Heel spurs

Definition

A heel spur is a bony projection on the sole (bottom) of the heel bone. This condition may accompany or result from severe cases of inflammation to the structure called plantar fascia. The plantar fascia is a fibrous band of connective tissue on the sole of the foot, extending from the heel to the toes.

Description

Heel spurs are a common foot problem resulting from excess bone growth on the heel bone. The bone growth is usually located on the underside of the heel bone, and may extend forward toward the toes. A painful tear in the plantar fascia between the toes and heel can produce a heel spur and/or inflammation of the plantar fascia. Because this condition is often correlated to a decrease in the arch of the foot, it is more prevalent after the ages of six to eight years, when the arch is fully developed.

Causes & symptoms

One frequent cause of injury to the plantar fascia is pronation. Pronation is defined as the inward and downward action of the foot that occurs while walking, so that the foot's arch flattens toward the ground (fallen arch). A condition known as excessive pronation creates a mechanical problem in the foot, and the portion of the plantar fascia attached to the heel bone can stretch and pull away from the bone. This damage can occur especially while walking and during athletic activities.

Some symptoms at the beginning of this condition include pain and swelling, and discomfort when pushing off with the toes during walking. This movement of the foot stretches the fascia that is already irritated and inflamed. If this condition is not treated, pain will be noticed in the heel when a heel spur develops in response to the stress. This is a common condition among athletes and others who run and jump a significant amount.

An individual with the lower legs turning inward, a condition called genu valgus or "knock knees," can have a tendency toward excessive pronation. This can lead to a fallen arch and problems with the plantar fascia and heel spurs. Women tend to suffer from this condition more than men. Heel spurs can also result from an abnormally high arch.

Other factors leading to heel spurs include a sudden increase in daily activities, an increase in weight, or a thinner cushion on the bottom of the heel due to old age. A significant increase in training intensity or duration may cause inflammation of the plantar fascia. High-heeled shoes, improperly fitted shoes, and shoes that are too flexible in the middle of the arch or bend before the toe joints will cause problems with the plantar fascia and possibly lead to heel spurs.

Bone spurs may cause sudden, severe pain when putting weight on the affected foot. Individuals may try to walk on their toes or ball of the foot to avoid painful pressure on the heel spur. This compensation during walking or running can cause additional problems in the ankle, knee, hip, or back.

Diagnosis

A thorough history and physical exam is always necessary for the proper diagnosis of heel spurs and other foot conditions. X rays of the heel area are helpful, as excess bone production will be visible.

Treatment

Acupuncture and acupressure can used to address the pain of heel spurs, in addition to using friction massage to help break up scar tissue and delay the onset of bony formations. Physical therapy may help relieve pain and improve movement. The Feldenkrais method could be especially helpful for retraining some of the compensation movements caused by the pain from the spur. Guided imagery or a light massage on the foot may help to relieve some of the pain. Other treatments include low-gear cycling, and pool running. Some chiropractors approve of moderate use of aspirin or ibuprofen, or other appropriate anti-inflammatory drugs. Chiropractic manipulation is not recommended, although chiropractors may offer custom-fitted shoe orthotics and other allopathic-type treatments outlined below.

Allopathic treatment

Heel spurs and plantar fascitis (inflammation of the plantar fascia) are usually controlled with conservative treatment. Early intervention includes stretching the calf muscles while avoiding reinjury to the plantar fascia. Decreasing or changing activities, losing excess weight, and improving the fit of shoes are all important measures to decrease foot pain. Modification of footwear includes well-padded shoes with a raised heel and better arch support. Shoe inserts recommended by a healthcare professional are often very helpful when used with exercises to increase the strength of the foot muscles and arch. The inserts prevent excessive pronation and continued tearing of the plantar fascia.

To aid in the reduction of inflammation, applying ice for 10–15 minutes after activities and the use of anti-inflammatory medications, such as aspirin or ibuprofen, can be helpful. Corticosteroid injections may also be used to reduce pain and inflammation. Physical therapy can be beneficial with the use of heat modalities, such as ultrasound, that create a deep heat and reduce inflammation. If the pain caused by inflammation is constant, keeping the foot raised above the heart and/or compressed by wrapping with a bandage will help. Taping can help speed the healing process by protecting the fascia from reinjury, especially during stretching and walking.

