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Spur poking into tissue?

Posted by Scott R on 12/10/00 at 07:27 (034581)

Dr Z and Dr. B, I need to confirm something for the book. Is it definitely true that spurs are always bendable (not hard and rigid) and that pain never results from them poking into tissue?

Re: Spur poking into tissue?

Dr. Zuckerman on 12/10/00 at 17:41 (034605)

The Term spur is a very mis-leading word to use for this very painful heel condition. There is a calcification that is due to periosteal reaction from the fibers of the plantar fasia tearing at the insertion into the medial tubercle of the calcaneus. There have been thousands and thousands of x-ray's taken with ' heel spurs' that never hurt the patients and are just asymtomatic findings . I guess the reason they are called heel spurs is due to the way they look when viewing a lateral x-ray . The pain results from the fibers tearing at the interface of the plantar fascia into the bone. This causes a reactive inflamatory process causing swelling, pain,
and the laying down of bone to repair this injury. Plantar fasciitis and or heel calcification is a repetitive motion injury. Now you can also have plantar fasciitis as a secondary condition due to posterior tibial tendon dysfunction, trauma, Rheumatoid arthritis, biomechanical dysfunction, weight, standing, climbing sports etc. . So they don't poke into the tissue. They are soft calfication with incomplete healing whereby the plantar fascia fibers don't heal due to the lack of bone being
laid down by the human healing process. Spurs can be hard which is good because they have completely healed the area. The ones that are soft are like a mal union where there is incomplete calfication or not enough calification to strengthen the area. This is why heel spur excision or scraping of the area works. It causes bleeding and thus the body reacts with a new inflamatory process which consists of additional calfications and or fibrobastic tissue healing. You have to heal the torn fibers in true pf and or pf with calcificationl. Now ESWT in my opinon and in alot of the literature by sound waves stimulates the healing process to lay down fibroblasts which are necessary to heal plantar fascia torn fibers.

Re: More talking by Dr. Z

Dr. Zuckerman on 12/10/00 at 17:49 (034606)

The idea that the spur is poking or sticking into the soft tissue like a foreign body isn't true. So why does EPF work. EPF usually isn't done at the plantar fascia bone junction or where the exact attachment is . Why does it work is due to the release of the plantar fascia from pulling on the traumatic area and now is can heal. or should heal. When I do Miminial incision heel spur surgery. I cut and scrape the area at the eact location where the plantar and the calcification are interfaced. Many times when i scoop out the calfication which is a very quick and easy step once you locate this very small area it is very soft. In the video where i do the procedure you see me showing the very soft 'heel spur' In fact with this specific patient on x-ray there was no 'heel spur' on his x-ray. This was
due to the calcification being soft and therefore not strong enough to keep the pf fibers attached to the heel. I hope that I haven't complicated this explanation . IF I have Tell me and I will think of other way to explain this. Scott this is a very important area that needs to be explained so that every one understands this. The first thing that i tell my patients after saying the word heel spur is that you aren't walking on a sharp piece of bone or that it isn't sticking into the foot like a piece of glass or nail It may feel like it does but I show them pictures of the heel spur and its relationship So let me know if I am explaining this in a very simple matter or if I should go at it again. I don't want the public to think that the spur must come out because it is the root of all evil foot pain. !!!!!

Re: More talking by Dr. Z

lenore on 12/10/00 at 19:59 (034625)

if the spur isnt hard then why when i was having mine removed did it feel like the dr was in there with a file. i felt the pressure for some time wjile he was removing it and post op he said my bone was very hard??? almost asked him during surgeery but the meds made me not really care at the time.

Re: More talking by Dr. Z

Barbara TX on 12/10/00 at 20:19 (034629)

EXCELLENT EXPLANATION. It is very difficult fo the layperson to get a handle on what pf really is - lots of doctors don't go over it properly. They just prescribe remedies without the patient understanding - which is fine, if you are sure that your doctor is the very very best, and miserable if your doctor is the very very worst. The only way to tell is by his results and doing some research yourself. You ahve now explained, Dr. Z., how it could be that someone's grandfather (who was it again?) smashed the bottom of his heel with a ladle and solved the problem. He caused enough trauma to the area to re-start the inflammatory process again from the beginning so the thing could finally heel properly. The ESWT is like a soup spoon with spark plugs, doing damage on the cellular level. Sounds like good science to me! B.

Re: More talking by Dr. Z

Dr. Zuckerman on 12/11/00 at 03:00 (034652)

I find that alot are soft. This is when there is incomplete healing. Yes there are some that are hard. I am not sure why but my theory is that some is hard and the rest is soft. Yo make the x-ray look good you try to take all of the spur ( calcification out) it is well known by most surgeons that all you need to do is just remove some of the spur or calcification to the result.s So end of the calfication is soft but the entire calcification is hard and it is very hard to come the hard part out to make the x-ray look good. There have been time and I time patients that I may not beable to remove all of the calcification the reason I say this is due to the judgement that causing more trauma just to make the x-ray look good may not be in the best interest of the patient. All you have to do is remove or cause some bleeding at the pf -heel spur- soft calcification interface. With do the surgery to get rid of the pain not to make the x-ray look good without the spur showing. I have alot of patients where I only did a partial removal of the spur with very great results. You see you only have to create a trauma to the area that is not healing.

