Table 2.

Overuse injuries in young athletes with heel pain

Diagnosis	Presentation	Clinical findings	Radiology
Sever’s disease (calcaneal apophysitis)	Athletes in growth spurt participating in running activities may be unilateral but more often bilateral pain which increases with activity	Tight heel cords, tenderness on palpation at the insertion of the Achilles tendon pain over nodules at the insertion site	Sclerosis and fragmentation of the calcaneal apophysis radiology may be suggestive but not diagnostic
Achilles tendinopathy (tendinitis, paratendinopathy, tendinosis)	Stiffness of tendon which progresses to pain with continued activity	Tenderness/thickening on palpation of tendon; tight heel cords, crepitus or swelling over Achilles tendon	US shows thickening of tendon and possibly intratendinous tears; MRI shows intratendinous tears, thickening and/or degeneration of tendon
Retrocalcaneal bursitis	Pain, with localized swelling anterior to the Achilles tendon	Tenderness on palpation and/or swelling in the retrocalcaneal area	In some cases posterior superior enlargement of the calcaneus; US and MRI may show bursal swelling
Haglund’s syndrome (runner’s bump, calcaneal exostosis, pump bump)	Enlarged posterosuperior calcaneal prominence	Subcutaneous Achilles bursa may be tender to palpation; posterosuperior calcaneal prominence	Plain radiograph; pseudoexostosis localized between the calcaneus and the Achilles tendon
Stress fracture of the calcaneus	Pain, swelling at fracture site	Pain with compression of the calcaneus; pain on palpation at fracture site	Plain radiograph: normal (in most cases) or fine fracture line; bone scan or MRI (preferable) if plain radiographs are negative
Plantar fasciitis	Often unilateral, pain/local tenderness over proximal medial arch/heel with weight bearing, morning pain	Tenderness on palpation over the medial calcaneal tubercle at insertion of plantar fascia; often tight heel cords	Radiographs might show anterior inferior calcaneal spur; MRI and/or US not needed for diagnostic evaluation
Heel fat pad syndrome	Walking after rest or barefoot painful, pain increases with activity; often overweight patients	Pain on palpation of heel pad; tiptoe standing/walking may cause pain relief	Not helpful
Tarsal tunnel syndrome	Burning pain, with possible medial or foot sole paresthesia that increases with weight bearing; symptoms may coexist with plantar fasciitis	Positive Tinel’s sign; often hyperpronated or flat feet	Radiographs normal and are not helpful; electromyography/nerve conduction test if needed

Abbreviations: MRI, magnetic resonance imaging; US, ultrasound; CT, computed tomography.