Management of Plantar and Calcaneal Spurs
For plantar and calcaneal spurs, the best management begins with conservative treatment including offloading devices, appropriate footwear, and pain management, with surgical interventions reserved for cases that fail to respond to conservative measures. 1
Initial Conservative Management
Offloading and Footwear Modifications
- Use open-backed shoes to reduce pressure on the affected area, particularly for calcaneal spurs 1
- Consider heel lifts or orthoses to redistribute pressure and provide support 1
- For plantar spurs, use appropriately fitting footwear with adequate room for toes (1-2 cm longer than foot) 1
- Avoid barefoot walking both indoors and outdoors 1
- Consider felted foam in combination with appropriate footwear when other offloading devices are not available 1
Pain Management
- Implement activity modification and decreased weight-bearing activities 1
- Use nonsteroidal anti-inflammatory drugs (NSAIDs) for pain and inflammation control 1
- Apply stretching exercises targeting the plantar fascia and Achilles tendon 1
- Consider weight loss if indicated to reduce pressure on the affected foot 1
Physical Therapy
- Ultrasound therapy can provide significant analgesic effects for heel spur pain 2
- Shock wave therapy may achieve similar pain relief with fewer treatment sessions compared to ultrasound 2
- Physical therapy focusing on stretching and strengthening exercises for the foot and ankle 1
Intermediate Interventions
- For cases not responding to initial measures after 6-8 weeks, consider the following: 1
Immobilization
- Use immobilization cast or fixed-ankle walker-type device to restrict movement and reduce pressure 1
- Non-removable knee-high offloading devices may be beneficial, particularly for associated plantar ulcers 1
- For calcaneal spurs with insertional Achilles tendonitis, immobilization may be necessary in acute or refractory cases 1
Injections
- Consider corticosteroid injections for plantar spurs (avoiding injection into the Achilles tendon for calcaneal spurs) 1
- Bursa injections may be considered for bursitis associated with Haglund's deformity and calcaneal spurs 1
- Note: Avoid corticosteroid injections near the Achilles tendon insertion due to risk of tendon rupture 1
Advanced Interventions for Refractory Cases
Extracorporeal Shock Wave Therapy (ESWT)
- Consider ESWT for cases not responding to conservative treatment for 2-3 months 1
- ESWT shows greater analgesic efficacy with fewer sessions compared to ultrasound therapy 2
Surgical Interventions
- Surgery should only be considered after exhausting conservative treatment options for at least 6 months 3
- Surgical options include:
Surgical Outcomes and Considerations
- Open heel spur surgery has shown significant improvement in pain scores (VAS score reduction from 7 preoperatively to 2 at one year postoperatively) 3
- Endoscopic approaches may provide good to excellent results at 3 months postoperatively with minimal complications 4
- Potential complications of surgery include superficial wound infections, transient paresthesias, and rare recurrence of the spur 4, 3
Special Considerations
- For patients with diabetes and associated plantar spurs, follow specific offloading guidelines to prevent complications 1
- In patients with both moderate infection and moderate ischemia, address these issues before focusing on the spur itself 1
- Consider calcaneal osteotomy in some patients with bursitis associated with Haglund's deformity and calcaneal spurs 1
Treatment Algorithm
- Begin with 6-8 weeks of initial conservative measures (offloading, NSAIDs, stretching)
- If no improvement, progress to immobilization and/or injections for 6-8 weeks
- For persistent symptoms beyond 3-6 months despite conservative care, consider ESWT
- Reserve surgical interventions for cases failing 6+ months of comprehensive conservative management 1, 3