I am explaining this clearly because I want everyone to understand this. I am use to explaining this as I am doing the surgery and showing a doctor the consistency of the spur as it is removed.

Re: More talking by Dr. Z

Dr. Zuckerman on 12/11/00 at 03:09 (034654)

I remember a Dr. Al Brown who first did Miminial incision heel spur. He is in his 80' another one of the retired Florida Pods . He proved to me that you don't have to get all of the spur our to get the results. This was in the 1960's This is what made me realize why it worked. He did trauma to the area and caused bleeding and then healing. To this day I still use his # six bone currette to get that spur out . I put a rasp in there and then trick the spur to poke its head out and then use this #six scoop to catch it before it pokes it head back in. By the way this Dr. Brown use to find this area without fluroscope without x-ray just by feeling the area and knowing where to go. At that time they knew what worked but I don't think they knew why.

Re: More talking by Dr. Z

Barbara TX on 12/11/00 at 08:54 (034667)

I have read in the Merck manual that a heel spur becomes less and less painful the more it is fully formed (calcified) which meshes nicely with your explanation that it is not the hardness or softness of the spur, but that 'in between' time of healing that is not completing itself - the 'semi-soft' stage. Do you just do that scraping on the soft area of the fascia during MIS or do you make cuts into the body of the it and do a 1/3 little 'releasing' to take the tension out of it? I was reading Scott's posting of a conversation between DPM's and one mentioned that a surgeon had good success (the squeamish may turn away here) just taking a scalpel and taking a good stab through the bottom of the heel right into that place. Perhaps I should have said 'making an incision.' Anyway, that would be enough to cause a bleed, for sure. This is probably a conversation that is just gory enough to interest Dr. Lewi. B.

Re: More talking by Dr. Z

lenore on 12/11/00 at 12:58 (034691)

thanks for your responce . after seeing my post op xrays the dr did not remove the entire heel spur just the end of it and he also used a rasp finding it with a fluroscope. though your eplaination was a little unclear the words you used are fimilar after reading my surgery report. i wish i could say i was cured but am still in alot of pain , now 3 months post op. i think i did some damage a few weeks after surgery because until then i felt great. thanks again

Re: More talking by Dr. Z

Dr. Zuckerman on 12/11/00 at 21:52 (034710)

May need to be placed in removeable cast. So rest the foot.

Re: Spur poking into tissue?

Dr. Zuckerman on 12/10/00 at 17:41 (034605)

The Term spur is a very mis-leading word to use for this very painful heel condition. There is a calcification that is due to periosteal reaction from the fibers of the plantar fasia tearing at the insertion into the medial tubercle of the calcaneus. There have been thousands and thousands of x-ray's taken with ' heel spurs' that never hurt the patients and are just asymtomatic findings . I guess the reason they are called heel spurs is due to the way they look when viewing a lateral x-ray . The pain results from the fibers tearing at the interface of the plantar fascia into the bone. This causes a reactive inflamatory process causing swelling, pain,
and the laying down of bone to repair this injury. Plantar fasciitis and or heel calcification is a repetitive motion injury. Now you can also have plantar fasciitis as a secondary condition due to posterior tibial tendon dysfunction, trauma, Rheumatoid arthritis, biomechanical dysfunction, weight, standing, climbing sports etc. . So they don't poke into the tissue. They are soft calfication with incomplete healing whereby the plantar fascia fibers don't heal due to the lack of bone being
laid down by the human healing process. Spurs can be hard which is good because they have completely healed the area. The ones that are soft are like a mal union where there is incomplete calfication or not enough calification to strengthen the area. This is why heel spur excision or scraping of the area works. It causes bleeding and thus the body reacts with a new inflamatory process which consists of additional calfications and or fibrobastic tissue healing. You have to heal the torn fibers in true pf and or pf with calcificationl. Now ESWT in my opinon and in alot of the literature by sound waves stimulates the healing process to lay down fibroblasts which are necessary to heal plantar fascia torn fibers.

Re: More talking by Dr. Z

Dr. Zuckerman on 12/10/00 at 17:49 (034606)

The idea that the spur is poking or sticking into the soft tissue like a foreign body isn't true. So why does EPF work. EPF usually isn't done at the plantar fascia bone junction or where the exact attachment is . Why does it work is due to the release of the plantar fascia from pulling on the traumatic area and now is can heal. or should heal. When I do Miminial incision heel spur surgery. I cut and scrape the area at the eact location where the plantar and the calcification are interfaced. Many times when i scoop out the calfication which is a very quick and easy step once you locate this very small area it is very soft. In the video where i do the procedure you see me showing the very soft 'heel spur' In fact with this specific patient on x-ray there was no 'heel spur' on his x-ray. This was
due to the calcification being soft and therefore not strong enough to keep the pf fibers attached to the heel. I hope that I haven't complicated this explanation . IF I have Tell me and I will think of other way to explain this. Scott this is a very important area that needs to be explained so that every one understands this. The first thing that i tell my patients after saying the word heel spur is that you aren't walking on a sharp piece of bone or that it isn't sticking into the foot like a piece of glass or nail It may feel like it does but I show them pictures of the heel spur and its relationship So let me know if I am explaining this in a very simple matter or if I should go at it again. I don't want the public to think that the spur must come out because it is the root of all evil foot pain. !!!!!

