What are the treatment options for heel pain?

Treatment of Heel Pain

Begin with conservative management including stretching exercises (3-5 times daily), NSAIDs, activity modification, proper footwear with arch support, and heel cushions—this approach resolves symptoms in 90% of patients within 6-8 weeks. 1, 2

Initial Conservative Treatment (First 6 Weeks)

The cornerstone of heel pain management involves multiple simultaneous interventions started immediately:

Stretching Exercises

• Calf muscle and plantar fascia stretching performed 3-5 times daily is the most consistently effective intervention and should be the foundation of treatment 1, 3
• Eccentric exercises provide additional benefit for tendinopathies 1

Pain Control and Anti-Inflammatory Measures

• NSAIDs (ibuprofen 400 mg every 4-6 hours as needed) for pain relief and inflammation reduction 1, 4
• Ice therapy applied through a wet towel for 10-minute periods to reduce pain and swelling 1, 3

Footwear and Mechanical Support

• Over-the-counter heel cushions and arch supports as first-line orthotic intervention 1, 3
• Shoes with proper fit, adequate arch support, and cushioning 1
• For posterior heel pain (Achilles tendonitis/bursitis), use open-backed shoes to reduce pressure 1, 3
• Heel lifts or cushions to redistribute weight and reduce pressure 1, 3

Activity Modification

• Reduce activities that worsen pain but avoid complete rest to prevent muscle weakness and deconditioning 1, 3
• Weight loss if indicated to reduce pressure on the heel 1, 3

Additional Measures

• Padding and strapping of the foot 1, 3

Treatment at 6 Weeks If No Improvement

If symptoms persist after 6 weeks of appropriate conservative treatment, escalate to:

• Referral to a podiatric foot and ankle surgeon while continuing initial treatments 1, 3
• Customized orthotic devices (rather than over-the-counter options) 1, 3
• Night splinting for chronic pain (longer than 6 months) 1, 5
• Limited corticosteroid injections for plantar fasciitis (provides temporary relief) 1, 5

Treatment at 2-3 Months If Still No Improvement

For recalcitrant cases:

• Continue conservative measures 1
• Consider cast immobilization or fixed-ankle walker device 1, 3
• Extracorporeal shock wave therapy as a non-invasive option 1, 2
• Advanced imaging (MRI or ultrasound) to confirm diagnosis and rule out other pathology 1, 3
• Evaluate for surgical options (plantar fasciotomy) 1, 2

Critical Warnings and Pitfalls

Corticosteroid Injection Safety

• Never inject corticosteroids near the Achilles tendon due to high risk of tendon rupture 1, 3, 6
• Use corticosteroid injections judiciously and only for plantar fasciitis, not insertional Achilles tendinopathy 1, 3

Immobilization Caution

• Avoid complete immobilization to prevent muscular atrophy and deconditioning 1

Red Flags Requiring Immediate Evaluation

• Pain that becomes constant at rest 1
• Numbness or increasing swelling/redness (suggests infection or nerve compression) 1
• Burning or tingling (suggests neurologic causes requiring immediate subspecialist referral) 6

Diagnosis-Specific Modifications

For Insertional Achilles Tendinitis

• Open-backed shoes, heel lifts, NSAIDs, decreased activity, stretching exercises 6
• Absolutely avoid corticosteroid injections 3, 6

For Haglund's Deformity with Bursitis

• Open-backed shoes, accommodative padding, NSAIDs, corticosteroid injections (away from Achilles tendon), physical therapy 6

For Suspected Stress Fracture

• Protect and immobilize the foot 6
• Initial radiographs, followed by bone scan or MRI if radiographs negative 3, 6

For Neurologic Heel Pain

• Immediate subspecialist referral for EMG, nerve conduction studies, and MRI 3, 6

Expected Timeline

• Most patients respond to conservative treatment within 6-8 weeks 1, 2
• Therapeutic response may be seen in a few days to a week, but most often by two weeks 1
• 90% of patients improve with conservative techniques 2