Management of Heel Pain

Diagnosis

Radiographic studies are recommended to confirm diagnosis in traumatic heel pain, as suggested by the American College of Foot and Ankle Surgeons 1
Imaging (MRI or ultrasound) should only be considered if symptoms persist despite appropriate conservative management 2, 1

Rest and activity modification are recommended as first-line treatment for overuse injuries, according to the American College of Foot and Ankle Surgeons 1
Patients with flat feet should avoid barefoot walking and flat shoes, and use well-fitted athletic or walking shoes to manage symptoms, as recommended by the American Academy of Family Physicians and the American Diabetes Association 1, 3
Heel cushions and arch supports can be used for mild cases, and padding and strapping of the foot can provide temporary relief, according to the American Academy of Family Physicians 1
Regular calf muscle stretching exercises and strengthening exercises for foot intrinsic muscles are recommended for managing flat feet, with a focus on eccentric exercises for non-insertional tendinopathy 1, 2
Weight loss is recommended if indicated, to reduce the severity of flat feet symptoms, and low-impact aerobic exercises can be beneficial for patients with plantar fasciitis 1, 4
Over-the-counter heel cushions and arch supports, as well as night splinting, can be used to help reduce symptoms in patients with plantar fasciitis, and orthotic devices can address foot alignment issues 1, 2, 5
Oral or topical NSAIDs can be used for symptom relief in patients with plantar fasciitis, but long-term NSAID use should be avoided, especially in patients with active inflammatory bowel disease, and topical NSAIDs have similar efficacy with fewer systemic side effects 1, 2, 4, 6

Surgical intervention is recommended for persistent pain despite 2-3 months of comprehensive conservative treatment, progressive deformity affecting function, or rigid flatfoot with underlying pathology, according to the American Academy of Family Physicians 1
For flexible flatfoot, modified Evans procedure, calcaneal osteotomy, and tendon transfers are recommended, while for rigid flatfoot or advanced deformity, subtalar arthrodesis, double or triple arthrodesis, and plantar fasciotomy for associated plantar fasciitis are recommended 1
Extracorporeal shock wave therapy is an emerging option for refractory cases, and surgical consultation may be necessary for refractory cases that do not respond to conservative management 1, 2

Diabetic patients require more careful monitoring and specialized footwear, as recommended by the American Diabetes Association, and pediatric patients with asymptomatic flat feet can be observed, while those with painful flat feet require conservative management with stretching and soft orthotics 1, 3

Patients should be evaluated every 2-4 weeks, and treatments should be continued until symptoms resolve, with referral to a specialist recommended if no improvement is seen after 6-8 weeks of treatment, according to the American Academy of Family Physicians 1, 2
Physical therapy referral for a supervised exercise program can be considered for patients with plantar fasciitis, and rheumatology referral can be considered if arthropathy is suspected 4, 6
The American Academy of Family Physicians recommends considering referral to a podiatric foot and ankle surgeon if no improvement occurs after 2-3 months of comprehensive conservative treatment, and surgical consultation may be necessary for refractory cases 1, 2