Heel Pain: Not Always a Plantar Fasciitis

In 2006, heel pain represented 12.1% of all musculoskeletal foot and ankle complaints seen in UK primary care, and plantar fasciitis was cited in 7.5% of those consultations (Thomas et al., 2019). The differential diagnosis of the heel pain can include plantar fasciopathy/fasciitis, heel fat pad syndrome (HFPS), nerve irritation, calcaneal stress fracture and lumbar radiculopathy (Chang et al., 2022), systemic causes such as Rheumatoid arthritis, seronegative spondilarthropathies (Allam and Chang, 2021).

DIFFERENTIAL DIAGNOSIS

1. Plantar Fasciopathy / Plantar Fasciitis

This is the most common cause of heel pain and involves the plantar fascia, a thick connective tissue composed of three bands: medial, central, and lateral.
The classic symptom is sharp, stabbing pain with the first steps in the morning.
Pain is usually felt on the inner (medial) side of the heel, but it can also occur on the outer side of the foot when the lateral cord is involved.
Despite the term “-itis,” the condition is typically degenerative rather than inflammatory, which explains why many people experience recurrent flare-ups over time (Sullivan, Pappas & Burns, 2020).
Mid-portion plantar fascia pathologies, such as fibrosis or partial tearing, can mimic plantar fasciitis, causing heel pain and pain with the first steps in the morning. However, treatment may differ, and imaging such as ultrasound or MRI can help confirm the correct diagnosis.

2. Heel Fat Pad Syndrome

Act as a cushion to absorb the shock and plantar forces distribution during the gait (Chang et al., 2022)
Pain is often deep, bruise-like, and located under the centre of the heel.
Worse with walking on hard surfaces or prolonged standing. Pain may also be present at night or at rest.
Often confused with plantar fasciopathy.

3. Calcaneal Stress Fracture

Usually due to increased load, running, or impact activities, risk factors such as osteoporosis, extended corticosteroid (Ragul Rajivan et al., 2025)
Pain tends to be more constant, can be tender with the squeeze test of the calcaneus.
Early X-rays are often normal; an Ultrasound scan can diagnose it, but an MRI would be the gold standard (Ragul Rajivan et al., 2025)

4. tunnel tarsal syndrome/ baxter nerve entrapment

Often misdiagnosed as plantar fasciitis, Baxter nerve entrapment accounts for 15% of chronic heel pain (Donovan, Rosenberg and Cavalcanti, 2010), mainly seen in runners (Meadows and Finnoff, 2014). Compression may occur between the abductor hallucis and quadratus plantae muscles or from nearby bony structures. Often burning, tingling, or radiating, unlike classic plantar fasciitis. Symptoms may worsen with prolonged standing or walking.
Tunnel tarsal syndrome involves compression of the tibial nerve within the tarsal tunnel behind the ankle. Causes include ganglions, varicose veins, flat feet, trauma, or scar tissue, though in 40% of cases no cause is found (Meadows and Finnoff, 2014). Symptoms include burning pain, tingling, and sometimes radiating into the arch.

5. Lumbar Radiculopathy

Heel pain may originate from the lower back, especially when nerve root irritation is present. Researchers have reported an association between radiculopathy and plantar heel pain secondary to nerve entrapment, particularly at the L5–S1 level. Heel pain can also occur due to a phenomenon called “double crush,” involving simultaneous nerve compression at the lumbosacral region and within the tarsal tunnel (DeHeer, 2020).
Clues: back pain, numbness/tingling, pain radiating down the leg, or symptoms changing with spinal movement.
Heel pain is often less localized than with local foot conditions.

6. Systemic causation
Systemic conditions can cause plantar heel pain, but they are relatively uncommon compared with local mechanical etiologies such as plantar fasciopathy or nerve entrapment. Assess for unilateral or bilateral enthesitis, conditions such as psoriasis, uveitis, sacroiliitis, and laboratory tests such as rheumatoid factor, HLA-B27(Allam and Chang, 2021).

