What is the initial management for posterior heel pain without signs of infection or trauma, tender to touch?

Initial Management of Posterior Heel Pain Without Infection or Trauma

Begin immediate conservative treatment with rest, activity modification, open-backed shoes, heel lifts, NSAIDs, and stretching exercises targeting the Achilles tendon and plantar fascia, as this approach successfully resolves symptoms in 90% of patients within 6-8 weeks. 1, 2

Diagnostic Considerations

The clinical presentation of posterior heel pain with tenderness to touch most commonly indicates:

• Insertional Achilles tendonitis - pain localizes at the tendon insertion site on the posterior calcaneus 1
• Retrocalcaneal bursitis with Haglund's deformity - posterior and lateral heel pain with prominent posterior superior calcaneus 1
• Achilles enthesopathy - inflammation at the tendon-bone junction 3

Key examination findings to confirm diagnosis:

• Palpate the Achilles insertion site for point tenderness 1
• Assess for prominent posterior superior calcaneus (Haglund's deformity) 1
• Perform calcaneal compression test (medial-to-lateral squeeze) - if positive, consider stress fracture 1
• Note if pain is relieved walking barefoot but worsened by shoes, suggesting Haglund's deformity or bursitis 1, 2

First-Line Conservative Treatment Protocol

Implement all of the following measures simultaneously for 6-8 weeks:

Footwear Modifications

• Open-backed shoes to reduce direct pressure on the posterior heel 1, 2
• Heel lifts or orthoses to redistribute weight and reduce tensile stress on the Achilles tendon 1, 2, 4
• Ensure proper fit, width, and cushioning 2

Activity Management

• Rest and activity modification - reduce activities that worsen pain but avoid complete immobilization to prevent muscle atrophy 1, 2
• Limit running and prolonged standing 5

Anti-inflammatory Measures

• NSAIDs (oral or topical) for pain relief and inflammation reduction 1, 2
• Ice therapy applied through a wet towel for 10-minute periods, 3-5 times daily 2

Therapeutic Exercises

• Stretching exercises for the Achilles tendon and plantar fascia, performed 3-5 times daily 1, 2
• Eccentric exercises have proven beneficial for tendinopathies 2
• Gentle range-of-motion exercises 2

Additional Measures

• Weight loss if indicated to reduce pressure on the heel 1, 2
• Accommodative padding around the affected area 1

Critical Warnings

• Never inject corticosteroids near the Achilles tendon - this significantly increases the risk of tendon rupture 1, 2
• Corticosteroid injections may be considered for retrocalcaneal bursitis only, avoiding the tendon itself 1

Imaging Considerations

Initial imaging is not routinely required unless:

• Patient meets Ottawa Ankle Rules criteria (inability to bear weight immediately after injury, point tenderness over malleoli/talus/calcaneus, or inability to ambulate 4 steps) 1
• Suspicion of stress fracture based on positive calcaneal compression test 1
• Pain persists beyond 1 week despite conservative treatment - then consider MRI without contrast or CT without contrast 1

When to Escalate Treatment

If no improvement after 6-8 weeks of appropriate conservative treatment 1, 2:

• Refer to podiatric foot and ankle surgeon 1, 2
• Consider advanced imaging (MRI, ultrasound) to confirm diagnosis 2
• Evaluate for immobilization with cast or fixed-ankle walker 2
• Consider extracorporeal shock wave therapy for persistent cases 2
• Surgical options (Achilles debridement, retrocalcaneal bursa excision) reserved for recalcitrant cases after 6 months 3, 5

Common Pitfalls to Avoid

• Reexamine at 3-5 days post-initial visit - excessive swelling and pain within the first 48 hours can limit initial examination accuracy 1
• Do not overlook stress fractures - symptoms often precede radiographic findings 1
• Avoid complete immobilization during initial treatment to prevent muscular atrophy 2
• Most patients (90%) respond to conservative treatment within 6-8 weeks, so premature escalation to invasive treatments is unnecessary 2, 5