First-Line Treatment for Heel Pain
Begin immediately with conservative treatment consisting of regular calf and plantar fascia stretching exercises (3-5 times daily), over-the-counter arch supports or heel cushions, NSAIDs for pain relief, activity modification, and proper footwear with adequate arch support—continuing this regimen for 6 weeks before considering referral. 1, 2
Initial Conservative Management (0-6 Weeks)
Patient-Directed Measures
- Perform calf-muscle and plantar fascia stretching exercises 3-5 times daily, which forms the cornerstone of treatment 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 (prefabricated orthotics are as effective as custom devices in the first 12 weeks) 1, 2
- Avoid flat shoes and barefoot walking 2
- Modify activities that worsen pain, particularly prolonged standing, walking, and running 2, 3
- Consider weight loss if indicated to reduce pressure on the foot 4, 2
Medical Interventions
- Prescribe NSAIDs (such as naproxen) for pain relief and inflammation reduction 2
- Apply padding and strapping of the foot for additional support 1, 2
- Ensure proper footwear with adequate arch support and cushioning 2
Expected Timeline
Most patients (90%) will respond to these conservative measures within 6-8 weeks 2, 5. The condition is self-limiting in the majority of cases 5.
If No Improvement After 6 Weeks
Refer to a podiatric foot and ankle surgeon while continuing initial treatments 4, 1, 2. Add the following interventions:
- Customized orthotic devices (though these show only moderate benefit in the medium term of 7-12 weeks with no clear advantage over prefabricated orthotics) 1, 2
- Night splinting for dorsiflexion 1, 2
- Limited corticosteroid injections (use cautiously—effects are short-lived and carry risks of fat pad atrophy and plantar fascia rupture) 1, 3
- Consider casting or fixed-ankle walker-type device 1, 2
If No Improvement After 2-3 Months (Chronic Recalcitrant Cases)
Continue conservative measures and consider:
- Cast immobilization if not previously used 2
- Extracorporeal shock wave therapy (ultrasonography-guided focal treatment is useful for chronic cases) 2, 5, 3
- Surgical options including plantar fasciotomy 2, 5
- Surgical release of the first branch of the lateral plantar nerve if nerve entrapment is suspected (83% complete pain resolution in recalcitrant cases) 6
Critical Caveats and Pitfalls
Avoid Achilles Tendon Injury
Never inject corticosteroids near the Achilles tendon due to high risk of tendon rupture 1, 2. When treating insertional Achilles tendinopathy, use open-backed shoes and heel lifts instead 1.
Diagnostic Considerations
- Tenderness at the medial calcaneal tubercle on examination is characteristic of plantar fasciitis 1
- If pain occurs on compression of the lateral calcaneus wall slightly posterior to the subtalar joint facet, suspect calcaneal stress fracture 4, 1
- Radiographs are first-line imaging for all heel pain to identify fractures, spurs, and Haglund deformity 1
- Bone scan is indicated for suspected stress fracture with negative radiographs 4, 1
- EMG and nerve conduction studies are required if nerve entrapment (Baxter's nerve or tarsal tunnel syndrome) is suspected 1
Predictors of Treatment Failure
Patients with limited ankle dorsiflexion (inability to dorsiflex past -5°), non-severe first-step pain (≤7 on ordinal scale), and heel valgus in relaxed stance are nearly 4 times more likely to fail conservative treatment and may benefit from earlier advanced therapies 7.