Treatment of Plantar Calcaneal Spurs
Begin with a comprehensive 6-8 week trial of conservative management including orthotic devices with heel lifts, NSAIDs, plantar fascia and Achilles stretching exercises, and appropriate footwear modifications, as this approach is effective for the vast majority of patients. 1
Initial Conservative Treatment (First-Line)
The American Academy of Family Physicians recommends implementing all conservative measures simultaneously rather than sequentially: 1
- Orthotic devices and heel lifts to reduce pressure on the affected plantar surface 1
- NSAIDs to reduce inflammation and pain 1
- Stretching exercises specifically targeting the plantar fascia and Achilles tendon 1
- Footwear modifications including open-backed or accommodative shoes to reduce pressure 1
- Weight loss if indicated 1
Critical caveat: Avoid using conventional or standard therapeutic footwear alone, as these are insufficient for proper offloading. 1 If other offloading devices are unavailable, use felted foam in combination with appropriate footwear. 1
Evaluation of Treatment Response
Evaluate response at 6-8 weeks and continue all treatments until symptoms fully resolve if improvement occurs. 1
Second-Line Treatment (If No Improvement After 6-8 Weeks)
Continue initial conservative treatments while adding: 1
- Immobilization with a cast or fixed-ankle walker-type device 1
- Corticosteroid injection into the plantar fascia, carefully avoiding the Achilles tendon 1
Surgical Referral Criteria (After 2-3 Months of Combined Therapy)
Refer to a podiatric foot and ankle surgeon for evaluation if no improvement occurs after 2-3 months of combined conservative and second-line therapy. 1 At this point, consider additional imaging studies to confirm diagnosis and rule out other conditions. 1
Surgical Options for Refractory Cases
When conservative treatment fails after at least 5-6 months, surgical options include: 2, 3, 4
- Endoscopic approach: Involves heel spur removal, lateral to medial release of the medial 75% of plantar fascia, debridement of calcaneal periostitis, and potential decompression of the nerve to the abductor digiti quinti, with good to excellent results in 90-100% of patients 2, 4
- Open surgical approach: Provides comparable results to arthroscopy with fewer complications, better visualization, and lower cost, achieving 90% satisfactory outcomes at long-term follow-up 3, 5
Important Clinical Pearls
The radiographic presence of a spur does not always correlate with symptoms. 1 The pathology primarily involves mucoid and fibrinoid degeneration of the plantar fascia itself rather than the spur, which is why conservative treatment targeting inflammation and biomechanics is so effective. 5
Spurs often reform radiographically after complete excision, yet patients remain asymptomatic, and fascial transection does not cause arch collapse. 5 This further supports that the fascia pathology, not the spur itself, drives symptoms.