What are the treatment options for heel pain?

Treatment for Heel Pain

Start with conservative measures including calf-muscle stretching (3-5 times daily), NSAIDs, over-the-counter heel cushions and arch supports, activity modification, and proper footwear—this approach resolves symptoms in 90% of patients within 6 weeks. 1, 2

Initial Conservative Treatment (First 6 Weeks)

Patient-directed measures should be implemented immediately:

• Stretching exercises: Perform calf-muscle and plantar fascia stretches 3-5 times daily—this is the most consistently effective intervention 3
• Cryotherapy: Apply ice through a wet towel for 10-minute periods to reduce pain and inflammation 1, 3
• NSAIDs: Use ibuprofen 400 mg every 4-6 hours as needed for pain relief (do not exceed 3200 mg daily) 1, 3, 4
• Footwear modifications: Avoid flat shoes and barefoot walking; use shoes with proper arch support and cushioning 1, 3
• Orthotic devices: Start with over-the-counter heel cushions and arch supports to redistribute weight and reduce pressure 1, 3
• Activity modification: Reduce activities that worsen pain but avoid complete rest to prevent muscle weakness 3
• Weight loss: If indicated, to reduce pressure on the heel 1, 3

Important caveat: NSAIDs provide modest benefit when added to conservative measures, with evidence showing a trend toward improved pain relief especially between 2-6 months, though the effect is not dramatically superior to placebo 5

Secondary Interventions (If No Improvement After 6 Weeks)

Refer to a podiatric foot and ankle surgeon if symptoms persist beyond 6 weeks 1, 3. Continue initial measures and add:

• Customized orthotic devices: More effective than over-the-counter options for persistent cases 1
• Night splinting: Particularly beneficial for chronic pain lasting longer than 6 months 1, 3
• Corticosteroid injections: Use judiciously and in limited numbers—provides temporary relief but only marginal gains over conservative therapy 1, 6
• Casting or fixed-ankle walker device: For immobilization during activity if needed 1

Critical warning: Never inject corticosteroids near the Achilles tendon due to high risk of tendon rupture 1, 3

Refractory Cases (No Improvement After 2-3 Months)

If conservative measures fail after 2-3 months, continue initial treatments and consider:

• Cast immobilization: If not previously used 1
• Extracorporeal shock wave therapy: For chronic recalcitrant cases lasting 6 months or longer, though evidence for effectiveness remains equivocal 1, 2, 6
• Surgical plantar fasciotomy: Reserved as last resort when all conservative measures have failed 1, 2
• Re-evaluate diagnosis: Explore other causes of heel pain including stress fracture, Achilles tendonitis, Haglund's deformity, or neurologic causes 1, 7

Condition-Specific Modifications

For insertional Achilles tendonitis (posterior heel pain):

• Use open-backed shoes to reduce pressure on the area 1
• Add heel lifts or orthoses 1
• Avoid corticosteroid injections in this location 1
• Refer to podiatric surgeon if no improvement in 6-8 weeks 1

For Haglund's deformity with bursitis (lateral heel pain relieved barefoot, worsened by shoes):

• Open-backed shoes and accommodative padding 1, 3
• Corticosteroid injections may be used here (unlike Achilles tendon area) 1

Common Pitfalls to Avoid

• Don't use complete immobilization as first-line treatment—this causes muscular atrophy and deconditioning 3
• Don't inject steroids near tendons—particularly the Achilles tendon insertion 1, 3
• Don't delay referral beyond 6-8 weeks of failed conservative treatment 1, 3
• Don't assume the heel spur is the pain source—inflammation of surrounding tissues and possible nerve compression cause symptoms, not the spur itself 3

Expected Timeline

Most patients respond to conservative treatment within 6-8 weeks, with 90% improving without surgery 1, 2. A therapeutic response is sometimes seen within days to a week but most often by 2 weeks 4.