Can urgent care obtain a heel X‑ray and prescribe oral prednisone for my acute heel pain after a recent activity change or fall, and will they perform a local steroid injection?

Can Urgent Care Manage Acute Heel Pain with X-ray, Oral Prednisone, and Steroid Injection?

Yes, urgent care facilities can obtain heel X-rays and prescribe oral prednisone, but steroid injections should be avoided near the Achilles tendon due to rupture risk, and oral corticosteroids are not indicated for acute musculoskeletal heel pain.

X-ray Availability at Urgent Care

• Urgent care centers routinely perform heel and ankle radiographs when patients meet clinical criteria for imaging 1.
• The American College of Radiology recommends initial radiographs if you meet Ottawa Ankle Rules criteria: inability to bear weight immediately after injury, point tenderness over the malleoli/talus/calcaneus, or inability to ambulate 4 steps 2, 1.
• Weight-bearing radiographs of the foot are the initial imaging modality of choice, with 85% sensitivity and 95% specificity for identifying fractures and other bony pathology 1.
• If initial radiographs are negative but pain persists beyond 1 week, MRI without contrast or CT without contrast are equivalent alternatives for detecting occult fractures 1.

Common Pitfall with Imaging

• The American Academy of Family Physicians emphasizes always reexamining 3-5 days post-injury, as excessive swelling and pain can limit the initial examination within 48 hours 1.
• Stress fractures often show symptoms before radiographic findings become visible, requiring technetium bone scanning or MRI for early diagnosis 1.

Oral Prednisone for Acute Heel Pain

Oral corticosteroids are NOT recommended for acute musculoskeletal heel pain. The evidence does not support their use in this context:

• A randomized controlled trial of prednisone 50 mg daily for 5 days in emergency department patients with acute musculoskeletal low back pain showed no benefit in pain reduction, functional status, or return to work 3.
• More patients receiving prednisone sought additional medical treatment (40% vs 18%) compared to placebo, suggesting potential harm 3.
• Oral corticosteroids are indicated for specific conditions like rheumatoid arthritis or asthma exacerbations 4, 5, but not for acute traumatic or mechanical heel pain.

When Oral Corticosteroids Might Be Considered

• Only in chronic inflammatory conditions like insertional Achilles tendonitis or retrocalcaneal bursitis after conservative measures fail, and even then, NSAIDs are preferred first-line 6.

Steroid Injections for Heel Pain

Corticosteroid injections should be used judiciously and are absolutely contraindicated near the Achilles tendon due to significant rupture risk 1, 6.

• For Haglund's deformity with retrocalcaneal bursitis, corticosteroid injections may be considered but must avoid the Achilles tendon 1.
• The American Academy of Family Physicians warns that injections near tendons increase the risk of tendon rupture, particularly around the Achilles tendon area 6.
• Most urgent care facilities do not perform heel steroid injections due to these risks and the need for precise anatomical placement.

Appropriate Initial Management at Urgent Care

The American Academy of Family Physicians recommends the following initial treatment algorithm for acute heel pain 1, 6:

• Rest and activity modification to prevent ongoing damage 6.
• NSAIDs (oral or topical) for pain relief and reducing inflammation 1, 6.
• Cryotherapy (ice application) for 10-minute periods through a wet towel 6.
• Appropriate footwear with proper arch support and cushioning 6.
• Heel cushions or over-the-counter arch supports to redistribute weight 6.
• Weight loss if indicated to reduce pressure on the heel 6.

When to Refer Beyond Urgent Care

• No improvement after 6-8 weeks of appropriate conservative treatment 1, 6.
• Need for advanced imaging (MRI, bone scan) if radiographs are negative but symptoms persist 1.
• Consideration of physical therapy, custom orthotics, or surgical intervention 6.
• Immediate subspecialist referral if neurologic symptoms (burning, tingling) are present 1.

Clinical Decision Algorithm

1. Obtain heel X-rays if Ottawa Ankle Rules criteria are met (inability to bear weight, point tenderness over calcaneus/talus/malleoli, inability to ambulate 4 steps) 2, 1.
2. Prescribe NSAIDs (not prednisone) for pain and inflammation 1, 6.
3. Recommend conservative measures: rest, ice, heel cushions, proper footwear 6.
4. Avoid steroid injections at urgent care, especially near the Achilles tendon 1, 6.
5. Arrange follow-up in 3-5 days for reexamination if initial swelling limits assessment 1.
6. Refer to orthopedics or podiatry if no improvement in 6-8 weeks or if advanced imaging/intervention needed 1, 6.