Saturday, October 11, 2008

Heel pain and calcaneal spurs

Plantar calcaneal spurs are common, however their pathophysiology is poorly understood. In a Chinese study in 1996
Lu H et al reviewed 137 X-ray films of the involved feet in order to find out the relationship between the length, shape and the direction of the spurs with the heel pain.
Lu H et al found:
(1) There are no clear relationship between heel pain and the length, shape and the direction of the calcaneal spur.
(2) The plantar soft tissue of the painful foot was thickened, indicating the heel pain was due to inflammation in the plantar soft tissue.
(3) Heel pain is related to the patient's age and sex.
(4) The spurs still exist and grow even bigger after the syndrome disappears.
However one will always find few things very tricky. If spurs are thought to be produced by pull of tight planter fascia then why it is reported in the above study that there is no relationship between heel pain & direction of the calcaneal spur?
Controversy in Pathogenesis:
Vertical loading response leading to out crop of calcanal spurs: an opinion gaining support
1. We will follow a recent study by
Menz HB et al in 2008. in a study Menz HB et al tried to find out whether longitudinal traction or vertical compression that is responsible for out crop of a heel spur? They found Calcaneal spurs are common in older men and women and are related to obesity, osteoarthritis and current or previous heel pain, but are unrelated to radiographic measurements of foot posture. These findings support the theory that plantar calcaneal spurs may be an adaptive response to vertical compression of the heel rather than longitudinal traction at the calcaneal enthesis.
The stimulating factor for the development of heel spur (calcaneal exostosis) is controversial.
Li J et al (2007) reported in a sample of elderly cadaveric specimens, using radiographic, gross morphological, and histological investigation, that heel spurs are generally not found in the trajectory of traction from the plantar aponeurosis enthesis or plantar muscles. Rather, they are variably associated with soft tissues including loose connective tissue, fibrocartilage, muscle, and aponeurosis. Furthermore, the bony trabeculae of the spur are not aligned in the direction of soft tissue traction, but rather in the direction of stress on the calcaneus during walking and standing. These results substantiate the view that the heel spur may be a skeletal response to stress and may serve to protect the bone against the development of microfractures.

Heal spur as a result of traction of planter fascia: an opinion loosing support
Kumai T et al reported spurs develop on the deep surface of the plantar fascia but their formation is heralded by degenerative changes that occur within it. According to differences between small and large spurs, we propose that there are 3 stages in their development: (1) an initial formation of cartilage cell clusters and fissures at the plantar fascia enthesis; (2) thickening of the subchondral bone plate at the enthesis as small spurs form; (3) development of vertically oriented trabeculae buttressing the proximal end of larger spurs. The spurs grow by a combination of intramembranous and chondroidal ossification.
Kumai T et al’s belief is contrary to popular belief (“subcalcaneal heel spurs cannot be traction spurs as they do not develop within the plantar fascia itself”). According to them heel spurs differs fundamentally from spurs in the achilles tendon i.e. heel spurs develop as a consequence of degenerative changes that occur in the plantar fascia enthesis.
Complication of heel spur
Heel spur leading to abductor digiti minimi atrophy (ADMA)
MRI studies reveal there is an association of atrophy of the abductor digiti minimi muscle, an manifestation of chronic compression of the inferior calcaneal nerve suggesting the clinical diagnosis of Baxter's neuropathy. MRI markers of potential etiologies, includes calcaneal spur formation, plantar fasciitis, calcaneal edema, Achilles tendinosis and posterior tibial tendon dysfunction.
Chundru U et al reported advancing age, calcaneal spur, and plantar fasciitis are significantly associated with atrophy of the abductor digiti minimi muscle. They further suggested a possible etiologic role for calcaneal spur and plantar fasciitis in the progression to Baxter's neuropathy.

Currently taping techniques are becoming popular with many clinicians specially physiotherapists & sports medicine professionals. Let us discuss a paper on effect of taping for calcaneal spurs.
Hyland MR et al of department of Physical Therapy, Mercy College, USA. did a RCT comprising of calcaneal taping, sham taping, and plantar fascia stretching for the short-term management of plantar heel pain. They found Calcaneal taping was shown to be a more effective tool for the relief of plantar heel pain than stretching, sham taping, or no treatment.
See the following URLs:
1. (comprehensive)
2. (quick learning)
3. (part 1)
4. (part 2)

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