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Can of worms- Is there really such thing as a heel spur?

Posted by Richard, C.Ped on 8/20/03 at 09:22 (127382)

What prompts me to ask this question dates back to lectures we received in schooling as well as continuing education classes that we, as C.Peds, must attend. I distinctly remember numerous orthopedic surgeons state that there is no such thing as an actual 'heel spur'. They stated that when and x-ray is taken from the inside (or medial side) of the foot, the area of the heel bone where the plantar fascia inserts as a transition from soft tissue (soft tissue is invisible on an x-ray) to hard tissue. The area will look like a 'pointed hook' going forward out of the bone, hence, the 'heel spur'.

I have also spoken recently with orthopedic surgeons in this area who have told me the same thing.

Not to start any controversy (because of the name of this website), but I wanted to get opinions about what others have learned.

Ricard, C.Ped

Re: Can of worms- Is there really such thing as a heel spur?

BGCPed on 8/20/03 at 12:09 (127396)

I often wondered that myself. I think in many cases the heel spur is used as a scare tactic in a way. You can x-ray 100 people and many will have a 'spur' show up on the film. It is easy to point at it and say thats the bad guy, that shouldnt be there.

Most people can understand that a ugly point under the heel must hurt and probably shouldnt be there. That makes it easy to start the cortisone series. If that doesnt work then cutting it out is the solution (which I dont agree with)

As most of us know you can have a spur show on film and the pt has never had heel pain in their life. You can also have accute pain that feels like a hot poker under the heel and no spur shows on film. I have also heard that it is not firm and rigid like normal bone but rather like the cartilage in the ear or something similar.

Perhaps some others can post their opinions as well.

p.s. another point. Many pt get orthotics and will say the heel feels much better the first time they stand up wearing them. If a spur was the cause I would think the relief would not be so great since the spur is still there. I think it is more a structural load issue as well as traction type tension being relieved.

Re: Can of worms- Is there really such thing as a heel spur?

kay on 8/20/03 at 13:07 (127408)

I've never shown spurs on mine and my feet hurt like hell!

Doctors have told me 85% of the time spurs alone do not hurt, it is what caused the spurs that hurts. If you look at the spurs in xrays the point doesn't go straight down anyway,,,it is pulled forward toward the toes, so you really aren't walking on the point.

Re: Can of worms- Is there really such thing as a heel spur?

Dr. David S. Wander on 8/20/03 at 14:17 (127413)

You've brought up an excellent point regarding 'heel spurs'. As you are aware, it is generally accetped that the absence or presence of a heel spur does not matter regarding plantar fasciitis. I am a firm believer that the actual 'spur' does not cause pain (infracalcaneal spur). Retrocalcaneal spurs DO cause pain. To answer your question, spurs do and don't exist. First, anatomical dissections have shown that the spur is actually above the plantar fascia, and the idea of the spur forming as the result of plantar fascia traction has been challenged for the past several years. When you look at an x-ray, many times a spur will APPEAR to exist on the lateral view. However, an x-ray is two dimensional and can not accurately show the width of the 'spur'. In actuality, if you were to turn the foot you would see that the 'spur' is actually a shelf of bone going across the calcaneus/heel bone. It is not a pointy protrustion that many people imagine. And as you've experienced, cutting out a hole for the spur is basically useless, since there is no sharp/pointy spur, but there may be a shelf of bone. In summary, although a spur may seem to exist, it is actually a shelf of bone running across the calcaneus, and is not normal anatomy and is actually above the origin of the plantar fascia. Although it may be confusing, I hope this helps.

Re: Can of worms- Is there really such thing as a heel spur?

Richard, C.Ped on 8/20/03 at 15:55 (127425)

Thats not confusing at all Dr. Wander. That is just what I have thought after seeing pictures of different surgerys as well as speaking with numerous doctors about this issue.

What I left out in the first post was close to what you were saying about how spurs do and don't exist. I remember being taught that everyone has a spur, but that is not the source of pain from plantar fasciitis.

I do appreciate your comments!
Richard

Re: Can of worms- Is there really such thing as a heel spur?

Richard, C.Ped on 8/20/03 at 16:21 (127429)

'p.s. another point. Many pt get orthotics and will say the heel feels much better the first time they stand up wearing them. If a spur was the cause I would think the relief would not be so great since the spur is still there. I think it is more a structural load issue as well as traction type tension being relieved.'

Exactly Brain...I hear that more often than not.
Richard

Re: Can of worms- Is there really such thing as a heel spur?

