What is the diagnosis and recommended treatment for a 51-year-old male with a 4-week history of heel pain that worsens with foot flexion?

Diagnosis and Treatment of Heel Pain Worsening with Foot Flexion

This presentation is most consistent with plantar fasciitis, and you should immediately initiate conservative treatment with calf and plantar fascia stretching exercises (3-5 times daily), NSAIDs, activity modification, proper footwear with arch support, and avoidance of barefoot walking. 1, 2

Key Diagnostic Features

The clinical presentation strongly suggests plantar fasciitis based on:

• Pain worsening with dorsiflexion (flexing the foot upward) is pathognomonic for plantar fasciitis, as passive ankle/first toe dorsiflexion elicits discomfort in the proximal plantar fascia 3
• Tenderness at the medial calcaneal tubercle on examination is characteristic 4
• Classic history includes heel pain with first steps in the morning or after prolonged sitting 3, 5
• Sharp pain with palpation of the medial plantar calcaneal region 3

Radiographs should be obtained as first-line imaging to rule out fractures, spurs, and other bony pathology, though diagnosis is primarily clinical 4, 2

Initial Treatment Protocol (0-6 Weeks)

Patient-Directed Measures

• Perform calf-muscle and plantar fascia stretching exercises 3-5 times daily 1, 2
• Apply ice through a wet towel for 10-minute periods to reduce inflammation 2
• Use over-the-counter heel cushions and arch supports 1, 2
• Avoid flat shoes and barefoot walking completely 1, 2
• Modify activities that worsen pain 2
• Consider weight loss if indicated 1, 2

Medical Interventions

• NSAIDs (such as naproxen) for pain relief and inflammation reduction 1, 2
• Padding and strapping of the foot for additional support 1, 2
• Proper footwear with adequate arch support and cushioning 2
• Corticosteroid injections may be considered in appropriate patients 1

If No Improvement After 6 Weeks

Refer to a podiatric foot and ankle surgeon while continuing all initial treatments 1, 4, 2

Add the following interventions:

• Customized orthotic devices (moderate benefit in 7-12 weeks, though no clear advantage over prefabricated orthotics) 2
• Night splinting 1, 2
• Limited number of corticosteroid injections 1, 2
• Casting or fixed-ankle walker-type device during activity 1, 2

If No Improvement After 2-3 Months

Continue conservative measures and consider:

• Cast immobilization if not previously used 1, 2
• Extracorporeal shock wave therapy 1, 2, 3
• Surgical plantar fasciotomy 1, 2, 3
• Explore alternative diagnoses 1, 2

Critical Caveats

• Avoid corticosteroid injections near the Achilles tendon due to risk of tendon rupture 4, 2
• Inject carefully to avoid the Achilles insertion site when using corticosteroids for plantar conditions 2
• If pain is lateral to the Achilles tendon with relief when walking barefoot, consider Haglund's deformity or insertional Achilles tendinitis instead 1
• If pain is medial to the Achilles tendon, consider flexor hallucis longus tendinopathy or tibialis posterior dysfunction 6
• If burning, tingling, or numbness accompanies pain, obtain EMG and nerve conduction studies to rule out nerve entrapment 4, 5

Expected Outcomes

• 90% of patients improve with conservative treatment 3
• Most patients respond within 6-8 weeks 2
• Approximately 80% fully recover within 3-6 months with conservative outpatient treatment 6
• Plantar fasciitis is a self-limiting condition 3