Heel Pain

Key Note

• Consider posterior tibial tendinopathy even if tenderness is localised to the heel, especially with medial malleolus pain or progressive arch lowering

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Differentials

• Achilles: Rupture, mid-portion or insertional tendinopathy, retrocalcaneal/subcutaneous calcaneal bursitis

• Calcaneus: Sever’s disease (children), stress/traumatic fracture, fat pad atrophy, foreign body

• Medial Malleolus: Tibialis posterior or flexor hallucis longus tendinopathy, tarsal tunnel syndrome

• Plantar: Plantar fasciitis (worse with first steps in the morning)

• Systemic: Spondyloarthritides (reactive arthritis, RA, OA), gout, septic arthritis

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History

• Activity-related pain (dancers, jumping sports, running on hard surfaces)

• Systemic signs: Diarrhoea, urethritis, ocular inflammation (reactive arthritis), morning stiffness (inflammatory cause)

• Burning/tingling pain → Neural involvement (tarsal tunnel syndrome)

• Progressive arch collapse → Posterior tibial tendon dysfunction

• Footwear changes (pronation control, worn-out shoes) affecting biomechanics

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Examination

• Medial malleolus: Tenderness, reduced inversion strength (posterior tibial tendinopathy)

• Calcaneus: Fat pad tenderness, swelling (bursitis/stress fracture)

• Functional tests:

  • Single heel raise → Tibialis posterior/Achilles dysfunction

  • Flatfoot posture → Posterior tibial tendon collapse

  • Great toe flexion → Flexor hallucis longus tendinopathy

  • Thompson test → Achilles rupture

  • Windlass test → Plantar fasciitis

• Nerve entrapment signs → Burning pain radiating to medial ankle/foot

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Management

General

• Heel pads, orthotics, offloading devices

• Activity modification, NSAIDs, weight reduction

• Ice post-activity (plantar fasciitis, Achilles tendinopathy)

Specific

• Physiotherapy: Stretching/strengthening (plantar fascia, Achilles, tibialis posterior), eccentric loading for chronic Achilles tendinopathy/plantar fasciitis

• Steroid injections (resistant cases, caution near Achilles due to rupture risk)

• Podiatry referral for recurrent/bilateral cases or footwear assessment

• Imaging (X-ray, US, MRI) if no improvement in 6–8 weeks, suspected fracture/tendon tear, or inflammatory/infectious concerns

• Shockwave therapy for chronic plantar fasciitis

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Additional Notes

• Sever’s disease: Calcaneal apophysitis in children → Rest, ice, heel cups, activity reduction

• Tarsal tunnel syndrome: Posterior tibial nerve compression → Orthotic support, activity modification

• Posterior tibial tendinopathy: Risk of adult-acquired flatfoot if untreated → Strengthening, posture correction, immobilisation if severe

• Consider spondyloarthropathy/inflammatory arthritis if bilateral heel pain, prolonged morning stiffness, or systemic features (uveitis, GI symptoms)