What is the treatment for a small plantar calcaneal spur?

Treatment for Small Plantar Calcaneal Spur

Conservative management is the first-line treatment for a small plantar calcaneal spur, including properly fitted footwear with orthoses, stretching exercises, NSAIDs, and activity modification.

Initial Conservative Management

When treating a small plantar calcaneal spur with normal alignment and no arthritic changes, follow this algorithmic approach:

1. Footwear Modifications:

   • Prescribe properly fitting footwear with adequate arch support
   • Consider orthoses or custom-made insoles to redistribute pressure 1
   • Avoid barefoot walking, thin-soled shoes, or walking in socks only 1

2. Physical Interventions:

   • Stretching exercises for the plantar fascia and Achilles tendon
   • Weight loss if indicated
   • Activity modification to reduce repetitive impact

3. Pharmacological Management:

   • NSAIDs for pain and inflammation control
   • Consider corticosteroid injection targeting the plantar fascia attachment if pain persists 2

Progression of Treatment

If symptoms persist after 6-8 weeks of conservative management:

1. Advanced Offloading:

   • Consider temporary offloading devices such as:
     • Removable walker boot
     • Forefoot offloading shoe
     • Cast shoe 1

2. Additional Therapies:

   • Extracorporeal shock wave therapy (ESWT) - particularly effective for spurs >5mm or horizontal/hooked spurs 3
   • Night splints to maintain dorsiflexion during sleep

When to Consider Surgical Intervention

Surgery should only be considered if conservative treatment fails after 3-6 months:

1. Minimally Invasive Options:

   • Percutaneous drilling of the calcaneus combined with plantar fascia release 4
   • Endoscopic treatment addressing the spur, plantar fasciitis, and calcaneal periostitis 5

2. Open Surgical Approaches:

   • Plantar fasciotomy
   • Resection of the calcaneal spur

Important Clinical Considerations

• The presence of a calcaneal spur doesn't always correlate with pain - spurs are found in 71.6% of painless feet 3
• Larger spurs (>5mm) and horizontal/hooked spurs may be more symptomatic than smaller or vertical spurs 3
• Ensure proper diagnosis, as heel pain can have multiple etiologies including neurologic causes, stress fractures, or bursitis 1

Monitoring and Follow-up

• Evaluate response to treatment every 4-6 weeks
• If no improvement occurs after 6 weeks of appropriate therapy, reassess diagnosis and consider advanced imaging or referral to a foot specialist 1
• Monitor for potential complications of treatments, particularly with corticosteroid injections (tissue atrophy, plantar fascia rupture)

Remember that most plantar calcaneal spurs respond well to conservative management, and surgical intervention is rarely required for small, asymptomatic spurs identified incidentally on radiographs.