Inflammatory (enthesitis): Spondyloarthropathies, Reactive arthritis
Autoimmune: Rheumatoid arthritis
Crystal-related: Gout, CPPD
Metabolic/endocrine: Diabetes, hypothyroidism, obesity, hyperparathyroidism
Neuropathic systemic: Diabetic neuropathy, B12 deficiency
Infectious: Reactive arthritis (acute enthesopathy may be related to an underlying systemic causation)
Widespread pain syndromes: Fibromyalgia

IMAGING

X-rays are useful in the initial evaluation of heel pain to assess bony pathology such as fractures, heel spurs, or arthritic changes, although they often appear normal in plantar fasciopathy. X-rays often appear normal for the first 2-3 weeks, even when a stress fracture is present (Bergman and Kaiser, 2025).
Ultrasound scan (POCUS) provides dynamic, bedside assessment and is highly effective for identifying plantar fascia thickening, tears, heel fat pad atrophy.
MRI offers the most comprehensive soft-tissue and bone evaluation, helping diagnose complex or unclear cases, including stress fractures, inflammatory enthesitis, and nerve entrapment.

MANAGEMENT AND CONCLUSION:

Heel pain may not always be due to plantar fasciitis, and in many cases, multiple structures can be involved. This is why, at Sonopodiatry clinic, we provide a complete approach to managing plantar heel pain by combining rapid diagnosis with effective treatment options. We provide POCUS ultrasound imaging at the time of your consultation, allowing us to immediately identify or exclude structures that may be causing your heel pain and guide your treatment plan without delays. Initial care focuses on evidence-based conservative management, including targeted exercises, activity modification, stretching and custom orthotics to help reduce your symptoms. If your heel pain has been present for a few weeks, we can offer Focused Extracorporeal Shockwave Therapy (F-ESWT), an evidence-based treatment designed to stimulate healing in chronic cases. In some situations, an ultrasound-guided injection may also be considered.

If needed, depending on each case, we may arrange an MRI or refer you to a specialist (such as a rheumatologist, spine specialist) or your GP for further investigation or/and information at the end of the consultation.
Our goal is to provide accurate diagnosis and effective treatment in one visit, helping you return to comfortable, pain-free movement as soon as possible.

Medial heel structures on long-axis ultrasound (Alpinion X-Cube i9 with SL3-19H linear probe )

Still not sure:
For more information or to book an appointment, please contact our practice at 07714792424 or info@sonopodiatry.co.uk

References:

Allam, A.E. and Chang, K.-V. (2021) Plantar Heel Pain, PubMed. Treasure Island (FL): StatPearls Publishing. Available at: https://www.ncbi.nlm.nih.gov/books/NBK499868/.

Bergman, R. and Kaiser, K. (2025) Stress Reaction and Fractures, Nih.gov. StatPearls Publishing. Available at: https://www.ncbi.nlm.nih.gov/sites/books/NBK507835/?utm_source=chatgpt.com (Accessed: 8 December 2025).

‌Chang, A.H. et al. (2022) ‘What do we actually know about a common cause of plantar heel pain? A scoping review of heel fat pad syndrome’, Journal of Foot and Ankle Research, 15(1). Available at: https://doi.org/10.1186/s13047-022-00568-x.

DeHeer, P. (2020) ‘When Heel Pain Results From Other Soft Tissue Pathology’, Podiatry Today, 33(11). Available at: https://www.hmpgloballearningnetwork.com/site/podiatry/when-heel-pain-results-other-soft-tissue-pathology (Accessed: 12 December 2025).

Donovan, A., Rosenberg, Z.S. and Cavalcanti, C.F. (2010) ‘MR Imaging of Entrapment Neuropathies of the Lower Extremity’, RadioGraphics, 30(4), pp. 1001–1019. Available at: https://doi.org/10.1148/rg.304095188.

Meadows, J.R. and Finnoff, J.T. (2014) ‘Lower Extremity Nerve Entrapments in Athletes’, Current Sports Medicine Reports, 13(5), pp. 299–306. Available at: https://doi.org/10.1249/jsr.0000000000000083.

‌Ragul Rajivan et al. (2025) ‘Delayed Diagnosis of Calcaneal Stress Fracture: A Case Report’, Cureus [Preprint]. Available at: https://doi.org/10.7759/cureus.83161.

Sullivan, J., Pappas, E. and Burns, J. (2020) ‘Role of mechanical factors in the clinical presentation of plantar heel pain: Implications for management’, The Foot, 42, p. 101636. Available at: https://doi.org/10.1016/j.foot.2019.08.007.

Thomas, M.J. et al. (2019) ‘Plantar heel pain in middle-aged and older adults: population prevalence, associations with health status and lifestyle factors, and frequency of healthcare use’, BMC Musculoskeletal Disorders, 20(337). Available at: https://doi.org/10.1186/s12891-019-2718-6.