What treatment options are recommended for a 56-year-old male patient with heel pain, intermittent heartburn, and neck pain, who does not meet the criteria for medical shoes and has no history of exercises or stretching?

Treatment Recommendations for Heel Pain, Heartburn, and Neck Pain

Heel Pain Management

This patient should begin simultaneous conservative treatments including stretching exercises (3-5 times daily), over-the-counter heel cushions or arch supports, NSAIDs, activity modification, ice therapy, and weight loss if indicated, with reassessment at 6 weeks. 1

Initial Conservative Treatment (First 6 Weeks)

The American Academy of Family Physicians recommends implementing all patient-directed measures simultaneously rather than sequentially 1:

• Stretching exercises: Calf muscle and plantar fascia stretches performed 3-5 times daily are the most consistently effective intervention 2
• Footwear modifications: Proper shoes with adequate arch support and cushioning 1
• Over-the-counter supports: Heel cushions and arch supports to redistribute weight and reduce pressure 2
• Activity modification: Reduce activities that worsen pain but avoid complete rest to prevent muscle weakness and deconditioning 1, 2
• Ice therapy: Apply through a wet towel for 10-minute periods to reduce pain and inflammation 2
• NSAIDs: Oral ibuprofen or naproxen for short-term pain relief 2
• Weight loss: If indicated, to reduce pressure on the heel 2

Second-Line Treatment (If No Improvement After 6 Weeks)

If symptoms persist after 6 weeks of conservative treatment, add 1:

• Customized orthotic devices: More effective than over-the-counter options for persistent cases 1
• Night splinting: Dorsiflexion night splints for chronic pain (longer than 6 months) 3
• Corticosteroid injections: May provide temporary relief but should be used judiciously 3

Critical Pitfall to Avoid

Never inject corticosteroids near the Achilles tendon due to significant rupture risk 1, 2. This patient's neck pain location should be clarified to ensure the heel pain is not posterior (Achilles-related) before considering injections.

When to Refer

Refer to a podiatric foot and ankle surgeon if no improvement occurs after 6-8 weeks of appropriate conservative treatment 1, 2. Surgical consultation may be necessary for chronic recalcitrant cases lasting 6 months or longer 1.

---

Intermittent Heartburn Management

For intermittent heartburn, initiate omeprazole 20 mg once daily taken before meals for up to 4 weeks to treat symptomatic GERD. 4

Treatment Details

• Dosage: Omeprazole 20 mg once daily 4
• Timing: Take before meals 4
• Duration: Up to 4 weeks for symptomatic GERD 4
• Administration: Swallow capsules whole; if unable to swallow, may open capsule and mix pellets with one tablespoon of applesauce (do not chew pellets) 4
• Antacids: May be used concomitantly with omeprazole 4

When to Escalate

If symptoms persist beyond 4 weeks or worsen, consider endoscopy to evaluate for erosive esophagitis, which would require 4-8 weeks of treatment 4. If heartburn becomes frequent or severe, reassess for complications.

---

Neck Pain Management

This patient should begin a structured program of stretching exercises and physical activity, as he reports doing no exercises or stretching, which is a modifiable factor contributing to his neck pain. 5

Initial Conservative Approach

The EULAR recommendations emphasize that physical activity and exercise have strong evidence for pain management 5:

• Stretching exercises: Gentle range-of-motion exercises for the neck performed regularly 5
• Physical activity: Advice to stay active rather than remain sedentary 5
• Ergonomic assessment: Evaluate workplace and home positioning that may contribute to posterior neck pain 5

When to Consider Referral

If the patient cannot initiate physical activity and exercises without help, consider referral to a physiotherapist for individually tailored graded physical exercise or strength training 5. If psychosocial factors such as fear of movement or catastrophizing cognitions underlie a disabled, sedentary lifestyle, consider a multidisciplinary intervention including cognitive-behavioral therapy 5.

Red Flags Requiring Immediate Evaluation

Ensure the neck pain is mechanical in nature. If neurologic symptoms (burning, tingling, numbness, weakness) are present, immediate subspecialist referral for evaluation and diagnostic testing is necessary 1, 6.

---

Integrated Treatment Algorithm

1. Week 0-6: Implement all conservative measures simultaneously for heel pain, start omeprazole for heartburn, and initiate stretching/exercise program for neck pain
2. Week 6: Reassess heel pain; if no improvement, add customized orthotics, night splints, or consider corticosteroid injection (avoiding Achilles tendon area)
3. Week 4: Reassess heartburn; if persistent, consider endoscopy or extended treatment
4. Week 6-8: If neck pain persists despite stretching, refer to physiotherapy for supervised exercise program
5. Week 8+: If heel pain remains refractory, refer to podiatric surgeon for advanced imaging or surgical consultation