Heel Spur Study

This study of heel spurs statistically analyzes 46 patients treated at the Podiatry Group of Greater New York, and contends that the painful heel spur is a medical/biomechanical entity that is usually resolved without the need for surgical intervention.

A heel spur is an osteophytic proliferation just anterior to the calcaneal tuberosity that extends plantarly along its entire width. The boney prominence develops and points distally at the attachment of the plantar aponeurosis. The condition may be asymptomatic or may result in painful ambulation.

Clinical Picture
The patient usually presents with a complaint of pain located mainly under the medial plantar aspect of the heel. The onset is ordinarily gradual, the pain being most intense in the morning upon taking the first steps of the day, decreasing slightly after a period of ambulation, and then becoming more pronounced at day’s end.

In addition, the patient may relate a history of increased pain upon ambulation after periods of non-weightbearing. The condition is rarely totally disabling, although a limp may be present. There is normally no history of preceding illness or trauma to the area, and the condition may be present from a few days to a few months before a patient seeks treatment.

Etiology
From our study and a review of the current literature, it is evident that the major factor in the cause of heel spurs is undoubtedly mechanical, rather than infectious. A heel spur is generally thought to develop from traction on the periosteum that causes consequent subperiosteal ossification. By controlling pronation and lessening the bowstring effect of the plantar aponeurosis, the reactive force will be removed, and the inflammation should subside.

Although we are stressing the biomechanical cause for heel spurs, it should be noted that there are heel spurs caused by various infectious and arthritic conditions as well. Some of these conditions are rheumatic and psoriatic arthritis, ankylosing spondylitis, Reiter’s syndrome, and Strumpell-Marie disease. However, these cases have been found to be the exception, rather than the rule, as far as etiology is concerned.

DuVries listed three types of heel spurs:¹

1. Those that are large in size but asymptomatic because the angle of growth is such that the spur does not become a weightbearing point, and/or the inflammatory changes have been arrested. This type is usually found incidentally when the foot is X-rayed for some other purpose.
2. Those that are large in size and painful upon weightbearing, because the pitch of the calcaneus has been altered by a depression of the longitudinal arch, and as a result, the spur becomes a weightbearing point, sometimes causing intractable pain.
3. Those that exhibit only a rudimentary proliferation and whose outline is irregular and jagged. These usually are accompanied by an area of decreased density around the origin of the plantar fascia, indicating a subacute inflammatory process. All calcaneal spurs undoubtedly begin in this manner, but only a few become symptomatic at this stage, because in only these few are the etiologic factors acute.

Statistical Distribution
In 46 patients with painful heel spurs, there were 15 bilateral cases (25%), for a total of 61 painful heels. There were 31 right feet (51%) and 30 left feet (49%), a statistic that concurs with Lapidus’ study, which found that both right and left feet were equally involved.²

Sex. Of 46 patients, 25 were male (54%) and 21 were female (46%). These statistics were comparable to DuVries’ study, which found no sexual preference.¹ Lapidus, however, found a three to one ratio, with males predominating.²

Age. One patient was younger than 20 years of age (2.2%). Five patients (10.8%) were between 20 and 29. Eight patients (17.4%) were between 30 and 39. Eleven patients (24.0%) were between 40 and 49. Thirteen patients (28.2%) were between 50 and 59. Six patients (13.0%) were between 60 and 69, and two patients (4.4%) were between 70 and 79 years of age.

About one-half of the patients were between 40 and 59. Clearly this age group comprised the majority of cases. In Lapidus’ study of 323 patients with 364 painful heels, this age group also comprised an almost identical 51%.²

Pes Planus. We found 14 of 61 feet (23%) to be of pes planus type. This percentage falls exactly midway between Lapidus’ study (4%)² and the study of Costa Bertani³, where 40% of the patients were flatfooted. Obesity was recorded in nine cases (20%).

Radiology. Of the three types of spurs described earlier, we found that 13 feet (21%) were of type I, that is, a spur was evident on X-ray, but was asymptomatic. Thirty-three feet (54%) were of type II, where there was positive radiology for a heel spur, and the patient was symptomatic. Fifteen feet (25%) were of type III, where symptoms were evident, but no osseous spur was evident on X-ray.

