What are the diagnosis and treatment options for heel spurs with plantar fasciitis?

Diagnosis and Management of Heel Spurs with Plantar Fasciitis

Conservative treatment is the first-line approach for heel spurs with plantar fasciitis, including stretching exercises, proper footwear, orthotic devices, NSAIDs, and activity modification, with 90% of patients improving with these measures. 1, 2

Diagnosis

Clinical Presentation

• Pain on first steps in the morning or after prolonged sitting is the hallmark symptom of plantar fasciitis 2
• Pain with palpation of the medial plantar calcaneal region 2
• Discomfort in the proximal plantar fascia elicited by passive ankle/first toe dorsiflexion 2
• Pain that is typically worse with weight-bearing activities and improves with rest 3

Diagnostic Imaging

• Routine imaging is usually not necessary for initial diagnosis of plantar fasciitis 2
• When needed, options include:
  • X-rays may show a heel spur, indicating the condition has been present for at least 6-12 months, but the spur itself is not considered the cause of symptoms 3
  • MRI shows increased plantar fascia thickness and abnormal tissue signal in recalcitrant cases 2
  • Ultrasound has good sensitivity (80%) and specificity (88%) in diagnosing plantar fasciitis compared to MRI 4

Treatment Algorithm

Initial Treatment (First 6 Weeks)

• Patient-directed measures:
  • Regular calf-muscle and plantar fascia stretching exercises (3-5 times daily) 1
  • Cryotherapy (ice massage) for 10-minute periods through a wet towel 1
  • Over-the-counter heel cushions and arch supports 1
  • Activity limitation and avoidance of flat shoes and barefoot walking 4
  • Weight loss if indicated 4
• Medication:
  • NSAIDs (oral or topical) for pain relief and reducing inflammation 1, 5
• Other interventions:
  • Padding and strapping of the foot 4

If No Improvement After 6 Weeks

• Referral to a podiatric foot and ankle surgeon 4
• Continue initial treatments and add:
  • Customized orthotic devices 4
  • Night splinting 4
  • Limited corticosteroid injections (avoid near Achilles tendon) 4, 1
  • Casting or use of a fixed-ankle walker-type device during activity 4

If No Improvement After 2-3 Months

• Continue conservative measures 4
• Consider cast immobilization if not previously used 4
• Consider advanced options:
  • Surgery (plantar fasciotomy) 4, 2
  • Extracorporeal shock wave therapy 4, 3
• Explore other possible diagnoses 4

Special Considerations

For Insertional Achilles Tendonitis

• Use open-backed shoes to reduce pressure on the area 4
• Heel lifts or orthoses 4
• NSAIDs 4
• Decreased activity 4
• Stretching exercises 4
• Weight loss if indicated 4
• Avoid local corticosteroid injections near the Achilles tendon due to risk of tendon rupture 1, 6

Common Pitfalls to Avoid

• Overuse of corticosteroid injections, which can lead to plantar fascia rupture 6
• Complete immobilization, which can cause muscular atrophy 1
• Ignoring symptoms that persist beyond 6-8 weeks, which should prompt referral to a specialist 6
• Failure to address contributing factors such as improper footwear, obesity, or biomechanical issues 7

Treatment Efficacy

• Conservative treatment is effective in approximately 90% of patients 2, 7
• NSAIDs combined with a conservative treatment regimen may provide additional pain relief and decreased disability compared to conservative treatment alone 5
• Most patients respond to conservative treatment within 6-8 weeks 1
• Chronic cases lasting six months or longer may require more aggressive interventions such as extracorporeal shock wave therapy or surgery 2