What are the treatment options for a 68-year-old patient with heel pain?

Management of Heel Pain in a 68-Year-Old Patient with Plantar Fasciitis

The most effective treatment for this 68-year-old patient with plantar fasciitis includes regular calf-muscle stretching, NSAIDs, heel cushions or arch supports, activity modification, and proper footwear. 1, 2

Diagnosis

Based on the patient's presentation, the most likely diagnosis is plantar fasciitis:

• Morning pain worse with first steps (classic sign) 1
• Pain on weight bearing and when transitioning from sitting to standing 3
• Pain duration of 2.5 months 3
• Tenderness on palpation of the heel 1

First-Line Treatment Options

• Patient-directed measures:

  • Regular calf-muscle and plantar fascia stretching exercises (3-5 times daily) 3, 2
  • Cryotherapy (ice massage) for 10-minute periods through a wet towel to reduce pain and inflammation 2
  • Over-the-counter heel cushions and arch supports 3, 2
  • Activity limitation and avoidance of barefoot walking 3
  • Proper footwear with adequate arch support and cushioning 2

• Medication:

  • NSAIDs for pain relief and reducing inflammation 3, 2

• Additional interventions:

  • Padding and strapping of the foot to provide support 3
  • Weight management (particularly relevant given pre-diabetes) 3, 2

Treatment Algorithm

1. Initial 6-week treatment period:

   • Implement all first-line treatments listed above 3
   • Monitor for improvement in symptoms 3

2. If no improvement after 6 weeks:

   • Referral to a podiatric foot and ankle surgeon 3, 1
   • Continue initial treatments 3
   • Consider additional treatments:
     • Customized orthotic device 3
     • Night splinting to maintain dorsiflexion during sleep 3
     • Limited corticosteroid injections (use judiciously) 3, 2
     • Immobilization with a cast or fixed-ankle walker-type device 3

3. If no improvement after 2-3 months:

   • Continue conservative measures 3
   • Consider cast immobilization if not previously used 3
   • Evaluate for surgical options (plantar fasciotomy) or extracorporeal shock wave therapy 3, 4
   • Reconsider diagnosis and explore other potential causes 3

Special Considerations for This Patient

• Pre-diabetes: Weight management should be emphasized as it can reduce pressure on the heel and improve symptoms 2
• Age: At 68 years old, healing may take longer; patience with conservative treatment is important 5
• Possible traumatic component: The reported garden injury (stepping on a stone) may have exacerbated or triggered the condition 3

Common Pitfalls and Caveats

• Corticosteroid injections should be used judiciously due to risk of plantar fascia rupture 1, 2
• Complete immobilization should be avoided to prevent muscular atrophy 2
• Failure to address biomechanical factors (such as improper footwear) may lead to treatment failure 5
• 90% of patients improve with conservative measures, so surgery should only be considered after exhausting non-surgical options 4

Expected Outcomes

• Most patients respond to conservative treatment within 6-8 weeks 3, 4
• Full resolution may take up to 6 months in some cases 4
• If symptoms persist beyond 6 months despite appropriate treatment, consider referral for advanced imaging or surgical consultation 1, 4