tenderness occurs in the proximal third of the plantar fascia (1).
- Generally, minimal clinical signs of inflammation such as swelling and erythema will be present. Pain with midfoot, hindfoot, and ankle range of motion is generally absent (1).
- To exclude tarsal tunnel syndrome, percuss over the nerve below and posterior to the medial malleolus. This can reproduce pain, numbness and burning on the medial side of the foot, ankle or calf if there is tarsal tunnel syndrome (2).
- Press together the heads of the 2nd and 3rd metatarsals and then the 3rd and 4th. Reproduction of the pain suggests Morton's neuroma, with entrapment of the common digital nerve between the metatarsal heads (3).
- A stress fracture of the calcaneum will cause tenderness over the calcaneum rather than anterior to it (4).
Reference:
- Schneider HP et al. American College of Foot and Ankle Surgeons clinical consensus statement: diagnosis and treatment of adult acquired infracalcaneal heel pain. J Foot Ankle Surg. 2018 Mar-Apr;57(2):370-81.
- Nelson S. Tarsal Tunnel Syndrome. Clin Podiatr Med Surg. 2021 Apr;38(2):131-141
- Maneesh B et al. Morton's neuroma - Current concepts review. J Clin Orthop Trauma. 2020 May-Jun;11(3):406-409
- Italiano J. Diagnosis and Management of Calcaneal Stress Fractures. Radiol Technol. 2021 Nov;93(2):177-194