What is the best treatment approach for a patient with heel pain?

Heel Pain Treatment

Begin immediately with a structured conservative treatment regimen including daily calf and plantar fascia stretching (3-5 times daily), over-the-counter arch supports or heel cushions, NSAIDs (such as naproxen), ice application, activity modification, and proper footwear—continuing this approach for 6 weeks before escalating care. 1, 2

Initial Assessment and Diagnosis

Before initiating treatment, localize the pain anatomically as this guides both diagnosis and management 2:

• Plantar heel pain (medial calcaneal tubercle tenderness) indicates plantar fasciitis 2, 3
• Posterior heel pain suggests Achilles tendonitis or bursitis 2
• Lateral heel pain points to Haglund's deformity or sinus tarsi syndrome 2
• Pain with lateral calcaneal wall compression indicates possible stress fracture 2, 3
• Burning, tingling, or numbness suggests nerve entrapment requiring immediate subspecialist referral 2

Order initial radiographs only if Ottawa Ankle Rules criteria are met or if stress fracture is suspected 2, 3. For persistent pain with negative radiographs, technetium bone scanning can confirm stress fracture 2, 3.

First-Line Conservative Treatment (0-6 Weeks)

Implement all of these patient-directed measures simultaneously 1, 2:

• Stretching exercises: Perform calf-muscle and plantar fascia stretches 3-5 times daily 1, 3
• Cryotherapy: Apply ice through a wet towel for 10-minute periods to reduce inflammation 1
• Footwear modifications: Use shoes with adequate arch support and cushioning; avoid flat shoes and barefoot walking 1, 2
• Over-the-counter supports: Insert heel cushions and arch supports 1, 2
• NSAIDs: Prescribe naproxen 500 mg twice daily (or 250 mg every 6-8 hours) for pain relief and inflammation reduction, not exceeding 1000 mg daily after the first day 1, 4
• Activity modification: Reduce activities that worsen pain 1, 2
• Weight loss: Consider if indicated to reduce pressure on the foot 1, 2
• Padding and strapping: Apply for additional foot support 1

Most patients respond to this conservative regimen within 6-8 weeks 1. The evidence shows that while NSAIDs may provide incremental benefit when combined with conservative measures, the stretching and mechanical interventions form the foundation of treatment 5.

Second-Line Treatment (After 6 Weeks Without Improvement)

If no improvement occurs after 6 weeks, refer to a podiatric foot and ankle surgeon while continuing initial treatments and adding 1, 2, 3:

• Customized orthotic devices: Note that these show only moderate benefit in the medium term (7-12 weeks) with no clear advantage over prefabricated orthotics 1
• Night splinting: Add to maintain dorsiflexion during sleep 1, 3
• Limited corticosteroid injections: Use judiciously for plantar fasciitis 1, 3
• Casting or fixed-ankle walker device: Consider for immobilization if other measures fail 1, 3

Third-Line Treatment (After 2-3 Months Without Improvement)

For chronic recalcitrant cases lasting 6 months or longer, consider 1, 2:

• Cast immobilization: If not previously used 1
• Extracorporeal shock wave therapy: For persistent cases 1, 6
• Surgical options: Plantar fasciotomy as a last resort 1, 6
• Alternative diagnoses: Reassess for other causes 1

Approximately 90% of patients improve with conservative techniques, making surgery rarely necessary 6.

Critical Caveats and Pitfalls

Never inject corticosteroids near the Achilles tendon insertion site due to significant rupture risk 1, 2, 3. This is particularly important when treating insertional Achilles tendinopathy or posterior heel conditions.

For insertional Achilles tendinopathy specifically, use open-backed shoes, heel lifts or orthoses, and avoid corticosteroid injections entirely 2, 3.

For Haglund's deformity with bursitis, corticosteroid injections may be placed into the bursa itself but must carefully avoid the Achilles tendon 2.

Avoid complete immobilization initially to prevent muscular atrophy and deconditioning 2.

Reexamine patients 3-5 days post-injury if initial presentation involved trauma to avoid overlooking stress fractures, which may have negative initial radiographs 2, 3.

Diagnosis-Specific Modifications

Patients with severe ankle equinus (inability to dorsiflex past -5°) are nearly 4 times more likely to respond favorably to conservative treatment centered on Achilles stretching 7. Conversely, patients without severe equinus or without severe first-step pain may require earlier escalation to advanced therapies 7.