What is the best course of treatment for a patient with calcaneal spurring at the Achilles tendon insertion and plantar fascia origin, and a bipartite medial hallux sesamoid, presenting with heel and foot pain?

Treatment of Calcaneal Spurring with Heel Pain

Begin with a structured 6-week trial of conservative therapy combining daily stretching exercises (3-5 times daily targeting both the Achilles tendon and plantar fascia simultaneously), NSAIDs, heel cushions or arch supports, activity modification, and proper footwear—this resolves symptoms in 90% of patients within 3-6 months. 1, 2

Initial Conservative Management (First 6-8 Weeks)

Patient-Directed Interventions

• Stretching exercises are the most consistently effective intervention and should target both the Achilles tendon and plantar fascia simultaneously, performed 3-5 times daily 1, 3, 4
  • Simultaneous stretching of both structures produces superior outcomes compared to Achilles-only stretching, with 56% achieving complete symptom relief versus 28% with Achilles stretching alone 4
• Apply ice therapy through a wet towel for 10-minute periods to reduce pain and inflammation 1, 3
• Use over-the-counter heel cushions and arch supports to redistribute weight and reduce pressure on the calcaneal insertion points 1, 3
• Modify activities that worsen pain, but avoid complete immobilization to prevent muscle atrophy 1, 3
• Wear appropriate footwear with adequate arch support and cushioning; for posterior heel pain at the Achilles insertion, use open-backed shoes to reduce pressure 1, 3
• Pursue weight loss if indicated to reduce mechanical stress 1, 3

Pharmacologic Management

• NSAIDs (oral or topical) provide pain relief and reduce inflammation during the initial treatment phase 1, 3

Critical Warning

• Never inject corticosteroids near the Achilles tendon insertion due to high risk of tendon rupture 1, 5, 3
  • Corticosteroid injections may be considered for plantar fascia pathology but should be used judiciously and only after other measures fail 1

Understanding the Imaging Findings

Calcaneal Spurs

• The bony spurs visible on radiographs are not necessarily the primary pain source—rather, inflammation of surrounding soft tissues (plantar fascia, Achilles tendon, retrocalcaneal bursa) and possible nerve compression cause the symptoms 3, 6
• Radiographs have 85% sensitivity and 95% specificity for plantar fasciitis when showing thickened plantar fascia and fat pad abnormalities 1

Bipartite Sesamoid

• Radiographs can distinguish between bipartite versus fractured sesamoid, though this differentiation can be challenging 1
• A bipartite medial hallux sesamoid is typically an incidental finding and asymptomatic unless there is focal tenderness, swelling, or pain with weight-bearing on the first metatarsal 1
• If the sesamoid is asymptomatic, no specific treatment is required beyond addressing the heel pain

Escalation if No Improvement After 6-8 Weeks

Refer to Podiatric Foot and Ankle Surgeon

• Referral is appropriate when there is no improvement after 6-8 weeks of appropriate conservative treatment 1, 5, 3

Additional Treatment Options

• Continue all initial conservative measures 1
• Add customized orthotic devices (not just over-the-counter supports) 1
• Consider night splinting to maintain dorsiflexion during sleep 1
• Use cast immobilization or fixed-ankle walker-type device for 2-3 weeks in refractory cases 1
• Limited corticosteroid injections may be considered for plantar fascia pathology (avoiding Achilles insertion) 1

Further Escalation if No Improvement After 2-3 Months

Advanced Treatment Considerations

• Continue conservative measures and consider cast immobilization if not previously used 1
• Extracorporeal shock wave therapy is a non-invasive option for persistent heel pain 1, 3
• Surgical options include plantar fasciotomy for plantar fascia pathology or open debridement of retrocalcaneal bursa, calcaneal osteophyte, and diseased tendon for Achilles enthesopathy 1, 7
• Advanced imaging (MRI or ultrasound) may be needed to confirm diagnosis and rule out other conditions if not previously obtained 5, 3

Common Pitfalls to Avoid

• Do not assume the spur itself is causing pain—focus treatment on the soft tissue inflammation 3, 6
• Avoid complete immobilization, which leads to muscle weakness and deconditioning 3
• Do not use corticosteroid injections near the Achilles tendon under any circumstances 1, 5, 3
• Recognize that symptoms often precede radiographic changes in stress fractures, requiring bone scan or MRI if clinical suspicion is high despite negative radiographs 5

Red Flags Requiring Immediate Evaluation

• Constant pain at rest (suggests infection or other serious pathology) 3
• Progressive numbness or neurologic symptoms (requires immediate subspecialist referral) 5, 3
• Increasing swelling, redness, or warmth (suggests infection) 3
• Bilateral symptoms with pain in other joints (consider systemic arthropathy) 5