What is the best approach to manage heel pain in a patient, considering their overall health and medical history, including potential underlying conditions such as diabetes or rheumatoid arthritis?

Heel Pain Management

Initial Conservative Treatment (First 6 Weeks)

Begin with a structured 6-week trial of conservative therapy combining stretching exercises, NSAIDs, activity modification, and proper footwear—this approach resolves symptoms in approximately 90% of patients. 1, 2, 3

Patient-Directed Measures

• Stretching exercises are the most consistently effective intervention: Perform calf muscle and plantar fascia stretches 3-5 times daily. 2, 4
• Apply ice therapy through a wet towel for 10-minute periods to reduce pain and inflammation. 2
• Use over-the-counter heel cushions and arch supports to redistribute weight and reduce pressure. 1, 2
• Modify activities that worsen pain, but avoid complete rest to prevent muscle weakness and deconditioning. 2
• Avoid flat shoes and barefoot walking during the treatment period. 1, 4
• Implement weight loss if indicated, as excess weight increases pressure on the heel. 1, 2

Pharmacologic Management

• NSAIDs (such as naproxen or ibuprofen) provide pain relief and reduce inflammation. 1, 2, 5
• Naproxen 375-750 mg twice daily has demonstrated efficacy with fewer gastrointestinal side effects compared to aspirin or indomethacin. 5

Footwear Modifications

• Select shoes with proper fit, width, adequate cushioning, and arch support. 2
• For posterior heel conditions (Achilles tendonitis, Haglund's deformity), use open-backed shoes to reduce pressure on the affected area. 1, 2

Diagnosis-Specific Considerations

Location-Based Differential Diagnosis

The pain location guides specific treatment approaches:

• Plantar heel pain (bottom of heel): Plantar fasciitis—most common cause. 1, 3
• Posterior heel pain: Insertional Achilles tendonitis or retrocalcaneal bursitis. 1, 6
• Lateral heel pain: Haglund's deformity or lateral ligament injury. 6
• Diffuse heel pain: Consider stress fracture, especially with history of increased activity or change to harder walking surfaces. 2, 6
• Burning or tingling: Neurologic causes requiring immediate subspecialist referral. 1, 2

Special Populations

For patients with diabetes or rheumatoid arthritis:

• Maintain heightened suspicion for systemic causes, infection (osteomyelitis), or vascular compromise. 6, 7
• Bilateral heel pain or pain in multiple joints suggests inflammatory arthritis rather than mechanical causes. 6
• Seek immediate evaluation if pain becomes constant at rest, or if numbness, increasing swelling, or redness develops. 2

Critical Safety Warning

Never inject corticosteroids near the Achilles tendon—this significantly increases the risk of tendon rupture. 1, 2, 4

• Corticosteroid injections may be considered for plantar fasciitis (avoiding the Achilles region) but should be used judiciously due to risk of plantar fascia rupture with overuse. 1, 4

Escalation at 6 Weeks Without Improvement

Refer to a podiatric foot and ankle surgeon if no improvement occurs after 6 weeks of appropriate conservative treatment. 1, 2, 4

Additional Treatment Options

• Add customized orthotic devices (more effective than over-the-counter options). 1, 4
• Implement night splinting to maintain dorsiflexion during sleep. 1
• Consider limited corticosteroid injections (avoiding Achilles tendon area). 1, 4
• Apply padding and strapping techniques. 1
• Use immobilization with a cast or fixed-ankle walker-type device for refractory cases. 1, 2

Escalation at 2-3 Months Without Improvement

Continue conservative measures and consider:

• Cast immobilization if not previously used. 1
• Extracorporeal shock wave therapy (non-invasive sound wave treatment). 1, 2
• Surgical intervention (plantar fasciotomy) for chronic recalcitrant cases lasting 6 months or longer. 1, 3
• Explore alternative diagnoses, particularly systemic causes if heel pain fails to respond as typical plantar fasciitis should. 7

Diagnostic Imaging Indications

Initial diagnosis is primarily clinical—imaging is reserved for specific scenarios:

• Radiographs if unable to bear weight immediately after injury, point tenderness over bones, or inability to walk 4 steps (Ottawa Ankle Rules). 6
• MRI or ultrasound for persistent pain beyond 1 week with negative radiographs. 6
• Technetium bone scan for suspected stress fracture with negative initial radiographs, as symptoms often precede radiographic findings. 6
• Advanced imaging (MRI, ultrasound) to confirm diagnosis in recalcitrant cases or rule out other pathology. 2, 4

Common Pitfalls to Avoid

• Do not overlook stress fractures: Patients often report increased walking activity before symptom onset, and radiographs may initially be negative. 6
• Reexamine 3-5 days post-injury: Excessive swelling and pain can limit the initial examination within 48 hours. 6
• Avoid complete immobilization unless specifically indicated, as this causes muscular atrophy and deconditioning. 2, 4
• Do not ignore symptoms persisting beyond 6-8 weeks—this should prompt specialist referral. 4