Management of Heel Pain with Plantar Calcaneal Spur and Achilles Tendon Enthesopathy
The recommended first-line treatment for heel pain with plantar calcaneal spur and Achilles tendon enthesopathy includes conservative measures such as regular calf-muscle stretching, orthoses, NSAIDs, activity modification, and appropriate footwear for 6 weeks before considering more advanced interventions. 1
Initial Conservative Management (First 6 Weeks)
For Plantar Calcaneal Spur:
- Mechanical interventions:
- Medial arch supports/orthoses
- Over-the-counter heel cushions
- Padding and strapping of the foot
- Pain and inflammation management:
- NSAIDs for pain control
- Ice massage to reduce inflammation
- Cryotherapy
- Activity modifications:
- Regular plantar fascia and calf muscle stretching exercises
- Weight loss if indicated
- Limitation of aggravating activities
- Avoidance of flat shoes and barefoot walking 2
For Achilles Tendon Enthesopathy:
- Footwear modifications:
- Open-backed shoes to reduce pressure on the area
- Heel lifts or orthoses
- Pain management:
- NSAIDs (Note: corticosteroid injections are NOT recommended for Achilles tendinopathy)
- Decreased activity
- Rehabilitation:
- Eccentric strength training exercises (particularly effective for Achilles tendinopathy)
- Stretching exercises for gastrocnemius-soleus complex
- Deep friction massage 2
If No Improvement After 6 Weeks
If symptoms persist after 6 weeks of conservative treatment, referral to a podiatric foot and ankle surgeon is appropriate. Additional treatments may include:
- Customized orthotic devices
- Night splinting
- Limited corticosteroid injections (for plantar fasciitis only, NOT for Achilles tendinopathy)
- Casting or use of a fixed-ankle walker-type device during activity 2, 1
If No Improvement After 2-3 Months
For persistent symptoms after 2-3 months of treatment:
- Continue initial treatment measures
- Consider cast immobilization if not previously used
- Evaluate for other possible diagnoses
- Consider advanced interventions such as:
- Extracorporeal shock wave therapy
- Surgical intervention (plantar fasciotomy for plantar fasciitis) 2
Important Clinical Considerations
Differential diagnosis: The radiographic findings of calcaneal spurs are common and may not always correlate with symptoms. Ensure the pain location matches the pathology (medial plantar pain for plantar fasciitis, posterior pain for Achilles tendinopathy) 1
Red flags requiring further investigation: Bilateral heel pain, night pain or rest pain, neurological symptoms, and history of trauma may indicate systemic disorders, tumors, infections, nerve entrapment, or fractures 1
Imaging utility: While X-rays can identify spurs, ultrasound may be more sensitive than MRI for detecting early changes of enthesopathy and calcification processes at insertion sites 3
Treatment success rate: Approximately 90% of patients with heel pain improve with conservative measures alone, making surgery a last resort after at least 6 months of failed conservative treatment 1
Special Considerations for Achilles Enthesopathy
For Achilles enthesopathy specifically, avoid corticosteroid injections as they can increase the risk of tendon rupture. In particularly acute or refractory cases, immobilization may be considered for 6-8 weeks before pursuing more invasive options 2