What are the treatment options for a patient experiencing pressure pain on their heels?

Treatment of Heel Pressure Pain

Start immediate conservative treatment for all patients with heel pressure pain, including stretching exercises (3-5 times daily), cryotherapy, footwear modifications, NSAIDs, activity modification, weight loss if indicated, and padding/strapping—this approach resolves symptoms in approximately 80-90% of patients within 6-8 weeks. 1, 2, 3

Immediate First-Line Treatment (Weeks 0-6)

Patient-Directed Interventions

• Perform calf muscle and plantar fascia stretching exercises 3-5 times daily as the cornerstone of treatment 2
• Apply ice through a wet towel for 10-minute periods to reduce inflammation 2
• Use over-the-counter heel cushions and arch supports immediately 2
• Avoid flat shoes and barefoot walking entirely 2
• Modify activities that worsen pain 2
• Pursue weight loss if indicated to reduce pressure on the foot 2

Medical Interventions

• Prescribe NSAIDs (such as naproxen) for pain relief and inflammation reduction 2
• Apply padding and strapping of the foot for additional support 2
• Ensure proper footwear with adequate arch support and cushioning 2
• Consider topical corticosteroid administered by iontophoresis, which has limited evidence for effectiveness 4

Critical Diagnostic Considerations During Initial Treatment

• Obtain radiographs as first-line imaging for all heel pain to identify fractures, spurs, and Haglund deformity 1
• Examine for tenderness at the medial calcaneal tubercle (characteristic of plantar fasciitis) 1
• Check for pain on compression of lateral calcaneus wall (indicative of calcaneal stress fracture) 1
• Note any swelling and warmth that may suggest stress fracture 1

If No Improvement After 6 Weeks

Refer to a podiatric foot and ankle surgeon while continuing all initial treatments 1, 2

Additional Interventions to Add

• Customized orthotic devices (moderate benefit only in medium term of 7-12 weeks, with no clear advantage over prefabricated orthotics) 2
• Night splinting for patients with chronic pain (longer than 6 months), which has limited evidence for effectiveness 2, 4
• Limited corticosteroid injections for temporary pain relief—injected corticosteroid provides some evidence for short-term effectiveness 4
• Consider casting or fixed-ankle walker-type device 1, 2

Advanced Imaging if Diagnosis Unclear

• Use MRI or ultrasound to evaluate heel fat pad pathology, stress fractures not visible on x-ray, or soft tissue pathology 1
• Order bone scan for suspected stress fracture with negative radiographs 1
• Obtain EMG and nerve conduction studies for suspected nerve entrapment (Baxter's nerve or tarsal tunnel syndrome) 1

If No Improvement After 2-3 Months

Continue all conservative measures and escalate to 2:

• Cast immobilization if not previously used
• Surgical options (plantar fasciotomy)
• Extracorporeal shock wave therapy (though evidence is conflicting for effectiveness in reducing night pain, resting pain, and pressure pain) 4
• Explore alternative diagnoses including systemic causes 5

Critical Pitfalls to Avoid

Never inject corticosteroids near the Achilles tendon due to risk of tendon rupture—inject carefully to avoid the Achilles insertion site when treating plantar conditions 2

Special Considerations for Insertional Achilles Tendinopathy

• Use open-backed shoes and heel lifts 1
• Avoid corticosteroid injections near the Achilles tendon to prevent rupture 1

When to Suspect Alternative Diagnoses

• Consider systemic causes if heel pain is recalcitrant to standard treatment 5
• Pain medial to the Achilles tendon may represent flexor hallucis longus tendinopathy or tibialis posterior dysfunction 6
• True Achilles tendinopathy presents with posterior heel pain proximal to the tendon insertion with thickening and tender, palpable nodules 6

Expected Outcomes

Most patients (80-90%) respond to conservative treatment within 6-8 weeks, with the condition being self-limiting in the majority of cases 6, 2, 3