What is the best course of action for a patient with persistent left heel pain unrelieved by pain medication, with normal vital signs?

Management of Persistent Left Heel Pain

For a patient with persistent left heel pain unrelieved by pain medication and normal vital signs, a comprehensive diagnostic evaluation followed by targeted treatment based on the specific cause is necessary. 1

Diagnostic Approach

• Determine the exact location of pain, which helps narrow down the diagnosis:

  • Medial plantar heel pain suggests plantar fasciitis 2
  • Posterior heel pain indicates Achilles tendonitis or bursitis 1
  • Lateral heel pain may suggest Haglund's deformity or sinus tarsi syndrome 1
  • Diffuse heel pain could indicate stress fracture or heel pad syndrome 1

• Assess pain characteristics:

  • Pain worse with first steps in morning suggests plantar fasciitis 3
  • Pain relieved when walking barefoot but worsened by shoes suggests Haglund's deformity or bursitis 1
  • Progressive worsening pain with activity suggests stress fracture 2
  • Burning or tingling suggests neurologic causes 1

Treatment Algorithm Based on Diagnosis

For Plantar Fasciitis (most common cause)

1. Initial treatment:

   • Rest and activity modification 1
   • NSAIDs for pain and inflammation 1
   • Stretching exercises for plantar fascia and Achilles tendon 1
   • Heel cushions, arch supports, or orthotics 1
   • Ice massage 3
   • Weight loss if indicated 1
   • Avoid flat shoes and barefoot walking 1

2. If no improvement after 6 weeks:

   • Referral to podiatric foot and ankle surgeon 1
   • Consider customized orthotic device 1
   • Night splinting 1
   • Limited corticosteroid injections 1
   • Casting or fixed-ankle walker-type device 1

3. If still no improvement after 2-3 months:

   • Consider cast immobilization 1
   • Evaluate for surgical options (plantar fasciotomy) 1
   • Consider extracorporeal shock wave therapy 1

For Insertional Achilles Tendonitis

1. Initial treatment:

   • Open-backed shoes to reduce pressure 1
   • Heel lifts or orthoses 1
   • NSAIDs 1
   • Decreased activity 1
   • Stretching exercises 1
   • Weight loss if indicated 1
   • Note: Corticosteroid injections are NOT recommended 1

2. If no improvement after 6-8 weeks:

   • Referral to podiatric foot and ankle surgeon 1
   • Immobilization cast or fixed-ankle walker-type device 1

For Haglund's Deformity with Bursitis

1. Initial treatment:

   • Open-backed shoes 1
   • Orthoses and accommodative padding 1
   • NSAIDs 1
   • Corticosteroid injections (avoiding the Achilles tendon) 1
   • Physical therapy 1

2. If no improvement after 6-8 weeks:

   • Referral to podiatric foot and ankle surgeon 1
   • Immobilization cast or fixed-ankle walker device 1
   • Consider bursa injection 1
   • Surgical options may include resection of the prominent calcaneus and inflamed bursa 1

For Neurologic Heel Pain

• Immediate subspecialist referral for evaluation and diagnostic testing 1
• Diagnostic studies may include electromyography, nerve conduction studies, and MRI 1
• Treatment depends on the specific neurologic cause 1

For Traumatic Heel Pain (Stress Fracture)

• Protect and immobilize the foot 1
• Consider imaging studies (X-ray initially, bone scan if needed) 1
• Rest from aggravating activities 4

Common Pitfalls and Caveats

• Failure to identify the specific cause leads to ineffective treatment 5
• Systemic causes of heel pain should be considered when pain is recalcitrant to treatment 5
• Corticosteroid injections should be used judiciously and are contraindicated near the Achilles tendon 1
• Most heel pain (90%) will respond to conservative treatment; surgery should be reserved for cases that fail conservative management 3
• Proper footwear with appropriate support is crucial for recovery from most heel pain conditions 4

When to Refer

• No improvement after 6-8 weeks of appropriate conservative treatment 1
• Suspicion of neurologic, traumatic, or systemic causes 5
• Need for advanced imaging or diagnostic testing 1
• Consideration of surgical intervention 1