Heel spur is a bone growth in the form of a beak, thorn or wedge located in the area of the heel bone hillock on its plantar side or in the area of attachment of the Achilles tendon. The symptoms of heel spur are caused by the constant traumatization of the surrounding tissues with the development of bursitis, periostitis and dystrophic changes. Initially, patients complain of periodic pain when walking, then there are acute starting pains that decrease during walking. To confirm the diagnosis, an X-ray of the foot is performed in a lateral projection. Treatment includes physiotherapy, blockades, physical therapy, massage.
ICD 10
M77.3 Heel Spur
Meaning
Heel spur (plantar fasciitis, plantar fasciitis) is an extremely widespread disease, accounting for about 10% of the total number of diseases of the musculoskeletal system. It usually develops in patients older than 40 years, according to statistics, about 20% of people in this age group suffer from pathology. Women get sick more often than men. In the elderly and senile age, the number of cases of the disease decreases, which is explained by the insignificant physical activity of patients. Pathology is extremely rare in children.
Heel spur causes
The disease refers to enthesopathies – inflammatory and degenerative lesions of tendons in the area of their attachment to the bone. The pathological process is provoked by overloads, occurs in the area of fixation of plantar aponeurosis to the calcaneal tubercle, less often – at the place of attachment of the Achilles tendon to the posterior surface of the calcaneal bone. Predisposing factors are:
- flat feet (diagnosed in 90% of patients), high or low arch of the foot;
- overweight;
- diseases of large joints (arthritis) and spine;
- neurodystrophic and vascular pathologies (obliterating endarteritis, atherosclerosis of the vessels of the lower extremities);
- prolonged stay on the feet associated with the conditions of professional activity (for sellers, hairdressers);
- using uncomfortable shoes;
- endocrine and metabolic diseases (diabetes mellitus, gout);
- prolonged overloads of the foot in athletes engaged in running.
The likelihood of developing a heel spur increases with some rheumatic diseases, including psoriatic and rheumatoid arthritis. One of the reasons for the development of fasciitis in these pathologies is considered to be multiple blockades with corticosteroids, provoking degeneration of plantar aponeurosis fibers.
Pathogenesis
As a result of overloads, micro-injuries of the fibers of the plantar fascia or Achilles tendon occur. Foci of aseptic inflammation form in the rupture zones. Damaged areas are replaced by less durable, but harder fibrous tissue. The strength of aponeurosis decreases, hard scars injure the surrounding tissues, causing the appearance of new micro-injuries. The inflammatory process provokes a gradual compaction, and then ossification of tendon fibers with the formation of a bone outgrowth.
Heel spur symptoms
Initially, there are unpleasant sensations and non-intense pain while walking. After some time, the pain syndrome acquires bright characteristic features. The patient complains of burning sharp pains, similar to the feeling of a nail in the heel, arising at the beginning of walking (after sleep or a long break) – the so-called “starting pains”. The first steps are the most painful.
In the process of walking, the pain syndrome decreases, and gradually increases in the evening. The pain can become persistent and cause long-term disability. A characteristic gait is formed – the patient does not step on the entire foot, but on the toe or on the edge of the foot. Sometimes, in order to relieve the leg and reduce pain, patients with heel spurs are forced to move on crutches. In severe cases, the pain syndrome bothers not only with movements, but also at rest.
The size of the spur has nothing to do with the severity of the symptoms of the disease. There may be a complete absence of clinical signs with large bone overgrowth and disability with complete or almost complete absence of signs of growth according to radiography. The greatest influence on the intensity of pain is the severity of inflammation of the nearby tendon bags (burs).
When examining the foot and ankle joint, pathological changes are usually absent. Soreness is determined by squeezing the heel from the sides, pressure on the heel bone mound or the achilles attachment area. In some cases, with a posterior spur, there is numbness and slight swelling of the heel area.
Diagnostics
Pathology is detected during the consultation of an orthopedist. The grounds for the diagnosis are characteristic complaints and the results of an objective examination, middle or elderly age. Carrying out additional diagnostic procedures with a typical clinical picture is considered redundant by some specialists. To differentiate with other pathologies and clarify the plan of therapeutic measures are used:
- Radiography of the calcaneus. It is the most common study, often performed in typical cases of the disease, is mandatory when examining children and the elderly. The pictures show a bone outgrowth in the form of a ridge, spike or wedge. The size of the outgrowth varies significantly, the absence of exostosis is not a reason to exclude the diagnosis of heel spur.