In 2000, a number of U.S. podiatrists were experimenting with a new technology known as Extracorporeal Pressure Wave Treatment (EPWT). This technology is similar to lithotripsy, which uses sound waves to break up kidney stones . Cost of EPWT was roughly comparable to that of surgery. Initial reports from practitioners using the treatment were positive.

Heel surgery

When chronic heel pain fails to respond to conservative treatment, surgical treatment may be necessary. Heel surgery can provide pain relief and restore mobility. The type of procedure used is based on examination and usually consists of releasing the excessive tightness of the plantar fascia, called a plantar fascia release. The procedure may also include removal of heel spurs.

Expected results

Usually, heel spurs are curable with conservative treatment. If not, heel spurs are curable with surgery, although there is the possibility of them growing back. About 10% of those who continue to see a physician for plantar fascitis have it for more than a year. If there is limited success after approximately one year of conservative treatment, patients are often advised to have surgery.

Prevention

To prevent this condition, wearing properly fitted shoes with good arch support is very important. If a person is overweight, weight loss can help diminish stress on the feet and help prevent foot problems. For those who exercise frequently and intensely, proper stretching is always necessary, especially when there is an increase in activities or a change in running technique. It is not recommended to attempt to work through the pain, as this can change a mild case of heel spurs and plantar fascitis into a long-lasting and painful episode of the condition.

In 2002, researchers attempted to compare the effects of various running techniques on pronation and resulting injuries like stress fractures and heel spurs. They suggested that it is possible to teach runners to stride in such a way as to minimize impact forces. One way is to lower running speed. Another is to take longer rest periods following a run.

Resources

BOOKS

Perkins, Kenneth E. "Lower Extremity Orthotics in Geriatric Rehabilitation." In Geriatric Physical Therapy, edited by Andrew Guccione. St. Louis, MO.: Mosby Year Book Inc., 1993.

PERIODICALS

Feeny, Tracy. "If The Shoe Fits." Advance Magazine for Physical Therapists. (July 1997): 7.

Hreljac, Alan. "Technique Impacts Overuse Injuries in Runners—Research Suggests Impact Forces and Rate of Pronation Influence Risk of Injury." Biomechanics. (September 1, 2002): 51.

ORGANIZATIONS

American Orthopedic Foot and Ankle Society. 222 South Prospect, Park Ridge, IL 60068.

American Podiatry Medical Association. 9312 Old Georgetown Road, Bethesda, MD 20814.

OTHER

Roberts. Plantar Fascitis. http://www.heelspurs.com (1998).

David Helwig

Heel Spurs

Definition

A heel spur is a bony projection on the sole (plantar) region of the heel bone (also known as the calcaneous). This condition may accompany or result from severe cases of inflammation to the structure called plantar fascia. This associated plantar fascia is a fibrous band of connective tissue on the sole of the foot, extending from the heel to the toes.

Description

Heel spurs are a common foot problem resulting from excess bone growth on the heel bone. The bone growth is usually located on the underside of the heel bone, extending forward to the toes. One explanation for this excess production of bone is a painful tearing of the plantar fascia connected between the toes and heel. This can result in either a heel spur or an inflammation of the plantar fascia, medically termed plantar fascitis. Because this condition is often correlated to a decrease in the arch of the foot, it is more prevalent after the age of six to eight years, when the arch is fully developed.

Causes and symptoms

One frequent cause of heel spurs is an abnormal motion and mal-alignment of the foot called pronation. For the foot to function properly, a certain degree of pronation is required. This motion is defined as an inward action of the foot, with dropping of the inside arch as one plants the heel and advances the weight distribution to the toes during walking. When foot pronation becomes extreme from the foot turning in and dropping beyond the normal limit, a condition known as excessive pronation creates a mechanical problem in the foot. In some cases the sole or bottom of the foot flattens and becomes unstable because of this excess pronation, especially during critical times of walking and athletic activities. The portion of the plantar fascia attached into the heel bone or calcaneous begins to stretch and pull away from the heel bone.

