Initial Workup and Management of Heel Pain
Begin with a focused history and physical examination to localize pain and identify the specific diagnosis, as the anatomic location of heel pain guides both diagnosis and treatment. 1
Clinical History - Key Questions
Pain location: Plantar heel pain suggests plantar fasciitis, posterior heel pain indicates Achilles tendonitis or bursitis, lateral heel pain points to Haglund's deformity or sinus tarsi syndrome, and diffuse heel pain suggests stress fracture or heel pad syndrome 1, 2
Pain timing: Pain with first steps in the morning or after prolonged sitting is classic for plantar fasciitis 3, 4
Activity changes: Progressively worsening pain following increased walking activity or change to harder walking surfaces suggests calcaneal stress fracture 2, 4
Footwear relationship: Pain relieved when walking barefoot but worsened by shoes suggests Haglund's deformity or bursitis 5, 1
Neurologic symptoms: Burning, tingling, or numbness indicates nerve entrapment rather than mechanical causes 1, 2
Trauma history: Recent fall from height or inversion injury requires consideration of acute fracture 1
Physical Examination - Essential Maneuvers
Palpation: Point tenderness at the medial plantar calcaneal region confirms plantar fasciitis; tenderness lateral to the Achilles tendon suggests Haglund's deformity; tenderness at the lateral calcaneal wall indicates stress fracture 5, 1, 4
Calcaneal squeeze test: Compress the calcaneus from medial to lateral—pain is highly suspicious for calcaneal stress fracture 1, 2
Ankle dorsiflexion assessment: Inability to dorsiflex the ankle past -5° predicts poorer response to conservative treatment and may require earlier advanced therapies 6
Passive dorsiflexion of ankle/first toe: Discomfort in the proximal plantar fascia with this maneuver supports plantar fasciitis diagnosis 3
Achilles tendon examination: Palpate for prominence medially and laterally to the insertion, and assess for spurring—avoid corticosteroid injections in this area due to rupture risk 5, 7
Imaging - When and What to Order
Initial radiographs: Order weight-bearing radiographs if the 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
For persistent pain: If radiographs are negative but pain persists >1 week, MRI without contrast or CT without contrast are equivalent alternatives 1, 2
For suspected stress fracture: Technetium bone scanning is recommended when initial radiographs are negative, as symptoms often precede radiographic findings 1, 2
Routine imaging not needed: For typical plantar fasciitis presentation, imaging is reserved for atypical presentations or those not responding to initial treatment 3, 8
Initial Conservative Treatment Algorithm
First-Line Treatment (0-6 Weeks)
Implement all of the following patient-directed measures simultaneously: 5
Stretching exercises: Regular calf-muscle and plantar fascia stretching 3-5 times daily—this is the most consistently effective intervention 5, 7
Footwear modifications: Avoid flat shoes and barefoot walking; use shoes with proper arch support and cushioning 5, 7
Over-the-counter supports: Heel cushions and arch supports to redistribute weight and reduce pressure 5, 7
Activity modification: Limit activities that worsen pain but avoid complete rest to prevent muscle weakness 5, 7
Cryotherapy: Ice application through a wet towel for 10-minute periods to reduce pain and inflammation 5, 7
NSAIDs: Oral or topical for pain relief and reducing inflammation 5, 7
Weight loss: If indicated, to reduce pressure on the heel 5, 7
Second-Line Treatment (6-8 Weeks if No Improvement)
Refer to a podiatric foot and ankle surgeon if no improvement occurs after 6 weeks of appropriate conservative treatment. 5, 7
Continue initial measures and add:
Customized orthotic devices: For better arch support and pressure redistribution 5
Night splinting: To maintain dorsiflexion during sleep 5
Corticosteroid injections: Limited number, appropriate for plantar fasciitis but never near the Achilles tendon due to rupture risk 5, 7
Immobilization: Casting or fixed-ankle walker-type device for refractory cases 5
Third-Line Treatment (2-3 Months if No Improvement)
Cast immobilization: If not previously used 5
Extracorporeal shock wave therapy: Non-invasive sound wave treatment for persistent heel pain 5, 7
Surgical consultation: Plantar fasciotomy for chronic recalcitrant cases lasting 6 months or longer 5, 3, 8
Diagnosis-Specific Modifications
Insertional Achilles Tendonitis
- Open-backed shoes to reduce pressure on the area 5
- Heel lifts or orthoses 5
- Avoid corticosteroid injections near the tendon insertion 5
- Immobilization for acute or refractory cases 5
Haglund's Deformity with Bursitis
- Open-backed shoes and accommodative padding 5
- Corticosteroid injections into the bursa (avoiding the Achilles tendon) 5
- Surgical resection of prominent posterior superior calcaneus if conservative treatment fails after 6-8 weeks 5
Neurologic Heel Pain
- Immediate subspecialist referral for evaluation and diagnostic testing including electromyography, nerve conduction velocity studies, and MRI 5, 1
Critical Pitfalls to Avoid
Corticosteroid injection placement: Never inject near the Achilles tendon—this significantly increases rupture risk 5, 7
Delayed reexamination: Always reexamine 3-5 days post-injury, as excessive swelling and pain can limit the initial examination within 48 hours 1
Overlooking stress fractures: Patients often report increased walking activity before symptom onset, and radiographs may initially be negative—maintain high clinical suspicion 1, 2
Premature imaging: For typical plantar fasciitis, diagnosis is clinical; imaging is unnecessary unless presentation is atypical or treatment fails 3, 8
Complete immobilization: Avoid prolonged complete rest to prevent muscular atrophy and deconditioning 7