What is the best approach to manage a patient with a calcaneal spur?

Management of Calcaneal Spur

Begin with conservative management using open-backed shoes, heel lifts or orthoses, appropriate footwear, NSAIDs, stretching exercises, and activity modification for 6-8 weeks before considering more aggressive interventions. 1

Initial Conservative Approach (First 6-8 Weeks)

Footwear Modifications

• Use open-backed shoes to reduce direct pressure on the posterior calcaneal spur 1
• Ensure shoes are 1-2 cm longer than the foot with adequate width at the metatarsal phalangeal joints 1
• Avoid barefoot walking both indoors and outdoors 1
• Consider heel lifts or orthoses to redistribute pressure away from the spur 1
• Add felted foam padding when custom orthotic devices are not immediately available 1

Medical Management

• Prescribe NSAIDs for pain control and inflammation reduction 1
• Implement stretching exercises targeting both the plantar fascia and Achilles tendon 1
• Recommend activity modification with decreased weight-bearing activities 1
• Advise weight loss if the patient is overweight, as this reduces mechanical stress on the heel 1

Common pitfall: Many clinicians focus solely on the radiographic spur itself, but histopathologic studies demonstrate that mucoid and fibrinoid degeneration of the plantar fascia—not the spur—is primarily responsible for symptoms. 2 The spur is often an incidental finding and treating the surrounding soft tissue inflammation is paramount.

Intermediate Management (After 6-8 Weeks Without Improvement)

Immobilization

• Apply an immobilization cast or fixed-ankle walker-type device to restrict movement and reduce pressure 1
• Continue all initial conservative measures during immobilization 1

Injectable Therapies

• Consider corticosteroid injections into the plantar fascia for plantar-based spurs 1
• For posterior calcaneal spurs associated with retrocalcaneal bursitis (Haglund's deformity), consider bursa injections 1

Important caveat: If symptoms persist despite 6-8 weeks of appropriate conservative therapy, refer to a podiatric foot and ankle surgeon for evaluation, as other diagnoses may need to be considered. 3

Advanced Interventions for Refractory Cases

Non-Surgical Advanced Options

• Extracorporeal Shock Wave Therapy (ESWT) should be considered for cases not responding to 2-3 months of conservative treatment 1

Surgical Management

When conservative measures fail after prolonged treatment (typically 5-6 months), surgical options include:

For Plantar Spurs:

• Plantar fasciotomy with resection of the medial 75% of the plantar fascia 1, 4
• Removal of the calcaneal spur if present 4
• Debridement of adjacent calcaneal periostitis, which is commonly present and contributes to symptoms 5
• Decompression of the nerve to the abductor digiti quinti if indicated 4

For Posterior Calcaneal Spurs:

• Resection of the prominent posterior superior aspect of the calcaneus and inflamed bursa 1
• Calcaneal osteotomy may be required in some patients to correct calcaneal alignment 1

Surgical outcomes: Endoscopic techniques achieve 79-85% excellent outcomes (pain range 0-2) at one-year follow-up, with good to excellent results in pain relief and return to normal activity. 5, 4 However, time to maximal improvement is often prolonged, and patients should be counseled accordingly. 2

Critical consideration: Despite complete surgical excision, subcalcaneal exostoses often reform radiographically, yet this does not correlate with symptom recurrence. 2 Additionally, fascial transection does not precipitate collapse of the longitudinal arch, contrary to historical concerns. 2

Special Populations

Diabetic Patients

• Follow specific offloading guidelines to prevent ulcer formation and complications 1
• Use non-removable knee-high offloading devices if plantar ulcers develop in association with the spur 1
• Address moderate infection and moderate ischemia before focusing on the spur itself 1

Major pitfall: Conservative therapy should always be attempted first, as surgical series report high failure rates when used as initial treatment. 6 Only proceed to surgery after documented failure of comprehensive conservative management lasting at least 3-6 months. 4, 5