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When Patients Have A Sudden Onset Of Heel Pain With No Obvious Swelling

Most providers diagnose heel pain as plantar fasciitis. Everyone knows the ice, stretch and support protocol. But what if it is not plantar fasciitis?

One subset of patients I see have a sudden onset of heel pain without swelling that I can note on exam. In my experience, these cases may fall into one of two diagnoses:

  • Heel bursitis. Only deep palpation away from the plantar fascia reveals a painful bursal sac.
  • Heel neuritis. This can cause heel rim pain, plantar heel pain, radiating pain or other neuropathic symptoms.

Plantar fasciitis can morph into bursitis due to chronic low grade inflammation but this is not the type of case in question here.

Sudden heel pain with a painful palpable mass at the plantar heel can be infracalcaneal bursitis. There may or may not be a reason for the bursae to swell, causing pain that the patient will remember (like stepping on a rock barefoot at the beach). There is a bursal sac that protects bony prominences, similar to what one will find at the hip, knee and under the metatarsals. This bursal sac only becomes sore and swollen when it is irritated.

How the patient feels while barefoot walking may help in your diagnosis. Plantar fasciitis typically hurts more at push-off so walking on the toes may hurt. Heel bursitis hurts more when walking on the heels alone. 

Heel neuritis can be local in nature (Baxter’s nerve entrapment), referred pain from the tarsal tunnel or referred pain from the low back and even cervical issues. Similar to how one might approach any peripheral nerve problem, you always have to think that it could be from higher up the chain, like a double crush syndrome. 

With a double crush syndrome, the nerve is irritated at the heel. For example, this could involve a perfect storm of sorts with a pes cavus foot, a bony heel and no fat pad. The nerve is also irritated at the back, piriformis, behind the knee due to a Baker’s cyst or in tight hamstrings or calves. What complicates this is that there is no test that confirms that the nerve is irritable. Nerve tests like nerve conduction studies look for damaged nerves, not excitable nerves. 

So when heel pain initially diagnosed as plantar fasciitis is not getting better with plantar fascia treatment, you must start looking for another working diagnosis. When there is no obvious swelling and no problems like a plantar fascia tear, heel stress fracture or bone bruise, you should look for heel bursitis and heel neuritis.

Dr. Blake is in practice at the Center for Sports Medicine, which is affiliated with St. Francis Memorial Hospital in San Francisco. He is a past president of the American Academy of Podiatric Sports Medicine. Dr. Blake is the author of the recently published book, “The Inverted Orthotic Technique: A Process Of Foot Stabilization For Pronated Feet,” which is available at www.bookbaby.com

Editor’s note: This blog originally appeared at www.drblakeshealingsole.com. It is adapted with permission from the author.

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