What is the treatment for neuropathy in a man's heel?

Treatment for Neuropathy in the Heel

Neurologic heel pain requires specialized evaluation including electromyography, nerve conduction studies, and MRI, followed by treatment with gabapentinoids, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, or sodium channel blockers as first-line pharmacologic options. 1

Understanding Heel Neuropathy

Neuropathy in the heel is characterized by pain, burning, tingling, or numbness caused by damage or irritation to nerves innervating the heel area. This can occur due to:

• Local nerve entrapment or irritation in the foot/ankle
• More proximal nerve impingement (such as from the lumbar spine)
• Systemic conditions (most commonly diabetes mellitus)

Clinical Presentation

• Burning or tingling sensations in the heel
• Pain that may be poorly localized
• Numbness or decreased sensation
• Symptoms may be worse at night or with prolonged standing

Diagnostic Approach

When neurologic heel pain is suspected, a thorough evaluation is necessary:

1. Localization of symptoms: Determine if symptoms are isolated to the heel or part of a more widespread neuropathy
2. Diagnostic testing: 1
   • Electromyography (EMG)
   • Nerve conduction velocity studies
   • Magnetic resonance imaging (MRI)
   • Laboratory tests to identify underlying causes (diabetes, vitamin deficiencies, etc.)

Treatment Algorithm

First-Line Pharmacologic Treatment

According to the most recent guidelines, first-line medications include: 1

• Gabapentinoids (e.g., pregabalin) - FDA approved for diabetic peripheral neuropathy 2
• Serotonin-norepinephrine reuptake inhibitors (e.g., duloxetine) - FDA approved for diabetic peripheral neuropathy 3
• Tricyclic antidepressants (e.g., amitriptyline)
• Sodium channel blockers (e.g., carbamazepine)

Note: Opioids, including tramadol and tapentadol, should NOT be used for neuropathic pain treatment due to potential adverse events. 1

Non-Pharmacologic Approaches

• Footwear modifications: Open-backed shoes to reduce pressure 1
• Orthotic devices: Custom orthoses or heel lifts 1
• Physical therapy: Stretching exercises and modalities
• Weight loss if indicated 1

Management of Underlying Conditions

• Optimize glucose control in diabetic patients to prevent progression 1
• Optimize blood pressure and lipid management to reduce risk or slow progression 1

When to Refer to a Specialist

Referral to a specialist is indicated when: 1

• Pain is not adequately controlled with first-line treatments
• Diagnosis remains unclear after initial evaluation
• Symptoms are progressive despite treatment
• Neuropathy appears to originate from the lumbar spine

Special Considerations

• Diabetic patients require annual comprehensive foot examinations to identify high-risk foot conditions 1
• Patients with peripheral vascular disease and neuropathy have increased risk of amputation, revascularization, and death 4
• Monitoring for progression is essential as neuropathy can lead to loss of protective sensation and increased risk of foot ulceration

Treatment Pitfalls to Avoid

• Delayed diagnosis: Neuropathy can be progressive; early intervention is key
• Inadequate dose titration: Medications often need gradual titration to effective doses
• Focusing only on symptom management: Identifying and treating underlying causes is essential
• Overlooking non-pharmacologic approaches: Comprehensive management includes footwear modifications and physical therapy
• Missing concurrent conditions: Heel pain may have multiple contributing factors (e.g., plantar fasciitis with neuropathic component)

Remember that treatment should address both symptom management and the underlying cause of neuropathy to improve quality of life and prevent progression of the condition.