How should I evaluate and manage an adult with two weeks of heel pain and no known comorbidities?

Evaluation and Management of Adult Heel Pain (2 Weeks Duration)

Initial Diagnostic Approach

For an adult with two weeks of heel pain and no comorbidities, begin by localizing the pain anatomically to guide your differential diagnosis, as pain location is the most reliable clinical indicator of the underlying condition. 1

Pain Location Assessment

Determine the precise location through focused palpation:

• Plantar medial heel pain (most common): Suggests plantar fasciitis, especially if pain occurs with first steps in the morning or after prolonged sitting 2, 3, 4
• Posterior heel pain at Achilles insertion: Indicates insertional Achilles tendinopathy or retrocalcaneal bursitis 1, 5
• Posterior-lateral heel prominence: Points toward Haglund's deformity with bursitis 1, 5
• Lateral heel pain: Consider calcaneofibular ligament sprain (especially with history of inversion injury) or sinus tarsi syndrome 1
• Diffuse heel pain with calcaneal squeeze test positivity: Suspect calcaneal stress fracture 1

Key History Elements

• Onset pattern: Insidious onset favors plantar fasciitis or tendinopathy; acute onset with trauma suggests fracture or ligament injury 1, 4
• Activity changes: Recent increase in walking/running activity or change to harder surfaces suggests stress fracture 1
• Footwear relationship: Pain relieved when barefoot but worsened by shoes indicates Haglund's deformity or bursitis 1, 5
• Neurologic symptoms: Burning, tingling, or numbness suggests tarsal tunnel syndrome or nerve entrapment 1, 4

Physical Examination Maneuvers

• Palpate specific anatomic landmarks: Medial plantar calcaneal tuberosity, Achilles insertion site, posterior-superior calcaneus, lateral malleolus, and calcaneofibular ligament course 1
• Calcaneal compression test: Squeeze the calcaneus medially to laterally—pain suggests stress fracture 1
• Passive dorsiflexion of ankle and first toe: Reproduces pain in plantar fasciitis 2, 4
• Point tenderness assessment: Central tenderness at Achilles insertion with palpable medial/lateral prominence confirms insertional tendinopathy 5

Imaging Decision Algorithm

Order weight-bearing foot radiographs initially only if the patient meets Ottawa Ankle Rules criteria: inability to bear weight immediately after injury, point tenderness over malleoli/talus/calcaneus, or inability to ambulate 4 steps. 1

For patients without trauma history or those not meeting Ottawa criteria:

• No imaging needed initially for classic plantar fasciitis presentation (medial plantar heel pain, morning pain, point tenderness at calcaneal tuberosity) 2, 3
• Order radiographs if considering stress fracture, Haglund's deformity, or to exclude bony pathology 1, 5
• Advanced imaging (MRI without contrast or ultrasound) is reserved for pain persisting beyond 1 week with negative radiographs, or for recalcitrant cases 1, 5

Common Imaging Pitfall

Calcaneal stress fractures often have negative initial radiographs because symptoms precede radiographic findings—if clinical suspicion is high, proceed directly to MRI or bone scan rather than waiting for repeat radiographs. 1

Initial Conservative Management (First 6-8 Weeks)

For Plantar Fasciitis (Most Common)

Implement all of the following simultaneously 1, 2:

• Stretching exercises: Calf muscle and plantar fascia stretches performed 3-5 times daily (most consistently effective intervention) 6, 2
• Activity modification: Reduce activities that worsen pain, but avoid complete rest to prevent muscle atrophy 6
• NSAIDs: Oral ibuprofen or naproxen for pain relief and inflammation reduction 1, 6
• Ice therapy: Apply through wet towel for 10-minute periods 6
• Footwear modifications: Shoes with adequate arch support and cushioning 1, 6
• Over-the-counter heel cushions and arch supports: Redistribute weight and reduce pressure 1, 6
• Weight loss if indicated: Reduces pressure on the heel 6

For Insertional Achilles Tendinopathy

Critical warning: Never inject corticosteroids near or into the Achilles tendon due to high risk of tendon rupture. 1, 6, 5

Treatment includes 1, 5:

• Open-backed shoes: Reduce pressure on posterior heel
• Heel lifts or orthoses: Decrease tension on insertion
• NSAIDs: For pain and inflammation
• Decreased activity and stretching exercises
• Physical therapy with eccentric exercises

For Haglund's Deformity with Bursitis

• Open-backed shoes and accommodative padding 1, 6
• Orthoses 1
• NSAIDs 1
• Corticosteroid injections into the retrocalcaneal bursa only (carefully avoiding the Achilles tendon) 1, 5
• Physical therapy 1

Reexamination Timing

Always reexamine 3-5 days post-initial visit, as excessive swelling and pain can limit the initial examination within the first 48 hours. 1

Referral Indications

Refer to a podiatric foot and ankle surgeon if no improvement occurs after 6-8 weeks of appropriate conservative treatment. 1, 6

Additional referral triggers include 1:

• Need for advanced imaging or diagnostic testing
• Consideration of surgical intervention
• Neurologic symptoms requiring subspecialist evaluation (electromyography, nerve conduction studies)

Advanced Treatment Options (After Failed Conservative Care)

For persistent plantar fasciitis beyond 6-8 weeks 1, 6, 2:

• Customized orthotic devices
• Night splinting
• Physical therapy modalities
• Cast immobilization or fixed-ankle walker

For chronic recalcitrant cases (≥6 months) 6, 2:

• Extracorporeal shock wave therapy
• Plantar fasciotomy (surgical option)

Expected Outcomes

Ninety percent of patients with plantar fasciitis improve with conservative treatment within 6-8 weeks. 2 Most patients respond to the initial conservative measures, making this a self-limiting condition with excellent prognosis when managed appropriately 2, 3.