What is the next step in managing a patient with mild degenerative changes in the forefoot, plantar calcaneal spur, and vascular calcification, with no evidence of acute fracture?

From the Guidelines

The next step in managing a patient with mild degenerative changes in the forefoot, plantar calcaneal spur, and vascular calcification without acute fracture should focus on conservative treatment, prioritizing well-fitted walking shoes or athletic shoes that cushion the feet and redistribute pressure, as recommended by the most recent guidelines 1. The patient's condition, characterized by mild degenerative changes in the forefoot, plantar calcaneal spur, and vascular calcification, suggests a need for careful management to prevent further complications and improve quality of life.

• Key considerations include:
  • Providing adequate footwear to reduce pressure on the affected areas, with features such as a broad and square toe box, laces with three or four eyes per side, padded tongue, quality lightweight materials, and sufficient size to accommodate a cushioned insole 1.
  • Custom orthotic inserts with a heel cup and arch support may be beneficial in redistributing pressure and reducing strain on the plantar fascia.
  • Weight management is crucial if the patient is overweight, as excess weight increases pressure on the foot structures.
  • Physical therapy focusing on foot strengthening exercises can improve foot mechanics.
  • Night splints may help maintain the foot in a dorsiflexed position during sleep, preventing morning pain. These conservative measures address the underlying biomechanical issues causing pain while avoiding more invasive interventions.
• It is essential to monitor the patient's progress and adjust the treatment plan as necessary, considering the chronic nature of the condition and the potential for future complications. The most recent and highest quality study 1 supports the use of well-fitted walking shoes or athletic shoes as a primary component of conservative treatment, emphasizing the importance of redistributing pressure and reducing strain on the affected areas.

From the Research

Next Steps in Management

The patient presents with mild degenerative changes in the forefoot, plantar calcaneal spur, and vascular calcification, with no evidence of acute fracture. The following steps can be considered:

• Conservative management for plantar fasciitis, which is a common cause of heel pain, as it is associated with degenerative changes and calcaneal spurs 2
• The use of oral nonsteroidal anti-inflammatory medications (NSAIDs) may provide some benefit in pain relief and reduction of disability when used in conjunction with a conservative treatment regimen 3
• For patients with resistant heel pain, surgical options such as mid-sole release of the plantar fascia combined with percutaneous drilling of the calcaneus may be considered 4
• Endoscopic treatment of calcaneal spur syndrome is another option, which involves treatment of the heel spur and plantar fasciitis, as well as decompression of the nerve to the abductor digiti quinti 5

Considerations

• The patient's symptoms and response to treatment should be closely monitored, as the natural history of plantar fasciitis and the effectiveness of various treatments are not well established 2
• The presence of vascular calcification should be taken into account when considering treatment options, as it may affect the patient's overall health and response to treatment
• The patient's overall health and any underlying conditions should be considered when developing a treatment plan, as certain conditions may affect the patient's response to treatment or increase the risk of complications 6