Some patients with mechanical heel pain may localize the pain to the posterior heel.


General features of mechanical posterior heel pain:

(1) pain aggravated by increased activity and wearing shoes

(2) pain relieved by walking barefoot or on sandals


Possible causes:

(1) tendonitis at the insertion of the Achilles tendon

(2) bursitis (involving the retrocalcaneal and/or retroachilles bursa)


Features of insertional Achilles tendonitis:

(1) slow, insidious onset of pain and swelling in the posterior heel

(2) tenderness is either central or global

(3) palpable prominence both medially and laterally to the insertion of the Achilles tendon

(4) lateral foot X-rays show an erosion or spur at the insertion for the tendon


Features of bursitis (Hagelund's disease):

(1) acute onset of pain with inflammation

(2) tenderness lateral to Achilles tendon

(3) palpable posterior lateral prominence (Hagelund's deformity; also referred to as "pump bump", with pumps referring to a woman's low-cut shoes)

(4) lateral foot X-rays show a prominence at posterior superior surface of the calcaneus

(5) a few patients may have an abnormal calcaneal alignment (varus)


Differential diagnosis:

(1) blisters or abrasion from ill-fitting shoes (new shoes, skin changes)

(2) acute trauma to the calcaneus or Achilles tendon

(3) arthritis (arthritis in other joints)

(4) tendonitis associated with spondyloarthropathy (involvement of other joints and tendons)


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