What is the appropriate management for an otherwise healthy 11‑year‑old boy with an incidentally discovered asymptomatic dorsal foot spur (tarsal boss)?

Management of Asymptomatic Dorsal Foot Spur in an 11-Year-Old Boy

For an asymptomatic dorsal foot spur (tarsal boss) in an otherwise healthy 11-year-old boy, no treatment is indicated—observation alone is appropriate. 1

Clinical Context and Natural History

A dorsal foot spur, also known as a tarsal boss or dorsal exostosis, is a bony prominence typically occurring at the tarsometatarsal or intertarsal joints. 2 In pediatric patients, these findings are often incidental and do not require intervention when asymptomatic. 1

The key principle here is that the absence of symptoms (pain, functional limitation, or recurrent injury) eliminates the indication for any active treatment. 1

Recommended Management Approach

Observation Only

• No immobilization, orthotics, or physical therapy is needed for asymptomatic findings. 1
• Reassure the family that this is a benign finding that does not require treatment unless symptoms develop. 1
• No routine follow-up imaging is necessary. 1

When to Initiate Treatment

Treatment should only be considered if the patient develops:

• Pain during physical activity that interferes with daily function or sports participation 1
• Visible swelling or inflammation over the bony prominence 2
• Footwear difficulties due to pressure from the prominence 2
• Recurrent trauma to the area causing symptoms 1

Conservative Treatment (If Symptoms Develop)

Should symptoms arise in the future, the initial approach must always be conservative for at least 6 months: 1

• Activity modification to reduce repetitive stress 1
• Shoe modifications including padding or accommodative footwear to reduce pressure over the prominence 2
• Immobilization via walking boot or cast if acute pain is present 3
• Physical therapy focusing on range of motion and strengthening 4

Conservative treatment achieves pain relief in approximately 53% of symptomatic cases and prevents surgery in 62-79% of patients, depending on the specific pathology. 3

Surgical Considerations (Only for Failed Conservative Treatment)

Surgery is indicated only when conservative treatment fails after at least 6 months AND symptoms significantly impact quality of life. 1

• Excision of the dorsal exostosis (open or arthroscopic) is the procedure of choice 2
• Arthroscopic resection can be performed through minimally invasive portals 2
• Fusion of underlying joints is reserved for cases with advanced arthritis 1

Critical Pitfalls to Avoid

• Do not treat asymptomatic findings—this leads to unnecessary interventions with potential complications 1
• Do not obtain serial imaging for asymptomatic lesions, as this provides no clinical benefit and increases cost 5
• Do not assume the finding will inevitably become symptomatic—many patients remain asymptomatic throughout life 1
• Do not rush to surgery even if symptoms develop—conservative management must be exhausted first for at least 6 months 1

Patient and Family Education

Educate the family that: 1

• This is a benign anatomical variant that requires no treatment while asymptomatic
• They should monitor for development of pain during activities or difficulty with footwear
• If symptoms develop, conservative measures are highly effective and should be tried first
• The child can participate in all normal activities without restriction