What is the best course of treatment for a patient with heel pain, tingling, and swelling, diagnosed with plantar fasciitis or heel spur syndrome, and also experiencing restless leg syndrome (RLS)?

Treatment of Heel Pain with Calcaneal Spurs and Concurrent Restless Leg Syndrome

Begin immediate conservative treatment for the heel pain with stretching exercises, NSAIDs, activity modification, proper footwear, and ice therapy, while simultaneously addressing the restless leg syndrome with gabapentin or pregabalin as first-line therapy, checking iron studies and supplementing if deficient. 1, 2, 3

Immediate Management of Heel Pain (First 6 Weeks)

Patient-Directed Interventions

• Perform calf-muscle and plantar fascia stretching exercises 3-5 times daily to reduce tension on the plantar fascia 2, 4
• Apply ice through a wet towel for 10-minute periods multiple times daily to reduce inflammation 2
• Use over-the-counter heel cushions and arch supports for immediate symptom relief 2
• Avoid barefoot walking and flat shoes, which exacerbate plantar fascia strain 2
• Modify activities that worsen pain, particularly prolonged standing or walking 1, 2

Medical Interventions

• Prescribe NSAIDs (such as naproxen) for pain relief and inflammation reduction 1, 2
• Recommend open-backed shoes to reduce pressure on the heel 5, 1
• Consider padding and strapping of the foot for additional support 1, 2
• Address weight loss if obesity is present, as it is a significant risk factor 4, 6

Critical Caveat for This Patient

The tingling and "burning" symptoms raise concern for neurologic involvement, potentially Baxter's nerve entrapment or tarsal tunnel syndrome, which can coexist with plantar fasciitis. 3, 1 If neurologic symptoms persist despite conservative heel pain treatment, referral for EMG and nerve conduction studies should be considered 3, 1.

Management of Restless Leg Syndrome

First-Line Pharmacologic Treatment

The American Academy of Sleep Medicine strongly recommends gabapentin or pregabalin as first-line therapy for RLS, with strong evidence supporting their use. 3 These agents have the advantage of potentially addressing both the RLS symptoms and any neuropathic component of the heel pain.

Iron Assessment and Supplementation

• Check serum ferritin and transferrin saturation before initiating treatment 3
• If ferritin is low with appropriate iron parameters, use ferrous sulfate supplementation 3
• For more severe iron deficiency, IV ferric carboxymaltose is strongly recommended 3

Medications to Avoid

Avoid dopamine agonists (pramipexole, ropinirole, rotigotine) as standard therapy due to high risk of augmentation with long-term use, though they may be considered for short-term use if patients prioritize immediate symptom relief over long-term adverse effects 3

If No Improvement After 6 Weeks

Escalation of Heel Pain Treatment

• Refer to a podiatric foot and ankle surgeon while continuing initial conservative treatments 1, 2
• Add customized orthotic devices (though evidence shows only moderate benefit at 7-12 weeks) 2
• Consider night splinting to maintain dorsiflexion during sleep 2, 4
• Limited corticosteroid injections may be used, but avoid injecting near the Achilles tendon due to rupture risk 1, 2

Advanced Interventions (After 2-3 Months)

• Consider casting or fixed-ankle walker-type device for immobilization 1, 2
• Extracorporeal shock wave therapy may be considered for recalcitrant cases 4, 7
• Surgical plantar fasciotomy is reserved for chronic cases lasting 6 months or longer with failed conservative treatment 4, 8

Important Clinical Pearls

Regarding the Calcaneal Spurs

The presence of heel spurs on x-ray does not indicate they are the cause of symptoms—they simply indicate the condition has been present for at least 6-12 months and represent a chronic degenerative process 7, 6. Treatment focuses on the plantar fasciitis itself, not the spurs.

Dual Benefit of Gabapentin/Pregabalin

Using gabapentin or pregabalin for RLS provides potential dual benefit if there is a neuropathic component to the heel pain, making these agents particularly appropriate for this patient 3.

Expected Timeline

Ninety percent of patients improve with conservative treatment, typically within 6-8 weeks 2, 4, 6. Persistence beyond this timeframe warrants subspecialist evaluation.