At the onset of this condition, pain and swelling become present, with discomfort particularly noted as pushing off with the toes occurs during walking. This movement of the foot stretches the fascia that is already irritated and inflamed. If this condition is allowed to continue, pain is noticed around the heel region because of the newly formed bone, in response to the stress. This results in the development of the heel spur. It is common among athletes and others who run and jump a significant amount.

An individual with the lower legs angulating inward, a condition called genu valgum or "knock knees," can have a tendency toward excessive pronation. As a result, this too can lead to a fallen arch resulting in plantar fascitis and heel spurs. Women tend to have more genu valgum than men do. Heel spurs can also result from an abnormally high arch.

Other factors leading to heel spurs include a sudden increase in daily activities, an increase in weight, or a change of shoes. Dramatic increase in training intensity or duration may cause plantar fascitis. Shoes that are too flexible in the middle of the arch or shoes that bend before the toe joints will cause an increase in tension in the plantar fascia and possibly lead to heel spurs.

The pain this condition causes forces an individual to attempt walking on his or her toes or ball of the foot to avoid pressure on the heel spur. This can lead to other compensations during walking or running that in turn cause additional problems to the ankle, knee, hip, or back.

Diagnosis

A thorough medical history and physical exam by a physician is always necessary for the proper diagnosis of heel spurs and other foot conditions. X rays of the heel area are helpful, as excess bone production will be visible.

Treatment

Conservative

Heel spurs and plantar fascitis are usually controlled with conservative treatment. Early intervention includes stretching the calf muscles while avoiding re-injuring the plantar fascia. Decreasing or changing activities, losing excess weight, and improving the proper fitting of shoes are all important measures to decrease this common source of foot pain. Modification of footwear includes shoes with a raised heel and better arch support. Shoe orthotics recommended by a healthcare professional are often very helpful in conjunction with exercises to increase strength of the foot muscles and arch. The orthotic prevents excess pronation and lengthening of the plantar fascia and continued tearing of this structure. To aid in this reduction of inflammation, applying ice for 10-15 minutes after activities and use of anti-inflammatory medication can be helpful. Physical therapy can be beneficial with the use of heat modalities, such as ultrasound that creates a deep heat and reduces inflammation. If the pain caused by inflammation is constant, keeping the foot raised above the heart and/or compressed by wrapping with an ace bandage will help.

Corticosteroid injections are also frequently used to reduce pain and inflammation. Taping can help speed the healing process by protecting the fascia from reinjury, especially during stretching and walking.

Heel surgery

When chronic heel pain fails to respond to conservative treatment, surgical treatment may be necessary. Heel surgery can provide relief of pain and restore mobility. The type of procedure used is based on examination and usually consists of releasing the excessive tightness of the plantar fascia, called a plantar fascia release. Depending on the presence of excess bony build up, the procedure may or may not include removal of heel spurs. Similar to other surgical interventions, there are various modifications and surgical enhancements regarding surgery of the heel.

Alternative treatment

Acupuncture and accupressure have been used to address the pain of heel spurs, in addition to using friction massage to help break up scar tissue and delay onset of bony formations.

Prognosis

Usually, heel spurs are curable with conservative treatment. If not, heel spurs are curable with surgery. About 10% of those that continue to see a physician for plantar fascitis have it for more than a year. If there is limited success after approximately one year of conservative treatment, patients are often advised to have surgery.

Prevention

To prevent this condition, wearing shoes with proper arches and support is very important. Proper stretching is always a necessity, especially when there is an increase in activities or a change in running technique. It is not recommended to attempt working through the pain, as this can change a mild case of heel spurs and plantar fascitis into a long lasting and painful episode of this condition.

Resources

ORGANIZATIONS

American Orthopedic Foot and Ankle Society. 222 South Prospect, Park Ridge, IL 60068.

American Podiatry Medical Association. 9312 Old Georgetown Road, Bethesda, MD 20814.

KEY TERMS

Calcaneous— The heel bone.

