What is the recommended treatment for a patient with trace plantar spurring and minor enthesopathic change at the Achilles insertion?

Treatment for Plantar Spurring and Achilles Enthesopathy

The recommended first-line treatment for trace plantar spurring and minor enthesopathic change at the Achilles insertion includes open-backed shoes, heel lifts or orthoses, NSAIDs, decreased activity, and stretching exercises. 1

Initial Conservative Management

For Plantar Spurring:

• Patient-directed measures:

  • Regular calf-muscle stretching exercises
  • Cryotherapy (ice application for 15-20 minutes several times daily)
  • Over-the-counter heel cushions and arch supports
  • Activity limitation during acute pain episodes
  • Avoidance of flat shoes and barefoot walking
  • Weight loss if indicated 1, 2

• Medication:

  • NSAIDs for pain and inflammation management
  • Acetaminophen as an alternative for those who cannot take NSAIDs 2

For Achilles Enthesopathy:

• Footwear modifications:

  • Open-backed shoes to reduce pressure on the Achilles insertion
  • Heel lifts or orthoses to reduce tension on the Achilles tendon 1

• Activity modifications:

  • Decreased activity during symptomatic periods
  • Stretching exercises focusing on calf muscles and Achilles tendon 1, 3

• Pain management:

  • NSAIDs for pain and inflammation
  • Important note: Local corticosteroid injections are NOT recommended for Achilles enthesopathy due to risk of tendon rupture 1

Treatment Timeline and Progression

1. First 6-8 weeks:

   • Continue initial conservative measures as outlined above
   • If improvement occurs, maintain treatments until symptoms resolve 1

2. If no improvement after 6-8 weeks:

   • Referral to a podiatric foot and ankle surgeon is appropriate
   • Continue initial treatments
   • Consider additional interventions:
     • Customized orthotic device
     • Night splinting
     • Immobilization cast or fixed-ankle walker-type device for particularly acute or refractory cases 1

3. If no improvement after 2-3 months:

   • Continue initial treatment measures
   • Consider cast immobilization if not previously used
   • Evaluate for other diagnoses 1

Special Considerations

• Biomechanical relationship: Research indicates a significant relationship between posterior calcaneal spurs and plantar calcaneal spurs, suggesting a biomechanical connection between the Achilles tendon and plantar fascia 4. This explains why treating both conditions simultaneously is often necessary.

• For inflammatory conditions: In cases where enthesopathy is related to seronegative spondyloarthropathy, ultrasound-guided corticosteroid injection into the retro-calcaneal bursa (not the tendon itself) may be considered for refractory cases 5, 6.

• Surgical options: Surgery is rarely needed but may be considered for truly refractory cases that fail to respond to 6+ months of conservative treatment 7, 3.

Common Pitfalls and Caveats

1. Avoid corticosteroid injections directly into the Achilles tendon as this increases risk of tendon rupture 1

2. Don't overlook proper footwear - inappropriate shoes are a common reason for treatment failure

3. Ensure adequate duration of conservative treatment - most cases respond to conservative measures if given sufficient time (typically 90% of patients) 2

4. Don't neglect stretching exercises - eccentric exercise training is considered the gold standard for Achilles tendinopathy 3

5. Consider the biomechanical relationship between the plantar fascia and Achilles tendon when treating either condition 4