Dr. Z on 8/20/03 at 17:05 (127436)

I agree that infracalcaneal spurs are not the cause of plantar fascitiis but are probaby a reaction from traction at the pf insertion.
Not all retrocalcaneal spurs cause pain or are they are the reason for insertional achilles tendonitis. I have seen many patient have spurring in the back of the heel bone with no pain at all.
We are probaby going to discover that the spurring there has nothing to do with the pain but the insertional fibers of the achilles tendon being damaged and thus causing pain in the same manner
I have used ESWT on many chronic insertional achilles tendonitis cases that had spurring. The pain resolved with no treatment directly at this calcification.

Re: Can of worms- Is there really such thing as a heel spur?

Dr. David S. Wander on 8/20/03 at 17:54 (127448)

Dr. Z, I did not mean to infer that all retrocalcaneal spurs hurt. My point was that although infracalcaneal spurs don't cause pain, there are many retrocalcaneal spurs that do cause pain secondary to the irritation caused from the bony prominence protruding through the Achilles tendon and/or rubbing the back of the shoe. My point was that in my experience infracalcaneal spurs are incidental findings that don't cause pain, and retrocalaneal spurs can cause pain. As you know, there have been several studies that have shown that despite what we may think or theorize, the plantar fascia is below the spur and no definite relationship has been established.

Re: Can of worms- Is there really such thing as a heel spur?

Dr. Z on 8/20/03 at 18:58 (127459)

Sounds good to me. David E-mail me at (email removed). I have some
GREAT news for you !!!!

Re: Can of worms- Is there really such thing as a heel spur?

Ed Davis, DPM on 8/20/03 at 20:12 (127482)

Richard:
No can of worms exists here. A heel spur is simply an elongated shelf of bone along the attachment of the plantar fascia. Since x-rays are two dimensional, the lateral view of the shelf appears to be a spur.
Ed

Re: Can of worms- Is there really such thing as a heel spur?

BGCPed on 8/20/03 at 20:34 (127488)

I think what this shows is that most of the Doctors on here are of the similar mindset. It is unfotunate but true that there are many that dont treat the pt from the same viewpoint. I think most of the ones that do the release and remove the spur are doing a great deal of harm. If it is ignorance or financial gain I cant say for sure.

Re: Can of worms- Is there really such thing as a heel spur?

Dr. Z on 8/20/03 at 20:53 (127491)

I would like to note something of interest. When I did alot of heel spur surgery here is what I found out. The results were the same whether I just cut the fascia at its insertion or if I cut removed some or all of the spur. The results were the same. This led me to believe that any trauma to the insertional area whether it be the spur and or the pf led to reduction of heel pain. This makes me conclude that it is the trauma to the area
whether it be from pf cutting or heel spur cutting. This is why I feel ESWT works. It produces trauma to the inserional areas which leads to neo-vascularization

Re: Can of worms- Is there really such thing as a heel spur?

Dr. David S. Wander on 8/21/03 at 07:17 (127508)

Ed, read my first posting on this subject and you'll see that you and I have stated the same facts. Nice to know there's at least one other doctor that shares my views!

Re: Can of worms- Is there really such thing as a heel spur?

Richard, C.Ped on 8/21/03 at 08:16 (127510)

I guess my real concern in posting this is the misuse of the term 'heel spur'. Should we or should we not inform posters to this board who usually write the usual, 'My doctor told me I have a heel spur. What should I do?' or something along those lines?

I think instead of constantly typing out a long answer each time about the proper definition of 'heel spur' -vs- plantar fasciitis (or even heel pain syndrome), I might be good to either have a seperate link to either this post, or to post an addendum of sorts to the heel pain book. It would be good information for those who need it.

Just a thought-
Richard

Re: Can of worms- Is there really such thing as a heel spur?

Ed Davis, DPM on 8/21/03 at 13:28 (127544)

David and BG:

I think that there is sufficient dissemination of information about this subject so that at least no professional can plead ignorance of this pathology and its treatment.
Ed

Re: Can of worms- Is there really such thing as a heel spur?

Ed Davis, DPM on 8/21/03 at 13:31 (127545)

Richard:

Perhaps writing your own handout/pamphlet explaining this to patients would save you from laryngitis.... ;)
Ed

Re: Can of worms- Is there really such thing as a heel spur?

Richard, C.Ped on 8/22/03 at 07:44 (127630)

No...I meant that we sould have a link to this post or something else that describes the difference between heel spur, plantar fasciitis as well as heel pain syndrome. I think if we can give new posters a quick link like we do with the heel pain book, they would understand the difference without us constantly having to type out the answer.
Richard

Re: Can of worms- Is there really such thing as a heel spur?

BGCPed on 8/22/03 at 19:08 (127726)

You are right Dr Ed. Like all info it can used for good, or ignored.....and ignore is the beginning of ignorance.

Cool I just made that up