How should I manage a patient presenting with heel‑spur pain?

Management of Heel Spur Pain

Begin immediate conservative treatment for all patients with heel spur pain, including stretching exercises 3-5 times daily, NSAIDs, ice therapy, activity modification, proper footwear with arch support, and over-the-counter heel cushions—continuing this regimen for 6 weeks before considering specialist referral. 1, 2

Understanding the Condition

The heel spur itself is not the primary pain source—rather, inflammation of the plantar fascia and surrounding tissues causes the symptoms. 3 This is critical to understand because treatment targets the inflammatory process, not the bony spur visible on x-rays. The condition typically presents with:

• Sharp pain at the medial calcaneal tubercle on palpation 1
• Pain with first steps in the morning or after prolonged sitting 4
• Discomfort worsened by weight-bearing activities 3

Initial Conservative Treatment (0-6 Weeks)

Implement all of the following simultaneously:

Patient-Directed Measures

• Stretching exercises for calf muscles and plantar fascia performed 3-5 times daily—this is the most consistently effective intervention 2, 3
• Ice therapy applied through a wet towel for 10-minute periods to reduce inflammation 2, 3
• Over-the-counter heel cushions and arch supports to redistribute pressure 2, 3
• Activity modification by reducing pain-provoking activities while avoiding complete rest to prevent muscle weakness 2, 3
• Proper footwear with adequate arch support and cushioning; avoid flat shoes and barefoot walking 2, 3
• Weight loss if indicated to reduce heel pressure 1, 3

Medical Interventions

• NSAIDs (such as naproxen or ibuprofen) for pain relief and inflammation reduction 2, 3
• Padding and strapping of the foot for additional support 2

Most patients respond to this conservative approach within 6-8 weeks. 2, 3

If No Improvement After 6 Weeks

Refer to a podiatric foot and ankle surgeon while continuing initial treatments and adding:

• Customized orthotic devices (though these show only moderate benefit at 7-12 weeks with no clear advantage over prefabricated options) 2
• Night splinting 1, 2
• Limited corticosteroid injections (see critical warning below) 1, 2
• Casting or fixed-ankle walker device 1, 2

If No Improvement After 2-3 Months

Continue conservative measures and consider:

• Cast immobilization if not previously used 1, 3
• Extracorporeal shock wave therapy as a non-invasive option 1, 3
• Surgical options (plantar fasciotomy) for chronic recalcitrant cases 1, 4

Critical Warnings and Pitfalls

Never inject corticosteroids near the Achilles tendon due to significant risk of tendon rupture. 1, 2, 3 When using corticosteroids for plantar conditions, inject carefully to avoid the Achilles insertion site. 2, 3

Additional caveats:

• Avoid complete immobilization to prevent muscular atrophy and deconditioning 3
• Seek immediate evaluation if pain becomes constant at rest, or if numbness or increasing swelling/redness develops, to rule out infection or nerve compression 3

Diagnostic Imaging Considerations

Obtain radiographs as first-line imaging to identify fractures, spurs, and other bony pathology. 1 However, understand that imaging is rarely needed for initial diagnosis, which is primarily clinical. 4

Consider advanced imaging (MRI or ultrasound) only when:

• Diagnosis remains unclear after clinical evaluation 1, 3
• Conservative treatment fails after 2-3 months 3
• You need to rule out stress fracture, soft tissue pathology, or nerve entrapment 1