What is the management for a patient with heel pain?

Management of Heel Pain

The management of heel pain should follow a stepped-care approach beginning with conservative measures including regular calf-muscle stretching, cryotherapy, appropriate footwear, orthotics, and NSAIDs, with more invasive interventions reserved for refractory cases. 1, 2

Initial Assessment and Diagnosis

• Determine the specific cause of heel pain based on location:

  • Plantar heel pain (most common): Plantar fasciitis, heel spurs, heel pad syndrome
  • Posterior heel pain: Achilles tendinopathy, Haglund's deformity
  • Medial heel pain: Tarsal tunnel syndrome
  • Lateral heel pain: Sinus tarsi syndrome
  • In children/adolescents: Consider Sever's disease (calcaneal apophysitis) 3

• Assess pain characteristics:

  • Plantar fasciitis: Pain worse with first steps in morning or after prolonged sitting 4
  • Achilles tendinopathy: Pain with activity, tenderness at tendon insertion 1

First-Line Management (0-6 weeks)

1. Patient-directed measures:

   • Regular calf and plantar fascia stretching (3-5 times daily, including before getting out of bed) 2
   • Cryotherapy (ice through wet towel for 10-minute periods) 2
   • Avoidance of barefoot walking and flat shoes 1, 2
   • Activity modification and limitation 1
   • Weight loss if indicated 1

2. Footwear and support:

   • Properly fitting footwear with adequate support 2
   • Over-the-counter heel cushions and arch supports 1
   • For Achilles tendinopathy: Open-backed shoes and heel lifts 1

3. Medications:

   • NSAIDs for short-term pain relief 1, 2
   • Paracetamol as alternative if NSAIDs contraindicated 2

4. Physical interventions:

   • Padding and strapping of the foot 1
   • Night splints for plantar fasciitis 1

Second-Line Management (6 weeks - 3 months)

If no improvement after 6 weeks, continue first-line measures and add:

1. Referral to podiatric foot and ankle surgeon 1

2. Additional interventions:

   • Customized orthotic devices 1
   • Limited corticosteroid injections (use with caution, particularly for Achilles tendinopathy) 1, 2
   • Cast immobilization or fixed-ankle walker-type device during activity 1
   • Transcutaneous electrical nerve stimulation (TENS) 2

Third-Line Management (beyond 3 months)

For persistent symptoms despite 3 months of conservative treatment:

1. Immobilization:

   • Cast immobilization if not previously used 1

2. Advanced interventions:

   • Extracorporeal shock wave therapy 1
   • Surgical options (e.g., plantar fasciotomy) - reserve for patients who have failed 3-6 months of conservative therapy 1, 2

Special Considerations

• For insertional Achilles tendinitis:

  • Avoid local corticosteroid injections (not recommended) 1
  • Use open-backed shoes to reduce pressure 1

• For suspected infection (septic bursitis):

  • Immediate aspiration for Gram stain, culture, cell count, and crystal analysis 2

• For diabetic patients:

  • More frequent foot examinations 2
  • Never walk barefoot, in socks only, or in thin-soled slippers 2
  • Evaluate for peripheral arterial disease and neuropathy 2

Follow-up and Monitoring

• Evaluate response to treatment every 4-6 weeks 2
• Continue treatments until symptoms resolve 1
• Consider alternative diagnoses if no improvement despite appropriate management 1

Treatment Success Rates

• Approximately 90% of patients with plantar fasciitis improve with conservative techniques without requiring surgery 2

The management of heel pain requires patience and persistence with conservative measures, as most cases will resolve without surgical intervention when treated appropriately.