What is the recommended treatment approach for a patient with a heel spur, considering their medical history and potential underlying conditions such as diabetes or rheumatoid arthritis?

Treatment of Heel Spur

Begin with conservative management including calf-muscle stretching, heel cushions, arch supports, NSAIDs, activity modification, and avoidance of barefoot walking; if no improvement occurs after 6 weeks, escalate to custom orthotics, night splinting, and consider corticosteroid injections, with surgical options reserved only after 2-3 months of failed conservative therapy. 1

Initial Conservative Treatment (First 6 Weeks)

The cornerstone of heel spur management involves a structured conservative approach that should be implemented immediately:

• Calf-muscle stretching exercises performed regularly to reduce tension on the plantar fascia 1
• Heel cushions and arch supports (over-the-counter initially) to reduce mechanical stress 1
• NSAIDs for pain relief and inflammation control, though evidence shows modest benefit when combined with other conservative measures 1, 2
• Activity limitation and avoidance of flat shoes and barefoot walking 1
• Ice massage applied to the affected area 1, 3
• Weight loss if indicated, as excess weight increases plantar pressure 1
• Padding and strapping of the foot to provide mechanical support 1

Important Clinical Note on NSAIDs

While NSAIDs are commonly prescribed, a randomized placebo-controlled trial showed no statistically significant difference between NSAID and placebo groups at 1,2, or 6 months, though there was a trend toward improved pain relief in the NSAID group between 2-6 months. 2 This suggests NSAIDs may provide modest benefit but should not be relied upon as monotherapy.

Escalation After 6 Weeks Without Improvement

If symptoms persist after 6 weeks, refer to a podiatric foot and ankle surgeon and add the following interventions while continuing initial measures: 1

• Customized orthotic devices to provide targeted pressure relief 1
• Night splinting to maintain dorsiflexion and stretch the plantar fascia during sleep 1
• Limited corticosteroid injections (use judiciously in appropriate patients) 1
• Casting or fixed-ankle walker-type device during activity for more severe cases 1

Advanced Treatment After 2-3 Months of Failed Conservative Therapy

If no improvement occurs after 2-3 months of comprehensive conservative treatment: 1

• Continue all initial treatment measures 1
• Add cast immobilization if not previously used 1
• Consider plantar fasciotomy (surgical release) 1
• Consider extracorporeal shock wave therapy as an alternative to surgery 1, 3
• Explore other diagnoses if symptoms remain refractory 1

Special Considerations for Patients with Diabetes

Critical Footwear Modifications

Patients with diabetes and heel spurs require heightened attention to prevent ulceration:

• Instruct patients NOT to walk barefoot, in socks only, or in thin-soled slippers whether at home or outside 1
• Prescribe properly fitting therapeutic footwear when foot deformity or pre-ulcerative signs are present 1
• Consider custom-made insoles or therapeutic shoes for at-risk patients with neuropathy 1

Surgical Considerations in Diabetic Patients

If conservative treatment fails in diabetic patients with plantar forefoot issues related to heel spur syndrome:

• Consider Achilles tendon lengthening when limited ankle dorsiflexion contributes to plantar pressure 1
• Avoid surgical intervention until conservative measures have been exhausted, as post-operative infection rates in diabetic neuropathy patients undergoing foot surgery reach 9.5% 1

Key Clinical Pitfalls to Avoid

Do not assume the heel spur visible on radiograph is the cause of symptoms - the presence of a heel spur on x-ray simply indicates the condition has been present for at least 6-12 months and does not correlate with symptom severity. 3 The actual pathology is typically plantar fasciitis, with the spur being an incidental finding.

Avoid premature surgical intervention - almost all patients respond to conservative nonsurgical therapy, and surgery should only be considered after comprehensive conservative treatment has failed for 2-3 months. 1, 4

In diabetic patients, never inject corticosteroids near the Achilles tendon and exercise extreme caution with any injection therapy due to increased infection risk and potential for tissue breakdown. 1

Patients with Rheumatoid Arthritis

While the provided evidence does not specifically address heel spurs in rheumatoid arthritis, these patients require:

• Coordination with rheumatology for systemic disease management
• More cautious use of corticosteroid injections given potential systemic immunosuppression
• Earlier consideration of custom orthotics due to multiple joint involvement
• Evaluation for other causes of heel pain including inflammatory arthropathies affecting the heel 1