Management of Heel Pain with History of Metatarsal Stress Fractures

Diagnostic Considerations

The American Family Physician recommends beginning immediate conservative treatment with calf-muscle stretching, NSAIDs, heel cushions/arch supports, activity modification, and avoiding flat shoes or barefoot walking, while obtaining weight-bearing radiographs to rule out calcaneal stress fracture given the patient's history of stress fractures 1, 2
Insertional Achilles tendonitis typically causes posterior heel pain at the tendon insertion, with pain aggravated by shoes but relieved when walking barefoot, as noted by the American Family Physician 1, 4
Haglund's deformity with bursitis causes posterior and lateral heel pain, also relieved by barefoot walking, according to the American Family Physician and Praxis Medical Insights 1, 3, 4

The Journal of the American College of Radiology recommends obtaining weight-bearing radiographs as the first imaging study 2
Radiographs should be the initial study for any patient with painful heel, with weight-bearing views specifically recommended, as stated by the Journal of the American College of Radiology 2
For plantar fasciitis, radiographs showing thickened plantar fascia and fat pad abnormalities have 85% sensitivity and 95% specificity, according to the Journal of the American College of Radiology 2
Stress fracture symptoms often precede radiographic findings by 2+ weeks, as noted by Praxis Medical Insights 3

The American Family Physician recommends regular calf-muscle stretching exercises, cryotherapy/ice massage, over-the-counter heel cushions and arch supports, activity limitation and modification, and avoiding flat shoes and barefoot walking 1
The American Family Physician also recommends NSAIDs for pain and inflammation, padding and strapping of the foot, and corticosteroid injections in appropriate patients 1, 3

If no improvement after 6 weeks, the American Family Physician recommends referring to a podiatric foot and ankle surgeon, continuing initial treatment measures, adding a customized orthotic device, implementing night splinting, and considering limited corticosteroid injections if not previously used 1
If no improvement after 2-3 months, the American Family Physician recommends continuing all initial measures, adding cast immobilization if not previously used, considering extracorporeal shock wave therapy, and considering plantar fasciotomy (surgical option) 1

Praxis Medical Insights recommends protecting and immobilizing the foot immediately if a stress fracture is confirmed, and orthopedic referral for definitive care 3
Prolonged standing (occupational exposure) is a significant risk factor for both plantar fasciitis and stress fractures, as noted by the American Family Physician 1

Praxis Medical Insights warns against delaying imaging in patients with stress fracture history, and avoiding corticosteroid injections near the Achilles tendon 3