What is the best treatment approach for a middle-aged or older patient with calcaneal enthesophytes, a history of plantar fasciitis or Achilles tendinitis, and potential impaired renal function?

Treatment of Calcaneal Enthesophytes

Begin with conservative management including calf-muscle stretching, NSAIDs (with caution in renal impairment), heel lifts or orthoses, activity modification, and weight loss if indicated, continuing for 6-8 weeks before escalating care. 1

Initial Conservative Treatment (First 6-8 Weeks)

The American College of Foot and Ankle Surgeons recommends starting with patient-directed measures combined with medical interventions 1:

Patient-Directed Measures:

• Regular calf-muscle stretching exercises (critical for addressing underlying biomechanics) 1
• Cryotherapy (ice massage to affected area) 1
• Over-the-counter heel cushions and arch supports 1
• Activity limitation and avoidance of flat shoes and barefoot walking 1
• Weight loss if indicated 1

Medical Interventions:

• NSAIDs with significant caveats for renal impairment: In patients with impaired renal function, NSAIDs should be used with extreme caution or avoided entirely, as they can cause dose-dependent reduction in renal blood flow and precipitate overt renal decompensation 2. Patients with impaired renal function are at greatest risk for NSAID-induced renal toxicity 2. If NSAIDs must be used, the lowest effective dose for the shortest duration is essential, with close monitoring of renal function 2.
• Padding and strapping of the foot 1
• Corticosteroid injections in appropriate patients (avoiding the Achilles tendon insertion) 1

Critical Distinction for Insertional Achilles Tendinitis: Local corticosteroid injections are NOT recommended for insertional Achilles tendinitis due to risk of tendon rupture 1. Open-backed shoes to reduce pressure on the posterior heel are specifically indicated 1.

Escalation at 6-8 Weeks Without Improvement

If no improvement occurs after 6 weeks for plantar fasciitis or 6-8 weeks for insertional Achilles tendinitis, refer to a podiatric foot and ankle surgeon while continuing initial treatments 1:

Additional Interventions:

• Customized orthotic devices (not just over-the-counter supports) 1
• Night splinting 1
• Limited number of corticosteroid injections (for plantar fasciitis only, avoiding Achilles tendon) 1
• Casting or fixed-ankle walker-type device during activity 1
• Immobilization in particularly acute or refractory cases 1

Further Escalation at 2-3 Months Without Improvement

If no improvement occurs after 2-3 months, continue initial treatment measures and consider 1:

• Cast immobilization if not previously used 1
• Surgery (plantar fasciotomy for plantar fasciitis; resection of calcaneal osteophyte and diseased tendon for Achilles enthesopathy) 1, 3
• Extracorporeal shock wave therapy 1
• Exploration of other diagnoses 1

Special Considerations for Renal Impairment

NSAIDs are contraindicated or require extreme caution in patients with advanced renal disease 2:

• Treatment with naproxen (and other NSAIDs) is not recommended in patients with advanced renal disease 2
• If NSAID therapy must be initiated, close monitoring of renal function is mandatory and patients must be adequately hydrated 2
• Elderly patients are more likely to have decreased renal function and are at greater risk for NSAID-induced renal toxicity 2
• Alternative analgesics such as acetaminophen may be considered, though evidence in this condition is limited 1

Severe or Refractory Cases

For severe enthesitis that fails initial conservative measures, TNF inhibitors should be considered, particularly when quality of life is significantly impaired 1. This is most relevant when calcaneal enthesophytes are part of a systemic inflammatory condition such as psoriatic arthritis or ankylosing spondylitis 1.

Common Pitfalls to Avoid

• Never inject corticosteroids directly into or near the Achilles tendon due to risk of tendon rupture 1
• Do not use NSAIDs liberally in patients with renal impairment without close monitoring, as this can precipitate acute renal failure 2
• Do not delay surgical referral beyond 2-3 months of failed conservative treatment, as prolonged symptoms may indicate need for definitive intervention 1
• Recognize that approximately 80% of patients improve with conservative treatment within 12 months, so patience with non-operative management is appropriate in most cases 4