Treatment of Heel Spurs and Plantar Fasciitis

A thick, strong band runs along the sole from the heel bone to the bases of the toes: the plantar fascia. It holds the arch under tension, acting like a bowstring with each step. Repeated strain causes microscopic tears and irritation where it attaches to the heel; this is called plantar fasciitis and is the commonest cause of heel pain.

A heel spur is a pointed bony projection beneath the heel bone visible on an X-ray. It is the bone's response to years of traction and is often a consequence of the process rather than the cause of pain. Many people with heel spurs have no pain, while many with pain have no spur on X-ray. Treatment therefore aims to reduce strain on the fascia rather than 'cut off' the spur.

Major factors increasing strain include excess weight, standing all day on hard surfaces, abruptly increasing running or walking distance, flat or high-arched feet, tight calf muscles and Achilles tendon, and thin-soled unsupportive shoes. In places with many steep streets, such as Ordu, walking uphill and downhill also increases loading on the sole.

The history described by patients is very typical and provides much of the diagnosis:

• Sharp, stabbing heel pain with the first steps after getting out of bed in the morning
• Pain easing after a few minutes of walking and increasing again towards the end of the day
• The same pain recurring when standing up after sitting for a long time
• Marked tenderness when pressing the inner underside of the heel
• Difficulty walking barefoot on hard surfaces and climbing stairs
• Calf tightness and difficulty pulling the ankle upwards in the morning

Diagnosis is based on history and examination. Tenderness at the inner underside of the heel, increased pain when the toes are pulled upwards and measurement of calf tightness are key findings. X-rays are usually taken to exclude fractures and other bone problems rather than to demonstrate a heel spur.

Ultrasound or MRI may be requested if symptoms persist despite several months of treatment, findings are unusual or the diagnosis is uncertain; these assess fascia thickness, possible tears and bone marrow oedema. Patients often ask which specialty to see for heel pain: initial assessment is by an orthopaedics and traumatology specialist, with the exercise programme coordinated with physiotherapy when needed.

Most plantar fasciitis improves without surgery, but patience is needed and recovery usually takes weeks to months. The mainstays are stretching, reducing load and appropriate shoes and insoles. Their effect is greatest when combined.

• Stretching: regular calf and Achilles stretches and toe stretches for the plantar fascia, several times daily
• Load modification: temporarily reducing running and long-distance walking, and avoiding barefoot walking on hard surfaces
• Shoes and insoles: heel cushioning and arch support, with custom insoles if needed
• Cold therapy and massage: a cold pack beneath the heel at the end of the day and ball massage of the plantar fascia
• Medication: anti-inflammatory medicines during painful periods, for a limited time on medical advice
• Night splint: holds the foot gently stretched overnight for pronounced first-step pain
• Weight management: directly reduces the load on the sole with each step

Additional methods are discussed if pain persists despite several months of regular exercise and appropriate insoles. ESWT (shockwave therapy) is a non-surgical method delivering sound waves from outside the body; it is used in selected patients with persistent plantar fasciitis, over several sessions, and its effects vary between patients.

The treatment commonly called a 'heel spur injection' is usually a corticosteroid injection. It may reduce pain in the short to medium term; however, frequent repetition can cause unwanted effects such as weakening of the plantar fascia and thinning of the fat pad under the heel, so the number is limited and injections are not given indiscriminately. The effects of regenerative treatments such as PRP in this region are still being researched, and they are not suitable for every patient; the evidence and treatment framework are explained on the regenerative and non-surgical treatments page.

The method depends on symptom duration, examination findings, occupation and accompanying conditions. Evidence and expected duration of benefit are clearly explained at consultation.

Only a small proportion of patients with heel pain are considered for surgery. The usual criterion is pain continuing to restrict daily life despite at least six months–one year of consistent non-surgical treatment. Surgery aims not to remove the spur but to partly reduce tension where the plantar fascia attaches to the heel; some patients also need a procedure for a tight calf muscle.

Every operation has its own recovery process and risks; reduced support of the foot arch is one of them. The decision therefore follows a review of whether non-surgical measures have genuinely been applied consistently.

Moving the ankle up and down several times and stretching the calf before getting out of bed can reduce first-step pain. Cushioned indoor shoes reduce load on the sole compared with bare feet or thin slippers. People who stand for long periods should change the surface they stand on where possible and take short seated breaks during the day.

People who exercise should increase distance and pace gradually rather than abruptly, and replace running shoes when worn. Assessment is needed if symptoms do not improve within a few weeks or are accompanied by heel swelling or redness or foot numbness. You can book by telephone or WhatsApp at AC CLINIC in Altınordu, Ordu, to identify the cause of heel pain and establish a treatment plan.