What is the best course of treatment for a female patient with a history of stress fractures in the metatarsal, presenting with non-radiating heel pain that worsens with weight-bearing and standing, and has no morning pain?

Management of Heel Pain with History of Metatarsal Stress Fractures

Begin immediate conservative treatment with calf-muscle stretching, NSAIDs, heel cushions/arch supports, activity modification, and avoid flat shoes or barefoot walking, while obtaining weight-bearing radiographs to rule out calcaneal stress fracture given the patient's history of stress fractures. 1

Diagnostic Considerations

Most Likely Diagnosis: Plantar Fasciitis

• The clinical presentation—pain worsening with weight-bearing after periods of rest (not present upon morning awakening but developing with walking)—is classic for plantar fasciitis 2, 3
• Pain typically localizes to the medial plantar calcaneal region at the fascia origin 3
• This is the most common cause of heel pain in adults, affecting over 1 million persons annually 2

Critical Alternative: Calcaneal Stress Fracture

• Given this patient's history of metatarsal stress fractures, calcaneal stress fracture must be ruled out 4, 5
• Calcaneal stress fractures present with progressively worsening pain following increased activity, and the patient's occupation (standing most of the time) is a significant risk factor 4
• The calcaneal squeeze test (compressing the calcaneus from medial to lateral) is highly suspicious for stress fracture if positive 4
• Tenderness localizes to the lateral calcaneal wall, slightly posterior to the subtalar joint 4

Other Differential Diagnoses to Consider

• Insertional Achilles tendonitis typically causes posterior heel pain at the tendon insertion, with pain aggravated by shoes but relieved when walking barefoot 1
• Haglund's deformity with bursitis causes posterior and lateral heel pain, also relieved by barefoot walking 1, 4

Initial Imaging Strategy

Obtain weight-bearing radiographs as the first imaging study 1

• Radiographs should be the initial study for any patient with painful heel, with weight-bearing views specifically recommended 1
• For plantar fasciitis, radiographs showing thickened plantar fascia and fat pad abnormalities have 85% sensitivity and 95% specificity 1
• Critical caveat: Stress fracture symptoms often precede radiographic findings by 2+ weeks 4, 5
• If radiographs are negative but clinical suspicion for stress fracture remains high (positive calcaneal squeeze test, lateral calcaneal wall tenderness), obtain technetium bone scan or MRI 4

Initial Treatment Protocol (First 6 Weeks)

Patient-Directed Measures

• Regular calf-muscle stretching exercises (addresses gastrocnemius tightness associated with plantar fasciitis) 1, 3
• Cryotherapy/ice massage to reduce inflammation 1, 2
• Over-the-counter heel cushions and arch supports 1
• Activity limitation and modification—reduce prolonged standing when possible 1, 2
• Avoid flat shoes and barefoot walking 1
• Weight loss if indicated (obesity is a risk factor) 1, 2

Physician-Prescribed Treatments

• NSAIDs for pain and inflammation 1, 3
• Padding and strapping of the foot 1
• Corticosteroid injections in appropriate patients (use judiciously, avoid if Achilles pathology suspected) 1, 4

Treatment Escalation Algorithm

If No Improvement After 6 Weeks

Refer to podiatric foot and ankle surgeon 1

• Continue initial treatment measures 1
• Add customized orthotic device 1
• Implement night splinting 1
• Consider limited corticosteroid injections if not previously used 1
• Consider casting or fixed-ankle walker-type device during activity 1

If No Improvement After 2-3 Months

• Continue all initial measures 1
• Add cast immobilization if not previously used 1
• Consider extracorporeal shock wave therapy 1, 2
• Consider plantar fasciotomy (surgical option) 1, 2
• Explore other diagnoses 1

Special Considerations for Stress Fracture History

If Stress Fracture Confirmed

• Protect and immobilize the foot immediately 4
• Non-weight bearing or protected weight-bearing 5
• Rest and avoidance of exercise to prevent fracture displacement, nonunion, and complications 5
• Orthopedic referral for definitive care 5

Risk Factor Modification

• The patient's history of metatarsal stress fractures indicates predisposition to stress injuries 5
• Prolonged standing (occupational exposure) is a significant risk factor for both plantar fasciitis and stress fractures 1, 2
• Any element affecting bone density should be evaluated 5

Common Pitfalls to Avoid

• Do not delay imaging in patients with stress fracture history—radiographs may be negative initially, but clinical suspicion should prompt advanced imaging 4, 5
• Avoid corticosteroid injections near the Achilles tendon—risk of rupture and fat pad atrophy 4, 3
• Do not assume plantar fasciitis without physical examination confirmation—point tenderness at the medial tubercle of the calcaneus confirms diagnosis 3
• Recognize that 90% of plantar fasciitis cases resolve with conservative treatment, but this may take 3-6 months 2, 3