Re: More talking by Dr. Z

lenore on 12/10/00 at 19:59 (034625)

if the spur isnt hard then why when i was having mine removed did it feel like the dr was in there with a file. i felt the pressure for some time wjile he was removing it and post op he said my bone was very hard??? almost asked him during surgeery but the meds made me not really care at the time.

Re: More talking by Dr. Z

Barbara TX on 12/10/00 at 20:19 (034629)

EXCELLENT EXPLANATION. It is very difficult fo the layperson to get a handle on what pf really is - lots of doctors don't go over it properly. They just prescribe remedies without the patient understanding - which is fine, if you are sure that your doctor is the very very best, and miserable if your doctor is the very very worst. The only way to tell is by his results and doing some research yourself. You ahve now explained, Dr. Z., how it could be that someone's grandfather (who was it again?) smashed the bottom of his heel with a ladle and solved the problem. He caused enough trauma to the area to re-start the inflammatory process again from the beginning so the thing could finally heel properly. The ESWT is like a soup spoon with spark plugs, doing damage on the cellular level. Sounds like good science to me! B.

Re: More talking by Dr. Z

Dr. Zuckerman on 12/11/00 at 03:00 (034652)

I find that alot are soft. This is when there is incomplete healing. Yes there are some that are hard. I am not sure why but my theory is that some is hard and the rest is soft. Yo make the x-ray look good you try to take all of the spur ( calcification out) it is well known by most surgeons that all you need to do is just remove some of the spur or calcification to the result.s So end of the calfication is soft but the entire calcification is hard and it is very hard to come the hard part out to make the x-ray look good. There have been time and I time patients that I may not beable to remove all of the calcification the reason I say this is due to the judgement that causing more trauma just to make the x-ray look good may not be in the best interest of the patient. All you have to do is remove or cause some bleeding at the pf -heel spur- soft calcification interface. With do the surgery to get rid of the pain not to make the x-ray look good without the spur showing. I have alot of patients where I only did a partial removal of the spur with very great results. You see you only have to create a trauma to the area that is not healing.

I am explaining this clearly because I want everyone to understand this. I am use to explaining this as I am doing the surgery and showing a doctor the consistency of the spur as it is removed.

Re: More talking by Dr. Z

Dr. Zuckerman on 12/11/00 at 03:09 (034654)

I remember a Dr. Al Brown who first did Miminial incision heel spur. He is in his 80' another one of the retired Florida Pods . He proved to me that you don't have to get all of the spur our to get the results. This was in the 1960's This is what made me realize why it worked. He did trauma to the area and caused bleeding and then healing. To this day I still use his # six bone currette to get that spur out . I put a rasp in there and then trick the spur to poke its head out and then use this #six scoop to catch it before it pokes it head back in. By the way this Dr. Brown use to find this area without fluroscope without x-ray just by feeling the area and knowing where to go. At that time they knew what worked but I don't think they knew why.

Re: More talking by Dr. Z

Barbara TX on 12/11/00 at 08:54 (034667)

I have read in the Merck manual that a heel spur becomes less and less painful the more it is fully formed (calcified) which meshes nicely with your explanation that it is not the hardness or softness of the spur, but that 'in between' time of healing that is not completing itself - the 'semi-soft' stage. Do you just do that scraping on the soft area of the fascia during MIS or do you make cuts into the body of the it and do a 1/3 little 'releasing' to take the tension out of it? I was reading Scott's posting of a conversation between DPM's and one mentioned that a surgeon had good success (the squeamish may turn away here) just taking a scalpel and taking a good stab through the bottom of the heel right into that place. Perhaps I should have said 'making an incision.' Anyway, that would be enough to cause a bleed, for sure. This is probably a conversation that is just gory enough to interest Dr. Lewi. B.

Re: More talking by Dr. Z

lenore on 12/11/00 at 12:58 (034691)

thanks for your responce . after seeing my post op xrays the dr did not remove the entire heel spur just the end of it and he also used a rasp finding it with a fluroscope. though your eplaination was a little unclear the words you used are fimilar after reading my surgery report. i wish i could say i was cured but am still in alot of pain , now 3 months post op. i think i did some damage a few weeks after surgery because until then i felt great. thanks again

Re: More talking by Dr. Z

Dr. Zuckerman on 12/11/00 at 21:52 (034710)

May need to be placed in removeable cast. So rest the foot.