What are the treatment options for plantar calcaneal bone spurs?

Treatment Options for Plantar Calcaneal Bone Spurs

Conservative treatment should be the initial approach for plantar calcaneal bone spurs, including NSAIDs, stretching exercises, orthotic devices, and appropriate footwear modifications, with surgical intervention reserved only for cases that fail to respond after 2-3 months of comprehensive conservative management. 1

Initial Conservative Management (First 6 Weeks)

Patient-Directed Measures

• Regular calf-muscle and plantar fascia stretching exercises
• Cryotherapy (ice application) for 15-20 minutes several times daily
• Over-the-counter heel cushions and arch supports
• Weight loss if indicated
• Activity limitation and modification
• Avoidance of flat shoes and barefoot walking

Provider-Directed Interventions

• NSAIDs (e.g., ibuprofen 400-600mg three times daily) for pain and inflammation 1, 2
• Padding and strapping of the foot
• Corticosteroid injections in appropriate patients (caution: avoid injecting directly into the Achilles tendon) 1

Secondary Management (If No Improvement After 6 Weeks)

At this point, referral to a podiatric foot and ankle surgeon is appropriate 1. Additional treatments include:

• Customized orthotic devices to redistribute pressure away from the spur
• Night splinting to maintain plantar fascia stretch
• Limited corticosteroid injections (if not previously administered)
• Casting or use of a fixed-ankle walker-type device during activity
• Physical therapy modalities:
  • Ultrasound therapy (series of ten treatments) 3
  • Shock wave therapy (series of four treatments) - may provide more efficient pain relief with fewer sessions 3

Tertiary Management (If No Improvement After 2-3 Months)

If no improvement occurs after 2-3 months of conservative treatment:

• Continue initial treatment measures
• Consider cast immobilization if not previously used
• Consider extracorporeal shock wave therapy
• Evaluate for surgical intervention:
  • Plantar fasciotomy
  • Calcaneal spur resection

Surgical Options

When conservative treatments fail, surgical interventions may be considered:

• Endoscopic treatment - allows for comprehensive approach including spur removal, plantar fascia release, and addressing adjacent calcaneal periostitis 4
• Digital flexor tenotomy - for cases with hammertoes and recalcitrant toe ulcers (92-100% healing rate) 1
• Metatarsal head resection - can reduce healing time by 29-64% compared to conservative treatment in selected cases 1

Special Considerations

For Patients with Diabetes

• More frequent foot examinations based on risk stratification 1
• Patients with loss of protective sensation (LOPS) or peripheral artery disease (PAD) require more vigilant monitoring
• Custom-made footwear may be necessary for significant deformities 1

Common Pitfalls to Avoid

• Failure to address biomechanical factors (abnormal pronation, tight Achilles tendon)
• Overuse of corticosteroid injections (risk of plantar fascia rupture)
• Premature return to high-impact activities before adequate healing
• Neglecting to modify footwear (continuing to wear flat shoes or walking barefoot)
• Focusing solely on the spur rather than addressing the underlying plantar fasciitis

Treatment Algorithm

1. Begin with 6 weeks of initial conservative measures
2. If no improvement, refer to specialist and implement secondary measures
3. If still no improvement after 2-3 months, consider tertiary options including surgical intervention
4. Post-treatment, implement preventive measures to avoid recurrence

The evidence strongly supports a stepwise approach, with most patients responding to conservative management. Surgical intervention should be reserved for cases that fail to respond to comprehensive conservative treatment after 2-3 months 1.