What are the treatment options for heel pad pain that occurs with weightbearing?

Treatment of Heel Pad Pain with Weightbearing

Begin with a 6-week trial of conservative therapy including daily calf and plantar fascia stretching (3-5 times daily), over-the-counter heel cushions or arch supports, NSAIDs, activity modification, proper footwear with arch support, and ice application—referring to a podiatric surgeon only if no improvement occurs after 6 weeks. 1

Initial Conservative Management (0-6 Weeks)

Patient-Directed Measures

• Perform regular calf-muscle and plantar fascia stretching exercises 3-5 times daily, which forms the cornerstone of treatment 1
• Apply ice through a wet towel for 10-minute periods to reduce inflammation and pain 1
• Use over-the-counter heel cushions and arch supports to redistribute weight and reduce pressure on the heel pad 1, 2
• Avoid flat shoes and barefoot walking, as these worsen heel pad stress 3, 1
• Modify activities that aggravate pain, particularly high-impact weightbearing activities 1, 2
• Consider weight loss if indicated to reduce pressure on the foot 3, 1

Medical Interventions

• NSAIDs (such as naproxen) for pain relief and inflammation reduction 1, 2
• Padding and strapping of the foot for additional support 3, 1
• Ensure proper footwear with adequate arch support and cushioning 1, 2

Most patients respond to conservative treatment within 6-8 weeks, so continue these measures throughout the initial treatment period 1, 2

If No Improvement After 6 Weeks

• Refer to a podiatric foot and ankle surgeon while continuing all initial treatment measures 3, 1
• Add customized orthotic devices (though note that these show only moderate benefit in the medium term of 7-12 weeks, with no clear advantage over prefabricated orthotics) 1
• Implement night splinting to maintain plantar fascia stretch during sleep 3, 1
• Consider a limited number of corticosteroid injections for persistent pain 3, 1
• Use casting or a fixed-ankle walker-type device during activity if symptoms are severe 3, 1

If No Improvement After 2-3 Months

• Continue all conservative measures and consider cast immobilization if not previously used 3, 1
• Evaluate for surgical options, specifically plantar fasciotomy 3, 1
• Consider extracorporeal shock wave therapy as an alternative to surgery 3, 1
• Explore alternative diagnoses including calcaneal stress fracture (progressively worsening pain with activity), nerve entrapment (burning, tingling, or numbness), or other heel pathology 2, 4

Critical Caveats and Pitfalls

• Avoid corticosteroid injections near the Achilles tendon due to risk of tendon rupture—inject carefully to avoid the Achilles insertion site when treating plantar conditions 1, 2
• Do not pursue complete immobilization for extended periods, as this can lead to muscular atrophy and deconditioning 2
• Ensure proper diagnosis by pain location: medial plantar heel pain suggests plantar fasciitis/heel pad syndrome, posterior heel pain suggests Achilles tendinopathy, and diffuse heel pain suggests stress fracture 2, 4
• Ninety percent of patients improve with conservative techniques, so surgery should be reserved only for chronic recalcitrant cases lasting 6 months or longer 5