What are the treatment options for heel and big toe pain?

Treatment of Heel and Big Toe Pain

For heel pain, begin with conservative therapy including rest, NSAIDs, stretching exercises (plantar fascia and Achilles tendon 3-5 times daily), heel cushions, arch supports, and activity modification for 6-8 weeks before considering advanced interventions. 1, 2

Diagnostic Localization

The location of pain determines the specific diagnosis and treatment approach:

Heel Pain Patterns

• Plantar heel pain (bottom of heel): Plantar fasciitis—pain worst with first steps in morning or after prolonged sitting, tender at medial plantar calcaneal region 1, 3
• Posterior heel pain: Achilles tendonitis or retrocalcaneal bursitis—pain at tendon insertion site 1, 2
• Lateral heel pain: Haglund's deformity, calcaneofibular ligament sprain (especially with history of inversion injury), or sinus tarsi syndrome 1, 4
• Diffuse heel pain: Calcaneal stress fracture (positive calcaneal squeeze test—pain when compressing heel from medial to lateral) or heel pad syndrome 1, 2

Big Toe Pain

While the evidence provided focuses primarily on heel conditions, big toe pain commonly indicates:

• First metatarsophalangeal joint pathology (hallux rigidus, gout, sesamoiditis)
• Turf toe (ligamentous injury)
• Morton's neuroma (if pain radiates from ball of foot) 5

Initial Conservative Treatment (First 6-8 Weeks)

For Plantar Fasciitis

• Stretching exercises: Calf muscle and plantar fascia stretching 3-5 times daily 2, 3
• Footwear modifications: Shoes with adequate arch support and cushioning 2, 3
• Over-the-counter supports: Heel cushions and arch supports 1, 2
• NSAIDs: For pain relief and inflammation reduction 1, 2
• Activity modification: Limit prolonged standing and high-impact activities 2, 3
• Weight loss: If indicated, to reduce pressure on the heel 2
• Ice massage: 10-minute periods through wet towel 2

For Achilles Tendonitis/Insertional Tendinopathy

• Open-backed shoes: To reduce pressure on posterior heel 1, 2
• Heel lifts or orthoses: To reduce strain on Achilles tendon 1, 2
• Eccentric strengthening exercises: Primary treatment for midportion Achilles tendinopathy 5
• NSAIDs: For pain and inflammation 1, 2
• Decreased activity: Avoid aggravating movements 1

For Haglund's Deformity with Bursitis

• Open-backed shoes: Critical to reduce pressure 1, 2
• Accommodative padding and orthoses: To redistribute pressure 1, 2
• NSAIDs: For inflammation 1, 2
• Physical therapy: Stretching and strengthening 1

For Lateral Ankle Ligament Injury (Calcaneofibular Ligament Sprain)

• PRICE protocol: Protection, rest, ice, compression, elevation 4
• Semirigid support devices or lace-up braces: Superior to elastic bandages 4
• NSAIDs: Improve healing, reduce edema and pain, decrease time to return to activities 4
• Functional rehabilitation: Preferred over complete immobilization—includes range of motion and strengthening exercises 4

Critical Pitfall: Corticosteroid Injection Safety

Never inject corticosteroids near the Achilles tendon due to risk of tendon rupture. 1, 2 Corticosteroid injections may provide temporary relief for plantar fasciitis but should be used judiciously. 1, 6

When Initial Treatment Fails (After 6-8 Weeks)

If no improvement after appropriate conservative treatment:

Second-Line Interventions

• Custom orthotic devices: If over-the-counter supports ineffective 2
• Night splints: For chronic plantar fasciitis (>6 months), maintains dorsiflexion during sleep 1, 3
• Corticosteroid injections: For plantar fasciitis only (avoid Achilles region), provides short-term relief 1, 6
• Physical therapy: Formal program with modalities 2
• Cast immobilization or fixed-ankle walker: For stress fractures or severe cases 2

Advanced Imaging Indications

• Initial radiographs: If Ottawa Ankle Rules criteria met (inability to bear weight immediately after injury, point tenderness over malleoli/talus/calcaneus, inability to ambulate 4 steps) 1
• MRI or CT without contrast: If radiographs negative but pain persists >1 week 1
• Technetium bone scan: For suspected stress fracture with negative radiographs (symptoms often precede radiographic findings) 1

Refractory Cases (After 2-3 Months)

Third-Line Options

• Extracorporeal shock wave therapy: For chronic plantar fasciitis, though evidence shows conflicting results for effectiveness 5, 6
• Platelet-rich plasma injection: Emerging option for plantar fasciitis 5
• Surgical referral: Consider plantar fasciotomy for plantar fasciitis unresponsive to 6 months of conservative care 2, 3

Mandatory Referral Criteria

Refer to podiatric foot and ankle surgeon if: 1, 2, 4

• No improvement after 6-8 weeks of appropriate conservative treatment
• Need for advanced imaging or diagnostic testing beyond initial radiographs
• Consideration of surgical intervention
• Neurologic symptoms (burning, tingling)—requires immediate subspecialist referral for EMG, nerve conduction studies, and MRI 1

Red Flags Requiring Urgent Evaluation

• Bilateral symptoms with pain in other joints: Consider inflammatory arthritis 1
• Fever, systemic symptoms: Rule out infection (osteomyelitis, soft tissue infection) 1
• History of trauma from height: Evaluate for acute calcaneal fracture 1
• Neurologic deficits: Immediate referral 1

Expected Outcomes

Most patients (90%) respond to conservative treatment within 6-8 weeks. 2, 3 However, 44% of plantar fasciitis patients may continue to have pain 15 years after diagnosis, emphasizing the importance of early aggressive conservative management. 5