What is the treatment for degenerative changes in the heel?

Treatment for Degenerative Changes of the Heel

The treatment for degenerative changes in the heel should begin with conservative management including proper footwear, orthoses, NSAIDs, stretching exercises, and ice therapy, with surgery reserved only for cases that fail 3-6 months of conservative treatment. 1, 2, 3

Initial Conservative Management

Pain Management

• Apply ice through a wet towel for 10-minute periods (cryotherapy) 2
• Use NSAIDs such as naproxen for short-term pain relief 2, 4
  • Naproxen has been shown to cause less gastric bleeding and erosion than aspirin 4
  • Consider celecoxib as an alternative if traditional NSAIDs are not tolerated 2
• Paracetamol can be used as an alternative to NSAIDs 2

Physical Therapy and Exercise

• Perform stretching exercises 3-5 times daily 2:
  • Before getting out of bed
  • Before climbing stairs
  • Before going to sleep
• Hold stretches for 6-10 seconds, then slowly relax
• Rest 2-3 seconds between repetitions
• Focus on stretching calf muscles and plantar fascia 2, 3

Footwear and Orthotic Devices

• Use properly fitting footwear with adequate support 2
• Consider open-backed shoes for Haglund's deformity 1
• Use custom or over-the-counter insoles to redistribute pressure 2
• Consider therapeutic footwear that demonstrates plantar pressure-relieving effect 2
• Never walk barefoot, in socks only, or in thin-soled slippers 2

Intermediate Interventions

If symptoms persist after 4-6 weeks of initial treatment:

Immobilization

• Consider immobilization cast or fixed-ankle walker-type device 1
• Night splints may be beneficial 3, 5

Injection Therapy

• Consider corticosteroid injections if first-line treatments fail 2, 6
  • Use with caution due to potential risks of plantar fascia rupture and fat pad atrophy 5
• Platelet-rich plasma (PRP) injections may be as effective or more effective than corticosteroid injections for chronic cases 6

Advanced Interventions

For cases that fail to respond to 3-6 months of conservative treatment:

Minimally Invasive Procedures

• Consider extracorporeal shock wave therapy 3
• Therapeutic ultrasound may stimulate healing response 5
• Botulinum toxin injections can relax calf muscles, decreasing stress on plantar fascia 5

Surgical Options

• Plantar fasciotomy (endoscopic approach preferred) 2, 3
• Gastrocnemius recession or medial head release to decrease stress on plantar fascia 5
• For Haglund's deformity: resection of the prominent posterior superior aspect of the calcaneus and inflamed bursa 1

Treatment Algorithm

1. First 4-6 weeks: Rest, activity modification, proper footwear, orthoses, NSAIDs, ice therapy, and stretching exercises
2. Weeks 6-12: Continue initial treatments; add immobilization devices and consider injection therapy
3. After 3-6 months of failed conservative treatment: Consider minimally invasive procedures or surgical intervention

Important Considerations

• Approximately 90% of patients improve with conservative techniques without requiring surgery 2, 3, 7
• Evaluate response to treatment every 4-6 weeks 2
• Consider referral to a foot specialist if no improvement occurs after six weeks 2
• For Haglund's deformity, symptoms are typically aggravated by pressure from shoes and relieved when walking barefoot 1
• Special consideration should be given to patients with diabetes, with more frequent foot examinations 2

Cautions and Pitfalls

• Corticosteroid injections should be administered with caution due to risk of plantar fascia rupture 5
• When injecting, avoid the Achilles tendon 1
• Surgical treatment should be reserved only for patients with persistent symptoms after 6-12 months of conservative management 7
• Proper diagnosis is essential as heel pain may have neurologic, traumatic, or systemic origins 8