What is the best treatment approach for a patient with heel pain, considering their medical history, age, and occupation?

Heel Pain: Evidence-Based Treatment Approach

Immediate Diagnostic Algorithm

The best treatment for heel pain depends entirely on identifying the specific anatomic cause through pain location, patient characteristics, and targeted physical examination—with plantar fasciitis being the most common diagnosis requiring conservative management, while red flags demand urgent specialist referral. 1

Step 1: Identify Red Flags Requiring Immediate Action

In diabetic patients with any foot wound, warmth, or erythema, exclude infection FIRST as this carries the highest mortality risk. 2

• Diabetic foot infection: Presence of redness, warmth, swelling, purulent drainage requires immediate antibiotics and wound debridement 2
• Charcot neuro-osteoarthropathy: Diabetic patient with neuropathy presenting with unilateral red, warm, swollen foot with intact skin—temperature difference ≥2°C between feet supports diagnosis; initiate immediate knee-high immobilization while pursuing MRI or bone scan 2
• Neurologic symptoms: Burning, tingling, numbness, or radiation beyond the heel requires immediate subspecialist referral for electromyography, nerve conduction studies, and MRI 1, 3

Step 2: Localize Pain Anatomically

Pain location is the primary guide to diagnosis: 1, 4

Plantar Heel Pain (Most Common)

• Plantar fasciitis: Medial plantar heel pain, worst with first morning steps and after prolonged rest; tenderness at calcaneal tuberosity increased with passive toe dorsiflexion 1, 4
• Calcaneal stress fracture: Progressively worsening pain following increased activity or harder walking surface; positive calcaneal squeeze test (medial-to-lateral compression); tenderness at lateral calcaneal wall 1, 2
• Heel pad syndrome: Deep, bruise-like pain in middle of heel; diffuse tenderness 1

Posterior Heel Pain

• Insertional Achilles tendonitis: Pain at tendon insertion site on posterior calcaneus 1, 3
• Haglund's deformity with retrocalcaneal bursitis: Posterior and lateral heel pain; prominent posterior superior calcaneus visible on exam and radiographs; pain relieved walking barefoot but worsened by shoes 1, 3

Lateral Heel Pain

• Lateral ankle ligament injury: History of inversion trauma; pain with dorsiflexion; tenderness over calcaneofibular ligament 1
• Sinus tarsi syndrome: Pain in space between calcaneus and talus 1

Special Populations

• Children/adolescents: Sever disease (calcaneal apophysitis) is the most common cause 1

Step 3: Determine Need for Imaging

Apply Ottawa Ankle Rules to decide on initial radiographs: 1

• Order X-rays if: inability to bear weight immediately after injury, point tenderness over malleoli/talus/calcaneus, or inability to ambulate 4 steps 1
• If radiographs negative but pain persists >1 week: MRI without contrast or CT without contrast are equivalent alternatives 1
• For suspected stress fracture with negative X-rays: Technetium bone scan or MRI, as symptoms precede radiographic findings (X-ray sensitivity only 12-56%) 1, 3, 2

Critical timing pitfall: Always reexamine 3-5 days post-injury, as excessive swelling within first 48 hours can limit initial examination 1, 2

Treatment Protocols by Diagnosis

Plantar Fasciitis (Most Common)

Initial conservative treatment includes: 1

• Rest and activity modification 1
• NSAIDs for pain and inflammation 1
• Structured stretching exercises for plantar fascia and Achilles tendon 1
• Heel cushions, arch supports, or orthotics 1
• Weight loss if indicated 1

Insertional Achilles Tendonitis

Treatment protocol: 1, 3

• Open-backed shoes to reduce posterior heel pressure 1, 3
• Heel lifts or orthoses to decrease Achilles insertion tension 1, 3
• NSAIDs for pain and inflammation control 1, 3
• Decreased activity with gradual return to function 3
• Structured stretching exercises for Achilles tendon and calf muscles 3
• Weight loss if indicated 1, 3

CRITICAL CONTRAINDICATION: Never inject corticosteroids near the Achilles tendon due to rupture risk. 1, 3

Haglund's Deformity with Retrocalcaneal Bursitis

Treatment approach: 1, 3

• Open-backed shoes and accommodative padding 1, 3
• Orthoses to redistribute pressure 1, 3
• NSAIDs for inflammation 1, 3
• Corticosteroid injections into the bursa (NOT near Achilles tendon) 1, 3
• Physical therapy 1, 3
• Immobilization with cast or fixed-ankle walker for 2-3 weeks in particularly acute or refractory cases 3

Calcaneal Stress Fracture

Management: 1

• Protect and immobilize the foot 1
• Initial X-ray, followed by bone scan or MRI if X-rays negative 1, 2
• Avoid weight-bearing until healing confirmed 1

Neurologic Heel Pain (Tarsal Tunnel Syndrome, Nerve Entrapment)

Immediate subspecialist referral to neurology or spine for: 1, 3

• Electromyography 1, 3
• Nerve conduction studies 1, 3
• MRI 1, 3

When to Refer to Podiatric Foot and Ankle Surgeon

Refer if: 1, 3

• No improvement after 6-8 weeks of appropriate conservative treatment 1, 3
• Need for advanced imaging or diagnostic testing 1, 3
• Consideration of surgical intervention 1, 3
• Persistent symptoms despite cast immobilization 3

Common Pitfalls to Avoid

• Do not assume isolated plantar fasciitis when pain radiates proximally or has neurologic features 3
• Do not rely solely on initial radiographs to exclude stress fractures—symptoms precede radiographic changes 1, 3, 2
• Never delay immobilization if Charcot neuro-osteoarthropathy is suspected in diabetic patients—consequences include limb loss 2
• Corticosteroid injections are contraindicated near the Achilles tendon insertion 1, 3
• Always reexamine 3-5 days post-injury as initial swelling obscures findings 1, 2
• In diabetic patients with foot wounds, infection must be excluded first before considering other diagnoses 2

Patient-Specific Considerations

For occupation-related factors: Patients with increased walking activity or change to harder surfaces are at higher risk for stress fractures 1, 2

For age considerations: Children and adolescents with heel pain most commonly have Sever disease (calcaneal apophysitis) 1

For medical history: Bilateral heel pain, pain in other joints, or known inflammatory arthritis conditions should prompt consideration of systemic arthritides 1