What is the likely diagnosis and initial management for a patient with three‑week right heel pain that began after walking in flip‑flops and playing pickleball, with C‑shaped medial‑lateral heel tenderness, pain worsened by weight‑bearing, first steps in the morning and descending stairs, aggravated by walking, pickleball and yoga, and relieved by rest, icing and ibuprofen (nonsteroidal anti‑inflammatory drug) plus acetaminophen?

Diagnosis and Management of Right Heel Pain

This patient has plantar fasciitis, and you should immediately initiate conservative treatment with daily plantar fascia and calf stretching (3-5 times daily), over-the-counter arch supports or heel cushions, NSAIDs for pain relief, activity modification including avoiding flip-flops and barefoot walking, and proper footwear with adequate arch support—continuing this regimen for 6 weeks before considering referral. 1

Clinical Diagnosis

The presentation is classic for plantar fasciitis based on several key features:

• C-shaped medial-lateral heel tenderness at the medial calcaneal tubercle is the characteristic examination finding for plantar fasciitis 2
• Pain worst with first steps in the morning and after prolonged rest is the hallmark symptom that distinguishes plantar fasciitis from other heel pathologies 3, 4, 5
• Aggravation by weight-bearing activities (pickleball, walking, descending stairs) and relief with rest fits the mechanical etiology 6
• Onset after walking in flip-flops represents a clear precipitating factor, as inadequate footwear is a known risk factor 4

The patient's symptoms have been present for only three weeks, which is important because symptoms resolve more quickly when treatment begins earlier in the disease course 3.

Initial Conservative Management (Weeks 0-6)

You should implement the following evidence-based interventions immediately:

Patient-Directed Measures

• Perform plantar fascia and calf-muscle stretching exercises 3-5 times daily—this is the cornerstone of treatment 1
• Apply ice through a wet towel for 10-minute periods to reduce inflammation 1
• Use over-the-counter heel cushions and arch supports immediately while awaiting any custom orthotics 1
• Avoid flat shoes (like flip-flops) and all barefoot walking—this is critical given the precipitating event 1
• Modify activities that worsen pain, specifically reducing pickleball intensity and modifying yoga poses that stress the heel 1

Medical Interventions

• Continue NSAIDs (such as naproxen) for pain relief and inflammation reduction, as the patient is already experiencing benefit from ibuprofen 1
• Ensure proper footwear with adequate arch support and cushioning for all activities 1
• Consider padding and strapping of the foot for additional support during activities 1

Expected Timeline

• Most patients respond to conservative treatment within 6-8 weeks 1
• 90% of patients improve with conservative techniques, though it may take 3-6 months for complete resolution 4, 6

If No Improvement After 6 Weeks

Refer to a podiatric foot and ankle surgeon while continuing initial treatments and adding 1:

• Customized orthotic devices (though these have only moderate benefit in the medium term of 7-12 weeks, with no clear advantage over prefabricated orthotics) 1
• Night splinting to maintain dorsiflexion during sleep 1
• Limited corticosteroid injections if pain remains severe 1
• Consider casting or fixed-ankle walker-type device for immobilization 1

If No Improvement After 2-3 Months

Continue conservative measures and consider 1:

• Cast immobilization if not previously used 1
• Extracorporeal shock wave therapy for recalcitrant cases 4
• Surgical options (plantar fasciotomy) as a last resort 1
• Explore alternative diagnoses including calcaneal stress fracture, nerve entrapment, or other pathology 2

Critical Caveats and Pitfalls

Imaging Considerations

• Radiographs are first-line imaging to rule out fractures, spurs, and Haglund deformity, though not typically needed for classic presentations 2
• MRI or ultrasound should be reserved for unclear diagnoses or cases not responding to initial treatment 2
• Calcaneal stress fractures can present similarly but show pain on lateral calcaneus compression and may have swelling/warmth 2

Treatment Warnings

• Avoid corticosteroid injections near the Achilles tendon due to risk of tendon rupture 1, 2
• Corticosteroid injections may temporarily relieve pain but increase risk of plantar fascia rupture and fat pad atrophy 6
• Do not delay treatment—earlier intervention leads to faster symptom resolution 3

Activity Modification

• The patient should temporarily reduce or modify pickleball rather than continuing at full intensity 1
• Yoga poses that dorsiflex the ankle or stress the plantar fascia should be avoided or modified 1
• Maintaining some activity is appropriate, but high-impact activities should be reduced during the initial treatment phase 1