- Ultrasound of the foot. There are signs of inflammation and thickening of plantar aponeurosis. The method is informative even in the absence of exostosis on radiographs, allows you to determine the therapeutic tactics, taking into account the severity of fasciitis, the presence of signs of achillobursitis or subcutaneous bursitis.
- Other visualization techniques. With an atypical picture of the disease and no changes in the X-rays, an MRI of the foot and a radioisotope scan can be prescribed.
Differential diagnosis is of particular importance when detecting signs of the disease in children, the elderly and young people. In young patients, especially athletes, foot injuries are primarily excluded. In elderly patients and children, pathology is differentiated with primary bone tumors and metastatic bone lesions and osteoporosis.
Heel spur treatment
Treatment is usually conservative, carried out on an outpatient basis. Surgical interventions are performed only with a prolonged course of the disease and severe disability.
Conservative therapy
Non-drug methods play a decisive role in the treatment of heel spurs. Medications are rarely prescribed. Applied:
- Optimization of the load on the legs. Patients are advised to reduce the time spent in a standing position and the duration of walking. When correcting the mode of motor activity, pain reduction within six months is observed in most patients, regardless of the use of other methods of treatment.
- Physical therapy. A set of exercises for heel spur is aimed at stretching plantar aponeurosis. It is performed for a long time in the absence of intense pain syndrome.
- Orthopedic devices. According to experts, orthopedic insoles of individual manufacture are the most effective. It is possible to use standard insoles and podpyatochnikov. At night, orthoses can be used to lengthen the plantar fascia.
- Immobilization. It is indicated for severe uncupable pain. An orthosis-boot is applied to the leg, providing for the possibility of support on the leg. The limitation of the technique is the undesirability of prolonged fixation due to possible muscle atrophy.
- Introduction of corticosteroids. It quickly eliminates even severe pain, but increases the likelihood of rupture of the plantar fascia, therefore, it is performed only in the absence of results from other therapeutic measures. The injection is performed from the inner surface of the foot to the point of greatest soreness. The course includes no more than 3 procedures, the interval between courses should be at least six months.
Shock wave therapy is considered a promising method of treating heel spurs. Taping is effective, but due to the need for bandaging and inconveniences for the patient, the method is usually used only at the initial stages of therapy, before the manufacture of insoles.
Surgical treatment
Surgical interventions are rarely performed. The indication for surgery is an intense pain syndrome in the absence of the effect of conservative treatment for 6-12 months. Fasciotomy of plantar aponeurosis is performed, sometimes in combination with nerve neurolysis, which innervates the muscle that withdraws the V finger. Operations are performed in a traditional or endoscopic way.
In the postoperative period, analgesics, physiotherapy, physical therapy are prescribed. The immediate results of interventions are usually good. In the long-term period, due to the weakening of the arch of the foot, the progression of flat feet is possible, which limits the use of surgical techniques.
Prognosis and prevention
The prognosis is favorable. The pain usually disappears completely within 1-2 years. Exostosis persists until the end of life, but subsequently does not cause unpleasant symptoms. With chronic bursitis, the duration of the disease may increase. Prevention includes normalization of body weight, exclusion of overloads, use of comfortable shoes, timely treatment of diseases that increase the risk of heel spur formation.
Literature
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- Plantar fasciitis. Repeated corticosteroid injections are safe // Can Fam Physician. — 1998. — Vol. 44. — P. 45-51.
- Tanz S.S. Heel pain // Clin. Orthop. Relat. Res. — 1963. — Vol. 28. — P. 169-178.
- Riepert T., Drechsler T., Urban R., Schild H., Mattern R. The incidence, age dependence and sex distribution of the calcaneal spur. An analysis of its X-ray morphology in 1027 patients of the central European population // RoFo. — 1995; 162: 502-505. link
- Bassiouni M. Incidence of calcaneal spurs in osteo-arthrosis and rheumatoid arthritis, and in control patients // Ann Rheum Dis. — 1965; 24: 490-493.
- Shaibani A., Workman R., Rothschild B.M. The significance of enthesopathy as a skeletal phenomenon // Clin Exp Rheumatol. — 1993; 11: 399-403. link
- Manual therapy interventions in the treatment of plantar fasciitis: A comparison of three approaches / Christopher Yelverton, Sunil Rama, Bernhard Zipfel // Health SA. — 2019; 24: 1244. link