What is the treatment for a moderately large plantar spur?

Treatment for Moderately Large Plantar Spur

The treatment for a moderately large plantar spur should begin with conservative measures including regular calf-muscle stretching, cryotherapy, over-the-counter heel cushions, arch supports, weight loss if indicated, activity limitation, and avoidance of flat shoes and barefoot walking for at least 6 weeks before considering more invasive options. 1

Initial Conservative Treatment (First 6 Weeks)

Non-pharmacological Interventions

• Mechanical offloading:
  • Regular calf-muscle stretching exercises
  • Use of over-the-counter heel cushions and arch supports
  • Avoidance of flat shoes and barefoot walking
  • Activity limitation to reduce pressure on the heel
  • Weight loss (if indicated)
  • Cryotherapy (ice massage) to reduce pain and inflammation

Pharmacological Interventions

• NSAIDs to manage pain and inflammation
• Padding and strapping of the foot to reduce pressure on the affected area

Secondary Interventions (If No Improvement After 6 Weeks)

If symptoms persist after 6 weeks of initial treatment, referral to a podiatric foot and ankle surgeon is appropriate. Additional treatments may include:

• Customized orthotic devices - Provide better support and offloading of pressure points
• Night splinting - Maintains plantar fascia in a stretched position overnight
• Corticosteroid injections - Limited number, for short-term pain relief
• Immobilization options:
  • Casting
  • Fixed-ankle walker-type device during activity

Advanced Interventions (If No Improvement After 2-3 Months)

If no improvement occurs after 2-3 months of secondary interventions:

• Cast immobilization (if not previously used)
• Extracorporeal shock wave therapy - May promote healing and reduce pain
• Surgical options:
  • Plantar fasciotomy - For cases resistant to conservative treatment 1
  • Calcaneal spur excision - Open or endoscopic approaches may be considered for refractory cases 2, 3

Special Considerations

Pre-ulcerative Lesions

For patients with pre-ulcerative lesions or excess callus on the foot:

• Provide appropriate treatment for any pre-ulcerative lesion
• Remove excess callus
• Treat ingrown toenails or fungal infections if present 1

For Patients with Diabetes

For patients with diabetes and plantar spurs:

• Use non-removable knee-high offloading devices as first-line treatment if ulceration is present
• Consider removable offloading devices if non-removable devices are contraindicated or not tolerated
• Address any infection or ischemia before aggressive offloading 1

Efficacy of Treatment

• With proper conservative treatment, approximately 80-90% of patients with plantar fasciitis/heel spurs improve within 12 months 4, 5
• Surgical intervention has shown good to excellent results in refractory cases, with significant improvement in pain scores and function 2

Common Pitfalls to Avoid

1. Premature surgical intervention - Surgery should only be considered after exhausting conservative options for at least 6 months
2. Overreliance on imaging - The presence of a heel spur on x-ray doesn't necessarily correlate with symptoms and indicates the condition has been present for at least 6-12 months 6
3. Inadequate offloading - Using conventional footwear alone without proper support is insufficient 1
4. Corticosteroid overuse - Multiple injections can lead to plantar fascia rupture and fat pad atrophy
5. Ignoring biomechanical factors - Failing to address underlying foot mechanics that contribute to the condition

By following this stepwise approach, most patients with moderately large plantar spurs can achieve significant pain relief and improved function without requiring surgical intervention.