When the spur was present, it was almost always horizontal in line, tapering off in line with the plantar fascia. We saw no evidence of spurs that were pitched plantarly.

Diagnosis
The primary symptom is severe pain in the entire plantar surface of the heel with poststatic dyskinesia. Pinpoint palpation usually elicits maximum pain in the area of the medial tubercle of the calcaneus.

When taking X-rays, one should always take bilateral weightbearing lateral views. In evaluating the X-rays, one must also take into consideration the pathological processes of early fibrosis, osteophytic deposits, and eventual calcification. From our study and those of others, it is evident that a spur need not be evident on X-ray for the heel-spur syndrome to exist.

Treatment
We have always been able to relieve symptoms by conservative measures: not one single patient in our study needed surgical intervention. All of our patients became symptom-free within a period of two weeks to a few months following initial therapy. In 39 patients where longterm follow-up was available, the average number of once-a-week treatments given was 4.23, with no recurrences.

Our weekly treatment regimen consisted of a two-pronged approach. First, a posterior tibial nerve block was instituted to accomplish two things: to produce anesthesia, while increasing circulation to help flush out some of the inflammatory process. Secondly, a longitudinal arch pad with a low-dye and Campbell’s rest strap were employed to help support the plantar fascia and relieve the strain at its origin on the calcaneus.

In about 15% of the cases, where the patient was slow in responding to treatment, the following one-time treatment was added:

• A local infiltrate of 2mg dexamethasone sodium phosphate and 30mg lidocaine hydrochloride were introduced into the area of maximum tenderness, using a gauge 23, 1 1/2 inch (4cm) needle.
• Fenoprofen calcium was prescribed, one 600 mg tablet three times per day for two weeks.
• Once the patient became asymptomatic, orthotic control was instituted to regulate the patient’s biomechanics, and to prevent recurrence.

Discussion and Conclusions
Plantar calcaneal spurring occurs most often at the origin of the plantar fascia from the calcaneus. The predominance of maximal tenderness on the medial plantar aspect of the calcaneus is most probably due to the greatest tension being on the medial process of the calcaneal tuberosity, from which a large percentage of the plantar fascia originates.

The majority of heel spurs appear in middle-age (between 40 and 59 years of age). Spurs can be coincidental findings without pain, or they may be absent entirely in the patient with painful heel-spur syndrome.

Both sexes, as well as both feet, are affected equally with no predominance. In our study, there was a 23% correlation between heel-spur syndrome and pes planus, with obesity being an additional predisposing factor. Heel spurs are ordinarily due to biomechanical rather than infectious factors. Our study found that they can usually be treated successfully without surgery.

References
¹ DuVries, Henri.: Calcaneal spur. Arch. of Surg. 1957; 74:536-542.
² Lapidus, P.W., & Guidoti, F.P.: Painful heel: report of 323 patients with 364 painful heels. Clin. Orthop. 1965; 39:178-186.
³ Bertani, Costa G.: Flatfoot as a factor in producing inferior exostosis of heel. Rev. Ass. Med. Argent., April, 1939; 53:455-462 (quoted from DuVries).

General References
Campbell’s Operative Orthopaedics (C.V. Mosby, St. Louis, 4th ed., 1962), p. 1624.
Freeling, R.: Common heel problems. The Jogger , May/June 9-10, 1981, p. 9.
Rubin, G., & Witten, M.: Plantar calcaneal spurs. Am. J. Orthop. 1963; 5:38.

BARRY KATZMAN submitted this paper during his precepteeship at the Podiatry Group of Greater New York. SIMON YOUNG is a Diplomate of the American Board of Podiatric Surgery. DENNIS SHAVELSON Associate Professor of Medicine at the New York College of Podiatric Medicine, is also a Diplomate of the American Board of Podiatric Surgery. Mailing address: Barry Katzman, 24825 Union Turnpike, Bellerose, NY 11426.

This information has been prepared by the Consumer Education Committee of the American College of Foot and Ankle Surgeons, a professional society of 5,700 podiatric foot and ankle surgeons. Members of the College are Doctors of Podiatric Medicine who have received additional training through surgical residency programs. The mission of the College is to promote superior care of foot and ankle surgical patients through education, research and the promotion of the highest professional standards. Copyright © 2004, American College of Foot and Ankle Surgeons, www.acfas.org