What are the treatment options for a patient with heel pain, considering potential comorbidities such as impaired renal function or gastrointestinal issues?

Treatment of Heel Pain

Begin immediate conservative treatment for all mechanical causes of heel pain with stretching exercises (3-5 times daily), cryotherapy, NSAIDs, activity modification, proper footwear with arch support, and padding—continuing for 6 weeks before considering specialist referral. 1, 2

Initial Conservative Management (0-6 Weeks)

Patient-Directed Interventions

• Perform calf muscle and plantar fascia stretching exercises 3-5 times daily to reduce tension along the plantar fascia 1, 2
• Apply ice massage through a wet towel for 10-minute periods to reduce inflammation 2
• Use over-the-counter heel cushions and arch supports for immediate symptom relief 1, 2
• Avoid flat shoes and barefoot walking, which increase plantar fascia strain 2
• Modify activities that worsen pain, particularly prolonged standing and high-impact activities 1, 2
• Consider weight loss if indicated, as obesity is a significant risk factor for plantar fasciitis 3

Medical Interventions

• Prescribe NSAIDs such as naproxen for pain relief and inflammation reduction 1, 2
• Consider padding and strapping of the foot for additional support 1
• Ensure proper footwear with adequate arch support and cushioning 1, 2

Critical NSAID Prescribing Considerations

When prescribing naproxen or other NSAIDs, exercise caution in specific populations:

• Avoid in patients with impaired renal function, as elderly and volume-depleted patients are at increased risk for renal toxicity; monitor renal function closely 4
• Use lowest effective dose in elderly patients due to increased risk of serious GI bleeding and ulceration, which elderly patients tolerate poorly 4
• Avoid in late pregnancy due to risk of premature ductus arteriosus closure and fetal complications 4
• Monitor patients on ACE inhibitors, ARBs, or diuretics for blood pressure changes and signs of renal deterioration 4
• Exercise extreme caution with concurrent warfarin or SSRIs due to synergistic GI bleeding risk 4

Diagnostic Imaging Approach

• Obtain radiographs as first-line imaging for all heel pain to identify fractures, spurs, and Haglund deformity 1
• Reserve MRI or ultrasound for unclear diagnoses, evaluation of heel fat pad pathology, or stress fractures not visible on x-ray 1
• Order bone scan for suspected stress fracture with negative radiographs 1
• Request EMG and nerve conduction studies only when nerve entrapment (Baxter's nerve or tarsal tunnel syndrome) is suspected 1

Physical Examination Findings to Guide Diagnosis

• Tenderness at the medial calcaneal tubercle indicates plantar fasciitis 1
• Pain on compression of lateral calcaneus wall, slightly posterior to subtalar joint facet, suggests calcaneal stress fracture 1
• Swelling and warmth may accompany calcaneal stress fracture 1
• Pain reproduced by passive ankle/first toe dorsiflexion indicates plantar fascia involvement 3

If No Improvement After 6 Weeks

Refer to a podiatric foot and ankle surgeon while continuing initial treatments and adding advanced conservative measures. 1, 2

• Add customized orthotic devices (note: moderate benefit only in medium term of 7-12 weeks, with no clear advantage over prefabricated orthotics) 2
• Implement night splinting for chronic pain (longer than 6 months), which has limited evidence for effectiveness 5
• Consider limited corticosteroid injections, which provide temporary pain relief in the short term 5
• Trial casting or fixed-ankle walker-type device for immobilization 1, 2

Critical Injection Precautions

• Never inject corticosteroids near the Achilles tendon due to rupture risk 1, 2
• Inject carefully to avoid the Achilles insertion site when treating plantar conditions 2

If No Improvement After 2-3 Months

• Continue conservative measures and consider cast immobilization if not previously used 2
• Evaluate for surgical options (plantar fasciotomy), though surgery should be reserved only for pain resistant to conservative treatment after more than 1 year 6
• Consider extracorporeal shock wave therapy, though evidence shows conflicting results for effectiveness 5
• Explore alternative diagnoses including nerve entrapments, systemic inflammatory conditions (seronegative spondyloarthropathies, reactive arthritis), atherosclerosis/ischemia, and fat pad degeneration 6, 7

Special Considerations for Insertional Achilles Tendinopathy

If heel pain localizes to the Achilles insertion:

• Use open-backed shoes and heel lifts to unload the tendon 8, 1
• Implement eccentric strength training, which is particularly effective 8
• Apply stretching and deep friction massage of the gastrocnemius-soleus complex 8
• Correct anatomic misalignment with shoe orthotics for overpronation or pes planus 8
• Absolutely avoid corticosteroid injections near the Achilles tendon 1

Expected Outcomes

• Most patients respond to conservative treatment within 6-8 weeks 2
• Ninety percent of patients improve with conservative techniques 3
• Plantar fasciitis is a self-limiting condition in the majority of cases 3