What is the current guideline for treating plantar and Achilles spurs?

Current Guidelines for Treating Plantar and Achilles Spurs

Conservative treatment should be the first-line approach for both plantar and Achilles spurs, with surgical interventions reserved only for cases that fail to respond after 6 months of appropriate conservative management. 1

Initial Conservative Treatment (First 6 Weeks)

For Plantar Spurs:

• Mechanical offloading interventions:
  • Regular calf-muscle stretching exercises
  • Over-the-counter heel cushions and arch supports
  • Avoidance of flat shoes and barefoot walking
  • Activity limitation
  • Weight loss (if indicated)
• Pain management:
  • Cryotherapy (ice application)
  • NSAIDs for pain and inflammation control

For Achilles Spurs:

• Eccentric exercise training (gold standard conservative treatment) 2
• Activity modification
• Appropriate footwear with heel lifts
• Cryotherapy for pain management
• NSAIDs for pain and inflammation

Secondary Interventions (After 6 Weeks if Symptoms Persist)

• Customized orthotic devices for better support and pressure redistribution
• Night splinting to maintain the plantar fascia in a stretched position
• Corticosteroid injections (with caution due to risk of plantar fascia rupture)
• Extracorporeal shock wave therapy for recalcitrant cases 3

Surgical Interventions (After 6 Months of Failed Conservative Treatment)

For Plantar Spurs:

• Consider surgical interventions only after conservative treatment failure for at least 6 months
• Options include:
  • Plantar fascia release
  • Metatarsal head (MTH) resection for recurrent plantar forefoot ulcers 4

For Achilles Spurs:

• Achilles tendon lengthening (ATL) - particularly effective for patients with limited ankle dorsiflexion 4
• Open debridement of the retrocalcaneal bursa, calcaneal osteophyte, and diseased tendon 5

Special Considerations for Patients with Diabetes

• For patients with diabetes and plantar spurs with ulceration:
  • Non-removable knee-high offloading devices as first-line treatment 4
  • Removable offloading devices if non-removable devices are contraindicated
  • Achilles tendon lengthening may be considered when non-surgical offloading fails, particularly for patients with an equinus position of the foot 4
  • Metatarsal head resection may be considered when infection or osteomyelitis is present 4

Important Clinical Considerations and Pitfalls

• Avoid premature surgical intervention - 90% of cases respond to conservative treatment eventually 6
• Avoid overreliance on imaging - the presence of a heel spur on X-ray doesn't necessarily correlate with symptoms
• Be aware of the association between conditions - patients with Achilles tendinopathy often have concomitant plantar spurs (41.9%), particularly older women 7
• Avoid corticosteroid overuse - can lead to plantar fascia rupture and fat pad atrophy
• Address biomechanical factors - underlying foot mechanics can contribute to both conditions

Treatment Algorithm

1. Start with 6 weeks of initial conservative treatment
2. If symptoms persist, implement secondary interventions for another 4-5 months
3. Consider surgical options only after 6 months of failed conservative management
4. For diabetic patients with ulceration, prioritize appropriate offloading devices

This approach aligns with current guidelines that emphasize exhausting conservative options before considering surgical interventions, with specific modifications needed for patients with diabetes or other complicating factors.