What are the management options for calcaneal spur and plantar fasciitis?

Management of Calcaneal Spur and Plantar Fasciitis

Begin with regular calf-muscle and plantar fascia-specific stretching exercises combined with activity modification, as this represents the most important initial intervention with approximately 90% of patients ultimately responding to conservative treatment. 1, 2

Initial Conservative Treatment (First 6 Weeks)

The following interventions should be implemented simultaneously:

Patient-Directed Measures

• Stretching exercises: Regular calf-muscle and plantar fascia-specific stretching are the cornerstone of treatment 1
• Ice massage: Apply to the affected area, especially after activity 1
• Footwear modifications: Avoid flat shoes and barefoot walking entirely 1
• Weight loss: If patient is overweight or obese 1
• Activity limitation: Reduce standing and walking; use crutches if necessary 3

Supportive Treatments

• Over-the-counter heel cushions and arch supports as initial orthotic intervention 1
• Padding and strapping of the foot for mechanical support 1
• Night splints to maintain dorsiflexion during sleep 1
• NSAIDs for pain control 3
• Taping can provide temporary relief by supporting the plantar fascia 4

Important Caveat

Avoid corticosteroid injections near the Achilles tendon insertion if insertional Achilles tendonitis is present, as this is specifically contraindicated 3

Secondary Interventions (After 6 Weeks Without Improvement)

Refer to a podiatric foot and ankle surgeon while continuing initial treatments and adding: 3, 1

• Customized orthotic devices tailored to the patient's specific foot structure 1
• Corticosteroid injections (limited number) into the plantar fascia - evidence shows transient benefit 1, 5
• Immobilization: Casting or fixed-ankle walker-type device during activity 1
• Iontophoresis with steroids may provide short-term benefit 5

Advanced Interventions (After 2-3 Months Without Improvement)

Continue all previous treatments and consider:

• Cast immobilization if not previously attempted 1
• Extracorporeal shock wave therapy (ESWT): Particularly ultrasonography-guided focal ESWT for recalcitrant cases 1
• Surgical intervention: Plantar fasciotomy when all conservative measures have failed, with success rates of 70-90% 1, 6

Surgical Options

Endoscopic plantar fascia release involves medial 75% fascial release, calcaneal spur removal, and potential nerve decompression, with good to excellent results in properly selected patients who have failed 5 months of aggressive conservative treatment 7

Key Clinical Pitfalls

• Do not inject corticosteroids into or near the Achilles tendon - this is contraindicated and can lead to tendon rupture 3
• Radiographic heel spurs do not correlate with symptoms - their presence or absence should not guide treatment decisions 8
• Consider alternative diagnoses if no improvement occurs, including neurologic heel pain, insertional Achilles tendonitis, or bursitis associated with Haglund's deformity 3
• Ultrasonography has 80% sensitivity and 88% specificity for diagnosis compared to MRI, making it a useful diagnostic tool when the diagnosis is uncertain 1

Evidence Quality Note

While multiple treatment modalities exist, the evidence for most interventions is limited, with stretching exercises and soft insoles showing the most consistent benefit 5. Conservative treatment ultimately succeeds in approximately 90% of patients, though the natural history of the condition makes it difficult to determine how much improvement is due to treatment versus spontaneous resolution 2.