Genu valgum— Deformity in which the legs are curved inward so that the knees are close together, nearly or actually knocking as a person walks with ankles widely apart of each other.

Plantar fascia— A tough fibrous band of tissue surrounding the muscles of the sole of the foot. Also called plantar aponeurosis.

Pronation— The lowering or descending of the inner edge of the foot by turning the entire foot outwards.

Heel Spurs

An understanding of the formation of heel spurs is closely linked to the causation of the related inflammatory condition of the foot, plantar fasciitis. The heel bone, known as the calcaneus, is the largest bone in the foot. It is subject to significant forces with every stride, or at every occasion when the foot is required to bear body weight. The plantar fascia is the long fibrous tissue that supports the arch of the foot, anchored at one end on the surface of the heel, and connected at the other end to the ball of the foot, or forefoot.

Plantar fasciitis is an irritation of the plantar tissue; the specific site of discomfort can be anywhere along the tissue band. Small calcium deposits, appearing as a thin bony growth in an x-ray, will sometimes form on the outer edge of the heel bone. These are heel spurs, which occur in widths that range from 0.1 in 0.3 in (1 mm to 5 mm). In approximately 70% of all plantar fasciitis cases, heel spur formation occurs, but the two conditions are not necessarily dependant on one another.

The plantar fasciitis condition is believed to be the primary cause of pain in the foot; the bony heel spur is a structural abnormality. The pain is produced as a result of the irritation, similar to tendonitis, caused to the plantar tissue. These combined conditions are common in persons over the age of 45 years, due to accumulated stresses generated on the foot; athletes in sports such as distance running are most susceptible to the onset of plantar fasciitis.

There are a number of factors that often contribute to the combined development of plantar fasciitis and heel spurs. Imbalances in the relationship between the calf muscles, Achilles tendon, and the muscles of the foot are the most prominent contributors. When the calf muscles are tight as a result of not being properly stretched, the plantar structure is overstretched and it becomes irritated. When an athlete uses footwear that is not sufficiently supportive, particularly in the shoe construction that contacts the heel, known as the heel counter, the junction between the heel bone and the plantar may be unnaturally stressed.

The combined effect of heel spurs and plantar fasciitis will never present a life-threatening condition to an athlete or a sedentary person. The conditions are most noticeable when the person is first mobile in the morning, and it tends to lessen as the foot and the plantar tissue are stretched by normal movement as the day progresses. The result of these conditions on both performance and day-to-day comfort can be dramatic. It is virtually impossible for an athlete in a running sport to perform to an optimal level if foot pain is experienced throughout all training and competitive sessions. There are numerous remedies that may be utilized in the treatment of a heel spur or plantar fasciitis condition. The least invasive approaches, useful in the short to medium term, include: rest; stretching programs for both the foot and specific plantar tissues, as well as the calf muscles and the Achilles tendon, to achieve a better balance between those structures; the application of ice to the entire bottom of the foot after all sports activity; anti-inflammatory medications; taping the foot for additional support during training or competition; an orthotic to correct misalignment in the strike of the foot; and shoes with proper fit and additional cushioning and support in the heel.

In the longer term, when the less invasive strategies have not succeeded in countering the effects of these conditions, some athletes have obtained relief through cortisone injections. Cortisone, as a powerful synthetic anti-inflammatory, is a prescription medication that must be carefully weighed as an option due to the pronounced risks generally associated with this type of glucocorticoid injection in a small structure such as the heel (risk of rupture of the plantar).

Surgery is almost always a final resort. In this procedure, the goal is to loosen the tight, inflamed plantar tissue through a procedure known as a release. Such procedures are not always successful; if the plantar is made too lax, the person may become flat footed, or in some cases the delicate nerve pathways of the foot may be damaged. A procedure that has received greater prominence in recent years is a non-invasive extracorporeal shock wave therapy (ESWT), in which waves are directed to the affected tissue, to stimulate a micro-tear of the plantar fiber, an event that is believed to stimulate healthy plantar growth.

see also Achilles tendonitis; Foot: Anatomy and physiology; Tendinitis and ruptured tendons.