What are the treatment options for bone spurs?

Treatment of Bone Spurs

For most bone spurs causing symptoms, conservative management with NSAIDs, physical therapy, and activity modification should be the first-line approach, reserving surgical intervention only for refractory cases that fail conservative treatment after an adequate trial period.

Understanding Bone Spurs

Bone spurs are abnormal bony projections that include both osteophytes (forming around joint lines) and enthesophytes (forming at tendon/ligament insertion sites). 1 The location and type of bone spur determines the treatment approach.

Key Anatomical Distinctions

• Osteophytes: Develop intra-articularly due to repetitive microtrauma and joint degeneration 2
• Enthesophytes: Form extra-articularly from capsular and ligamentous traction forces 2
• This distinction matters because enthesophyte fractures require different management than osteophyte-related pathology 1

Conservative Treatment Algorithm

First-Line Conservative Management

NSAIDs and activity modification should be initiated as the primary treatment for symptomatic bone spurs. 3 For calcaneal spurs specifically, a tiered approach is recommended where treatment progresses only if the current tier fails to resolve symptoms. 4

Initial Conservative Measures Include:

• Maximum tolerated doses of NSAIDs/COXIBs for pain and inflammation control 3
• Physical therapy focusing on:
  • Progressive range of motion exercises 1
  • Progressive resistance training 1
  • Eccentric loading protocols 1
• Activity modification to reduce joint strain 1
• Weight management if applicable, as excess weight contributes to spur development 4, 5

Duration and Response Assessment

Evaluate treatment response at 2-4 weeks initially. 3 If sufficient response occurs, continue treatment and re-evaluate at 12 weeks. 3 Consider tapering or on-demand treatment if sustained improvement is achieved. 3

Common pitfall: Progressing to invasive treatments too quickly without allowing adequate time for conservative measures to work.

When Conservative Treatment Fails

Indications for Surgical Intervention

Surgery should be considered only after conservative management has failed. 6 For plantar fasciitis with calcaneal spurs, a four-step surgical procedure has demonstrated effectiveness:

1. Plantar fascia release
2. Calcaneal spur grinding/removal
3. Inflammatory tissue removal
4. Calcaneal burr decompression 6

This approach resulted in significant improvements in functional scores (AOFAS improved from 74.93 to 94.78, VAS decreased from 3.18 to 1.07) with spur length reduction from 0.72 cm to 0.23 cm. 6

Critical Contraindications

Surgical excision is absolutely contraindicated in certain conditions, particularly fibrodysplasia ossificans progressiva (FOP), as surgery triggers more extensive ossification. 7 Any trauma, including positioning for procedures, can trigger new bone formation in susceptible individuals. 7

Adjunctive Treatments

Corticosteroid Use

Short courses of oral corticosteroids or intra-articular injections may be used as bridging therapy while awaiting the effect of other agents. 3 However, avoid long-term glucocorticoid use due to associated complications. 3

For acute flare-ups in specific conditions like FOP, a brief 4-day course of high-dose corticosteroids combined with NSAIDs started within 24 hours may reduce inflammation. 7

Important caveat: Intramuscular injections are absolutely contraindicated in conditions like FOP. 7

Bone Health Optimization

If bone spurs are associated with osteoporosis or metabolic bone disease:

• Supplemental calcium and vitamin D based on age-appropriate recommendations 3
• Bisphosphonates (alendronate, risedronate) as first-line for osteoporosis management 8, 9
• Weight-bearing exercise and lifestyle modifications 8

Special Populations and Considerations

Age-Related Factors

Bone spur frequency increases with age, particularly dorsal calcaneal spurs. 5 Older patients may require more aggressive bone health optimization alongside spur-specific treatment.

Activity-Related Spurs

Dorsal spurs appear more activity-related, while plantar spurs may result from prolonged standing and excess weight. 5 Treatment should address the underlying mechanical factors contributing to spur formation.

Fracture Through Bone Spurs

Enthesophyte fractures should be treated conservatively with focus on increasing range of motion, progressive resistance exercises, and eccentric loading, alongside strategies to reduce joint strain. 1 This differs from typical fracture management and surgical intervention is generally not indicated.

Treatment Progression Algorithm

1. Initial phase (0-4 weeks): Maximum tolerated NSAIDs/COXIBs, physical therapy, activity modification 3, 1
2. Early evaluation (2-4 weeks): Assess response; continue if improving 3
3. Extended conservative phase (up to 12 weeks): Continue successful conservative measures 3
4. Refractory cases: Consider surgical intervention only after documented failure of conservative treatment 6

Never progress to surgery without exhausting conservative options, as most bone spurs respond to non-operative management and surgery carries risks of complications and prolonged recovery.