What can I prescribe to a patient with heel and Achilles pain who had surgery a year ago in primary care and to whom should I refer them?

Management of Post-Surgical Heel and Achilles Pain in Primary Care

For a patient with persistent heel and Achilles pain one year after surgery, initiate conservative treatment with NSAIDs, activity modification, heel lifts or orthoses, and structured stretching exercises, while referring to a podiatric foot and ankle surgeon if no improvement occurs within 6-8 weeks. 1

Initial Primary Care Management

Diagnostic Clarification

Before initiating treatment, determine the specific pain location and characteristics:

• Posterior heel pain at the Achilles insertion suggests insertional Achilles tendonitis or surgical site complications 1
• Lateral heel pain may indicate Haglund's deformity, retrocalcaneal bursitis, or sinus tarsi syndrome 2
• Burning or tingling sensations warrant immediate consideration of neurologic causes requiring subspecialist referral 2
• Pain relieved when barefoot but worsened by shoes strongly suggests Haglund's deformity or bursitis 1, 2

Conservative Treatment Protocol

For insertional Achilles tendonitis (most common post-surgical presentation):

• Open-backed shoes to reduce pressure on the posterior heel 1
• Heel lifts or orthoses to decrease tension on the Achilles insertion 1
• NSAIDs for pain and inflammation control 1
• Decreased activity with gradual return to function 1
• Structured stretching exercises for the Achilles tendon and calf muscles 1
• Weight loss if indicated to reduce mechanical stress 1

Critical caveat: Avoid corticosteroid injections near the Achilles tendon due to rupture risk 2

For Haglund's deformity with bursitis:

• Open-backed shoes and accommodative padding 1
• Orthoses to redistribute pressure 1
• NSAIDs for inflammation 1
• Corticosteroid injections into the bursa (carefully avoiding the Achilles tendon itself) 1
• Physical therapy 1

Immobilization Considerations

In particularly acute or refractory cases, consider:

• Immobilization cast or fixed-ankle walker-type device for 2-3 weeks 1
• This is especially appropriate if the patient has not responded to initial conservative measures 1

Referral Algorithm

Refer to Podiatric Foot and Ankle Surgeon When:

• No improvement after 6-8 weeks of appropriate conservative treatment 1, 2
• Need for advanced imaging (MRI, CT, or bone scan) to evaluate surgical site complications, stress fractures, or other pathology 2
• Consideration of revision surgery or additional surgical intervention 1
• Persistent symptoms despite cast immobilization 1

The American College of Foot and Ankle Surgeons guidelines specifically recommend podiatric foot and ankle surgeon referral as the appropriate specialty for refractory heel and Achilles pathology 1

Immediate Subspecialist Referral (Neurology/Spine) If:

• Neurologic symptoms present: burning, tingling, numbness, or radiation beyond the heel 1, 2
• Suspected lumbar radiculopathy with pain radiating proximally through the posterior leg 3
• These patients require electromyography, nerve conduction studies, and MRI evaluation 1, 3

Common Pitfalls to Avoid

• Do not inject corticosteroids near the Achilles tendon - this is explicitly contraindicated due to rupture risk 2
• Do not assume isolated plantar fasciitis when pain radiates proximally or has neurologic features 3
• Do not rely solely on initial radiographs to exclude stress fractures, as sensitivity is only 12-56% 4
• Reexamine at 3-5 days if initial assessment is limited by swelling 2
• Consider systemic causes (arthritides, infections) when symptoms are bilateral or involve other joints 2

Expected Outcomes

Research indicates that 42% of patients report full recovery at 12 months post-Achilles surgery, with persistent deficits in function for over half of patients 5. Pain and activity limitations are the most common residual problems 5. This underscores the importance of aggressive conservative management and appropriate specialist referral when improvement plateaus.

The key decision point is 6-8 weeks: If conservative measures have not produced meaningful improvement by this timeframe, referral to a podiatric foot and ankle surgeon is warranted rather than continuing ineffective primary care management 1, 2.