What is the appropriate management for a patient presenting with unilateral heel pain?

Management of Unilateral Heel Pain

Begin with a systematic diagnostic approach based on pain location, then initiate conservative treatment immediately while ruling out serious pathology—most cases resolve within 6-8 weeks with appropriate conservative management. 1

Diagnostic Algorithm by Pain Location

Plantar (Bottom) Heel Pain

• Plantar fasciitis is the most common cause, presenting with sharp pain on the first steps in the morning or after prolonged sitting, with point tenderness at the medial plantar calcaneal region 1, 2
• Perform passive ankle/first toe dorsiflexion to elicit discomfort in the proximal plantar fascia 3
• Calcaneal stress fracture presents with progressively worsening pain following increased walking activity or change to harder surfaces—perform the calcaneal squeeze test (medial-to-lateral compression), which is highly suspicious if positive 1, 4
• Tenderness localizes to the lateral calcaneal wall, slightly posterior to the subtalar joint facet in stress fractures 1

Posterior Heel Pain

• Indicates Achilles tendonitis with pain at the tendon insertion site 1
• Haglund's deformity with retrocalcaneal bursitis causes posterior and lateral heel pain, particularly when a prominent posterior superior calcaneus is visible 1
• Pain relieved when walking barefoot but worsened by shoes strongly suggests Haglund's deformity or bursitis 1, 5

Lateral Heel Pain

• Consider lateral ankle ligament injury (calcaneofibular ligament sprain), particularly with history of inversion trauma and pain with dorsiflexion 1
• Lateral process fracture of the talus ("snowboarder's fracture") causes lateral and posterior ankle pain with antalgic gait following inversion trauma 1
• Rapid onset of swelling suggests acute ligamentous injury or fracture 1

Neurologic Causes

• Burning, tingling, or numbness accompanying heel pain indicates nerve entrapment 1, 4
• Immediate subspecialist referral is required for neurologic heel pain for electromyography, nerve conduction studies, and MRI 1

Initial Imaging Decision

Apply Ottawa Ankle Rules

• Order radiographs if the patient has: inability to bear weight immediately after injury, point tenderness over malleoli/talus/calcaneus, or inability to ambulate 4 steps 1
• If radiographs are negative but pain persists >1 week, MRI without contrast or CT without contrast are equivalent alternatives 1, 4
• For suspected stress fracture with negative initial radiographs, order technetium bone scanning, as symptoms often precede radiographic findings 1, 4

Critical Timing Consideration

• Always reexamine 3-5 days post-injury, as excessive swelling and pain can limit the initial examination within 48 hours 1

First-Line Conservative Treatment (Initiate Immediately)

For Plantar Fasciitis (Most Common)

• Stretching exercises for plantar fascia and Achilles tendon 3-5 times daily—this is the most consistently effective intervention 5, 3
• Rest and activity modification to prevent ongoing damage 5
• NSAIDs (oral or topical) for pain relief and reducing inflammation 5
• Ice therapy through a wet towel for 10-minute periods 5
• Over-the-counter heel cushions and arch supports 1, 5
• Proper footwear with adequate arch support and cushioning 5
• Weight loss if indicated to reduce pressure on the heel 1, 5

For Insertional Achilles Tendonitis

• Open-backed shoes to reduce pressure 1
• Heel lifts or orthoses 1, 5
• NSAIDs and decreased activity 1
• Stretching exercises (eccentric exercises have proven beneficial for tendinopathies) 5

For Haglund's Deformity with Bursitis

• Open-backed shoes 1
• Orthoses and accommodative padding 1
• NSAIDs 1
• Corticosteroid injections may be considered, but NEVER near the Achilles tendon 1, 5
• Physical therapy 1

For Traumatic Heel Pain (Stress Fracture)

• Protect and immobilize the foot 1
• Consider immobilization with cast or fixed-ankle walker-type device 5
• Imaging studies (X-ray initially, bone scan if needed) 1

Critical Pitfall to Avoid

Never inject corticosteroids near the Achilles tendon—this significantly increases the risk of tendon rupture. 1, 5 Use corticosteroid injections judiciously in all heel pain cases 5

Escalation Timeline

At 6 Weeks

• If no improvement with first-line treatments, add: padding and strapping of the foot, customized orthotic devices, and intensify weight management 5
• Continue all conservative measures 5

At 6-8 Weeks

• Refer to podiatric foot and ankle surgeon if no improvement occurs 1, 5
• Consider advanced imaging (MRI, ultrasound) to confirm diagnosis and rule out other conditions 5

At 2-3 Months (Chronic Recalcitrant Cases)

• Continue conservative measures 5
• Consider cast immobilization 5
• Evaluate for extracorporeal shock wave therapy (non-invasive sound wave treatment) 5, 3
• Consider surgical options (plantar fasciotomy) 5, 3

Red Flags Requiring Immediate Evaluation

• Pain becomes constant at rest 5
• Numbness or increasing swelling/redness (rule out infection or nerve compression) 5
• Bilateral symptoms with pain in other joints (consider arthritides) 1
• History of trauma with focal tenderness (rule out acute calcaneal fracture) 1, 4
• Progressively worsening pain without mechanical explanation (consider tumors, infections, or vascular compromise) 1, 4

Expected Outcomes

Most patients (90%) respond to conservative treatment within 6-8 weeks, with symptoms resolving more quickly when treatment begins earlier after symptom onset 1, 3, 6