What is the recommended treatment for an adult with a one‑month history of heel pain likely due to plantar fasciitis, Achilles‑tendon overload, or retro‑calcaneal bursitis?

Treatment of Adult Heel Pain at One Month

For an adult with one month of heel pain, initiate a comprehensive conservative treatment program including daily stretching exercises (plantar fascia and Achilles tendon 3-5 times daily), NSAIDs, activity modification, proper footwear with arch support, and heel cushions or orthotics—this approach resolves symptoms in approximately 90% of patients within 6-8 weeks. 1, 2

Initial Diagnostic Considerations

Before initiating treatment, localize the pain to guide therapy:

• Plantar heel pain (bottom of heel, worse with first morning steps) indicates plantar fasciitis 1, 2
• Posterior-superior heel pain (at Achilles insertion) suggests insertional Achilles tendinopathy 3
• Posterior and lateral heel pain (with prominent bone) indicates Haglund's deformity with retrocalcaneal bursitis 1
• Pain relieved barefoot but worsened by shoes points to Haglund's deformity or bursitis 1, 3

At one month duration, imaging is typically not required unless there is trauma history, inability to bear weight, or suspicion of stress fracture. 1

First-Line Conservative Treatment (Weeks 1-6)

Core Interventions—Implement All Simultaneously

Stretching exercises are the most consistently effective intervention and should be performed 3-5 times daily: 4

• Calf muscle stretches 1, 4
• Plantar fascia-specific stretches 1, 4
• Eccentric exercises for tendinopathies 4

NSAIDs for pain and inflammation: 1, 4

• Naproxen 500 mg twice daily is appropriate for acute painful conditions 5
• Continue for the initial 6-week treatment period 4
• Adjust dose in elderly or renally impaired patients 5

Activity modification: 1, 4

• Reduce activities that worsen pain but avoid complete rest to prevent muscle atrophy 4
• Limit prolonged standing and high-impact activities 2

Footwear modifications: 1, 4

• Shoes with proper arch support and cushioning 1, 4
• Open-backed shoes for posterior heel pain to reduce pressure on Achilles insertion 1, 4
• Avoid walking barefoot 2

Orthotic devices: 1, 4

• Over-the-counter heel cushions and arch supports initially 1, 4
• Heel lifts for insertional Achilles tendinopathy 1, 4

Ice therapy: 4

• Apply through a wet towel for 10-minute periods to reduce pain and inflammation 4

Weight loss if indicated to reduce heel pressure 1, 4

Critical Safety Warning

Never inject corticosteroids near or into the Achilles tendon—this significantly increases rupture risk. 1, 4, 3 If injection is considered for retrocalcaneal bursitis, it must be directed exclusively into the bursa, carefully avoiding the tendon. 3

Second-Line Treatment (Weeks 6-12 if No Improvement)

If symptoms persist after 6 weeks of appropriate conservative treatment: 1, 4

• Custom orthotic devices rather than over-the-counter options 1, 4
• Padding and strapping of the foot 4
• Physical therapy with supervised stretching and strengthening 1, 4
• Night splints to maintain dorsiflexion during sleep 2
• Corticosteroid injection (for plantar fasciitis only, never near Achilles tendon) 1, 2

When to Refer (After 6-8 Weeks)

Refer to a podiatric foot and ankle surgeon if no improvement occurs after 6-8 weeks of appropriate conservative treatment. 1, 4 At that point, consider: 1, 4

• Advanced imaging (MRI or ultrasound) to confirm diagnosis and exclude other pathology 1, 4
• Cast immobilization or fixed-ankle walker device 4
• Extracorporeal shock wave therapy for chronic cases 4, 2
• Surgical intervention (plantar fasciotomy) only after failure of conservative treatment for 6+ months 4, 2

Expected Outcomes

Most patients (approximately 90%) respond to conservative treatment within 6-8 weeks when the full treatment algorithm is properly implemented. 4, 2, 6 Since plantar fasciitis and related conditions are self-limiting, consistent adherence to the multi-modal conservative approach is essential before considering more invasive options. 2, 6

Common Pitfalls to Avoid

• Do not use corticosteroid injections near the Achilles tendon due to rupture risk 1, 4, 3
• Avoid complete immobilization early in treatment as it causes muscular atrophy 4
• Do not delay referral beyond 6-8 weeks if conservative treatment fails 1, 4
• Ensure all conservative measures are implemented simultaneously rather than sequentially for optimal outcomes 1, 4