What are the likely etiologies and initial management for a 71-year-old with three weeks of heel pain?

Heel Pain in a 71-Year-Old: Diagnosis and Management

For a 71-year-old with three weeks of heel pain, plantar fasciitis is the most likely diagnosis, and you should immediately initiate conservative treatment with daily stretching exercises (3-5 times daily), NSAIDs, heel cushions/arch supports, activity modification, and proper footwear—while simultaneously evaluating pain location and characteristics to rule out stress fracture, Achilles tendonopathy, or neurologic causes. 1, 2

Diagnostic Approach Based on Pain Location

The anatomic location of heel pain is your primary diagnostic guide 1:

Plantar (Bottom) Heel Pain

• Plantar fasciitis (most common): Pain with first weight-bearing steps in the morning or after prolonged sitting, with point tenderness at the medial plantar calcaneal region 1, 3, 4
• Calcaneal stress fracture: Progressively worsening pain following increased activity or change to harder walking surface; positive calcaneal squeeze test (compression from medial to lateral) 1, 3
• Nerve entrapment/neuroma: Pain accompanied by burning, tingling, or numbness 1, 3
• Heel pad syndrome: Deep, bruise-like pain in the middle of the heel 1, 3

Posterior Heel Pain

• Achilles tendonitis: Pain at the tendon insertion site 1, 2
• Haglund's deformity with retrocalcaneal bursitis: Posterior and lateral heel pain with prominent posterior superior calcaneus; pain relieved when walking barefoot but worsened by shoes 1, 2

Lateral Heel Pain

• Haglund's deformity or sinus tarsi syndrome 1, 5
• Lateral ankle ligament injury (calcaneofibular ligament sprain), particularly with history of inversion trauma 1

Critical Physical Examination Maneuvers

Perform these specific tests to differentiate diagnoses 1:

• Point tenderness palpation: Check the Achilles insertion, lateral malleolus, posterior superior calcaneus, lateral calcaneal wall, and calcaneofibular ligament course
• Calcaneal compression test: Squeeze the calcaneus from medial to lateral—positive test suggests stress fracture
• Passive dorsiflexion of ankle/first toe: Elicits discomfort in proximal plantar fascia if plantar fasciitis is present 4

Initial Imaging Decision

Order weight-bearing foot radiographs initially (sensitivity 85%, specificity 95% for plantar fasciitis) to exclude other causes and identify calcaneal spurs 1. However, radiographs are typically insensitive for fasciitis itself 1.

Do NOT order imaging if Ottawa Ankle Rules are not met (inability to bear weight immediately after injury, point tenderness over malleoli/talus/calcaneus, or inability to ambulate 4 steps) 1.

Advanced Imaging Algorithm

If radiographs are negative but pain persists >1 week, MRI without contrast or CT without contrast are equivalent alternatives 1. For suspected stress fracture with negative initial radiographs, order technetium bone scanning, as symptoms often precede radiographic findings 1, 5.

Immediate Conservative Treatment Protocol

Initiate all of the following simultaneously 2, 4:

First-Line Treatments (Start Immediately)

• Stretching exercises: Calf muscle and plantar fascia stretches 3-5 times daily—this is the most consistently effective intervention 2, 4
• NSAIDs: Oral or topical for pain relief and inflammation reduction 1, 2
• Heel cushions and arch supports: Over-the-counter options initially 2, 4
• Activity modification: Reduce activities that worsen pain, but avoid complete rest to prevent muscle weakness 2
• Ice therapy: Apply through a wet towel for 10-minute periods 2
• Proper footwear: Shoes with adequate arch support, cushioning, and proper fit 2

Additional Interventions if Plantar Fasciitis

• Heel lifts or orthoses to redistribute weight and reduce pressure 2
• Weight loss if indicated to reduce mechanical stress 1, 2

Specific Modifications Based on Diagnosis

• For Achilles tendonitis: Open-backed shoes, heel lifts, decreased activity, stretching exercises 2, 5
• For Haglund's deformity with bursitis: Open-backed shoes, accommodative padding, orthoses, NSAIDs, physical therapy 1, 5

Critical Warnings and Pitfalls

NEVER inject corticosteroids near the Achilles tendon—this significantly increases rupture risk 2, 5. Corticosteroid injections into the plantar fascia or retrocalcaneal bursa may be considered, but use judiciously 1, 2.

Do not overlook stress fractures: Patients often report increased walking activity before symptom onset, and radiographs may initially be negative (sensitivity only 12-56%) 5. If clinical suspicion is high, proceed directly to bone scan or MRI 1, 5.

Reexamine at 3-5 days post-initial visit if excessive swelling limited your initial examination 1.

Referral Algorithm

Refer to podiatric foot and ankle surgeon if 2, 5:

• No improvement after 6-8 weeks of appropriate conservative treatment
• Need for advanced imaging or diagnostic testing
• Consideration of surgical intervention (plantar fasciotomy) or extracorporeal shock wave therapy

Immediate subspecialist referral to neurology if neurologic symptoms are present (burning, tingling, numbness, or radiation beyond the heel) 5.

Expected Timeline

Most patients respond to conservative treatment within 6-8 weeks 2. If no improvement after 6 weeks, add padding and strapping, weight management, and customized orthotic devices 2. If no improvement after 2-3 months, consider cast immobilization or surgical options 2.