What is the treatment for calcaneal spurs?

Treatment for Calcaneal Spurs

The most effective treatment for calcaneal spurs begins with conservative measures including rest, activity modification, appropriate footwear selection, orthotic devices, NSAIDs, stretching exercises, and weight loss if indicated, with referral to a podiatric foot and ankle surgeon if no improvement occurs within 6-8 weeks. 1

Diagnosis and Assessment

• Pain location helps determine the specific condition: posterior heel pain suggests Achilles tendonitis or bursitis, lateral heel pain indicates Haglund's deformity, diffuse heel pain suggests stress fracture, and pain relieved when walking barefoot but worsened by shoes suggests Haglund's deformity or bursitis 1, 2
• Plantar fasciitis typically presents with pain on weight bearing and when transitioning from sitting to standing 1
• The presence of a heel spur on x-ray indicates the condition has been present for at least 6-12 months but is not necessarily the underlying cause of symptoms 3

First-Line Conservative Treatment

• Rest and activity modification to prevent ongoing damage and reduce pain 1
• Appropriate footwear selection:
  • Shoes with proper fit, width, and cushioning 1
  • Open-backed shoes to reduce pressure on the affected area for insertional Achilles tendonitis or Haglund's deformity 1, 2
• Orthotic devices:
  • Heel lifts or cushions to redistribute weight and reduce pressure 1
  • Custom or over-the-counter arch supports 1
• Pain management:
  • NSAIDs (oral or topical) for pain relief and reducing inflammation 1, 2
  • Cryotherapy (ice application) for 10-minute periods through a wet towel to reduce pain and swelling 1
• Stretching exercises:
  • Regular calf-muscle and plantar fascia stretching exercises (3-5 times daily) 1
  • Eccentric exercises for tendinopathies 1
• Weight loss, if indicated, to reduce pressure on the heel 1, 2

Second-Line Treatment (if no improvement after 6 weeks)

• Additional interventions including padding and strapping of the foot 1
• Customized orthotic devices if over-the-counter options are insufficient 1
• Corticosteroid injections (used judiciously and avoiding the Achilles tendon due to risk of tendon rupture) 1, 2
• Platelet-rich plasma injections may provide short-term relief 3

When Conservative Treatment Fails (after 6-8 weeks)

• Referral to a podiatric foot and ankle surgeon 1, 2
• Immobilization with a cast or fixed-ankle walker-type device 1
• Advanced imaging studies (MRI, ultrasound) to confirm diagnosis and rule out other conditions 1
• Consider extracorporeal shock wave therapy 3
• Surgical options may include:
  • Plantar fasciotomy if no improvement is seen after 2-3 months of conservative treatment 1
  • Arthroscopic treatment, which has shown good to excellent results in patients with refractory heel spur syndrome 4, 5

Treatment Algorithm Based on Specific Diagnosis

• For plantar fasciitis: rest, NSAIDs, stretching exercises, heel cushions, arch supports, and weight loss if indicated 2
• For insertional Achilles tendonitis: open-backed shoes, heel lifts, NSAIDs, decreased activity, stretching exercises, and weight loss if indicated 2
• For Haglund's deformity with bursitis: open-backed shoes, orthoses, NSAIDs, corticosteroid injections (avoiding the Achilles tendon), and physical therapy 2
• For neurologic heel pain: immediate subspecialist referral 2
• For traumatic heel pain (stress fracture): protect and immobilize the foot, and consider imaging studies 2

Common Pitfalls and Caveats

• Corticosteroid injections should be used judiciously and are contraindicated near the Achilles tendon due to risk of tendon rupture 1, 2
• Complete immobilization should be avoided to prevent muscular atrophy and deconditioning 1
• Overdebridement of hyperkeratotic tissue can make underlying skin susceptible to increased tenderness 1
• The presence of a heel spur on imaging does not necessarily indicate it is the cause of pain and should not be the sole focus of treatment 3
• Advanced physiotherapy techniques including Mulligan joint mobilization may be beneficial for pain reduction and improving range of motion 6

Expected Outcomes

• Most patients respond to conservative treatment within 6-8 weeks 1
• Arthroscopic treatment has shown good to excellent results in patients with refractory heel spur syndrome 4, 5