What is the treatment for enthesitis of the heel?

Treatment of Heel Enthesitis

For heel enthesitis in the context of spondyloarthritis or psoriatic arthritis, start with NSAIDs and physical therapy, then proceed to local corticosteroid injections (avoiding peri-tendon placement near the Achilles), and escalate to biologic therapy (TNF inhibitors, IL-17 inhibitors, or IL-12/23 inhibitors) if symptoms persist despite conservative measures. 1, 2

Initial Conservative Management

First-line treatment consists of NSAIDs combined with non-pharmacologic measures:

• NSAIDs are the cornerstone of initial therapy for enthesitis, with continuous dosing recommended initially until symptoms improve, then transitioning to on-demand use 1
• Selective COX-2 inhibitors should be used in patients at high risk for gastrointestinal complications 1
• Physical therapy is strongly recommended, with active supervised exercise preferred over passive modalities like massage or ultrasound 1
• Patient-directed measures include calf-muscle stretching, cryotherapy, heel cushions, activity modification, weight loss if indicated, and avoiding flat shoes or barefoot walking 1, 2

Local Corticosteroid Injections

If enthesitis persists after 6 weeks of NSAIDs and conservative measures, local corticosteroid injection is conditionally recommended:

• Injections should be perientheseal rather than intraentheseal when possible to minimize rupture risk 3
• Ultrasound guidance is strongly encouraged to confirm inflammation, exclude tendon rupture, and ensure accurate needle placement 2, 3
• Avoid peri-tendon injections of the Achilles, patellar, and quadriceps tendons due to significant rupture risk 1, 2
• For plantar fasciitis-related heel enthesitis, injection at the medial plantar calcaneal region is appropriate 2
• Consider diagnostic ultrasound before injection to document inflammation that would benefit from corticosteroid therapy 3

Critical caveat: The evidence for entheseal corticosteroid injection efficacy in spondyloarthritis is limited and based primarily on expert opinion rather than high-quality trials 3. One observational study failed to show benefit of sulfasalazine for peripheral enthesitis 1.

Escalation to Biologic Therapy

If enthesitis remains active despite NSAIDs and local measures, biologic DMARDs are indicated:

• TNF inhibitors are effective for enthesitis and represent the traditional first biologic choice 1, 4
• IL-17 inhibitors (secukinumab, ixekizumab) are strongly recommended for active disease despite NSAIDs, particularly when skin psoriasis is prominent 1
• IL-12/23 inhibitors may also be considered when skin involvement is relevant 1
• Conventional synthetic DMARDs (methotrexate, sulfasalazine, leflunomide) are NOT effective for isolated enthesitis and should not be used for this indication 1

Treatment Algorithm

1. Weeks 0-6: NSAIDs (continuous dosing) + physical therapy + patient-directed measures 1, 2
2. If no improvement at 6 weeks: Add local corticosteroid injection (ultrasound-guided, perientheseal) 1, 2, 3
3. If no improvement at 3 months: Initiate biologic DMARD (TNF inhibitor or IL-17 inhibitor) 1
4. If primary non-response to first TNF inhibitor: Switch to IL-17 inhibitor or different TNF inhibitor 1

Additional Considerations

• Systemic corticosteroids are strongly recommended against for enthesitis management 1
• Night splinting and customized orthotic devices may be added as adjunctive measures 1, 2
• Immobilization (casting or walker boot) is reserved for particularly acute or refractory cases 1, 2
• Surgical consultation (plantar fasciotomy for plantar fasciitis, Achilles debridement for Achilles enthesopathy) is considered only after 6 months of failed conservative and medical management 1, 2, 5

Heel enthesitis is the most frequent site of peripheral enthesitis in spondyloarthritis and may be the sole manifestation of disease for prolonged periods 6. The lower limb entheses are more commonly affected than upper limb sites 6.