Treatment of Left Heel Pain Radiating to Achilles Tendon
Begin with conservative management including calf-muscle stretching exercises (3-5 times daily), NSAIDs for pain relief, heel lifts or orthoses, open-backed shoes to reduce pressure, activity modification, and cryotherapy—avoiding corticosteroid injections near the Achilles tendon due to rupture risk. 1
Initial Diagnostic Considerations
The clinical presentation of heel pain radiating to the Achilles suggests insertional Achilles tendonitis as the primary diagnosis, though you must also consider retrocalcaneal bursitis and Haglund's deformity. 1, 2
Key examination findings to confirm:
- Tenderness at the Achilles tendon insertion site on the posterior calcaneus 1, 2
- Pain aggravated by increased activity and pressure from shoes, relieved when walking barefoot 1
- Prominence medially and laterally to the Achilles insertion on palpation 1
- Radiographs showing spurring or erosion at the Achilles insertion 1
First-Line Conservative Treatment (0-6 Weeks)
Implement all of the following simultaneously:
Mechanical interventions:
- Open-backed shoes to eliminate posterior heel pressure 1, 3
- Heel lifts or orthoses to reduce tensile stress on the tendon 1, 3
- Activity modification—continue activities that don't worsen pain but avoid complete immobilization to prevent muscle atrophy 1
Exercise therapy:
- Calf-muscle stretching exercises 3-5 times daily—this is the most consistently effective intervention 3
- Eccentric exercise programs have proven beneficial specifically for Achilles tendinosis 1, 4
- Avoid complete rest; tensile loading stimulates collagen production and proper fiber alignment 1
Pain management:
- NSAIDs (oral or topical) for pain relief—topical formulations eliminate GI hemorrhage risk 1, 3
- Cryotherapy through a wet towel for 10-minute periods for short-term pain relief 1, 3
Weight management if indicated to reduce mechanical stress 1, 3
Critical Warning: Corticosteroid Injections
Never inject corticosteroids near the Achilles tendon—they reduce tensile strength and predispose to spontaneous rupture. 1, 3 While peritendinous injections may provide short-term relief in acute phases, they don't alter long-term outcomes and may inhibit healing. 1 This is a common pitfall that must be avoided.
Second-Line Treatment (6-8 Weeks Without Improvement)
Refer to a podiatric foot and ankle surgeon if no improvement occurs after 6-8 weeks of appropriate conservative treatment. 1, 2, 3
Continue initial treatments and add:
- Immobilization with a cast or fixed-ankle walker-type device during activity 1, 3
- Night splinting to maintain dorsiflexion 1
- Customized orthotic devices if not already implemented 1
Advanced Imaging When Needed
If diagnosis is uncertain or symptoms persist despite treatment:
- Ultrasound demonstrates tendon thickening and heterogeneous echogenicity 1
- MRI shows partial tears, tendon thickening, bursitis, and chronic degenerative changes with 95% sensitivity and specificity 1
- Plain radiographs may reveal calcific tendinosis, calcaneal avulsion fracture, or soft-tissue swelling 1
Refractory Cases (2-3 Months Without Improvement)
Continue conservative measures and consider:
- Extracorporeal shock wave therapy—has high evidence-based effectiveness 1, 4
- Surgical debridement (plantar fasciotomy or Achilles debridement with repair) 1, 5
- Explore alternative diagnoses including neurologic causes, stress fracture, or systemic conditions 1, 2
Common Pitfalls to Avoid
- Don't inject corticosteroids near the Achilles tendon—this cannot be overstated 1, 3
- Don't completely immobilize initially—this causes muscle atrophy and deconditioning 1
- Don't delay referral beyond 6-8 weeks of failed conservative treatment 1, 2, 3
- Reexamine 3-5 days post-initial evaluation if excessive swelling limited your initial examination 2