Heel Spur Syndrome

Heel spurs, heel spur syndrome and plantar fasciitis are synonymous terms that refer to the same condition. Although hard to pronounce, plantar fasciitis is rapidly becoming the most commonly used term to describe these conditions. By breaking the term plantar fasciitis into its' root form, it's much easier to understand. Plantar is a geographic term that refers to the bottom of the foot (dorsal on top/plantar on bottom). Fascia is a tough, inelastic band. And 'itis' always refers to something that's inflamed (bronchitis, arthritis, etc.). When the root words are combined they describe is an inflammatory condition of a fascial band on the bottom of the foot; plantar fasciitis.

How do we develop plantar fasciitis? Plantar fasciitis is an overuse syndrome that is the result of excessive and repetitive loading of the plantar fascia. When we stand, load is applied to the arch of the foot causing the height of the arch to drop. This drop in the height of the arch places tension on the plantar fascia. If the load applied to the plantar fascia is greater than it can support, the fascia will become inflamed.

Treatment of Plantar Fasciitis

Treatment of plantar fasciitis is based in four broad categories of care; biomechanical methods, anti-inflammatories methods, shock wave therapy and surgery. Let's take a closer look at each of these four categories and see how they work.

We spoke earlier of load and how a change or increase in load may contribute to the onset of plantar fasciitis. The primary load that contributes to the onset of plantar fasciitis is the load generated by the calf. Therefore, the primary focus of treatment becomes finding ways to weaken the function of the calf. This can be accomplished by using a firm 3/8 heel lift or wearing shoes with a wedged sole or higher heel. Calf stretches will also help to weaken the CT Band hence decreasing the power of the calf and tending to 're-balance' the normal biomechanics of the foot and leg. The most effective calf stretches are done by standing on the edge of a stretching block for 60 seconds. Repeat this stretch 6 times each day.

Taping the arch, stretching splints, heel cushions and a host of other 'devices' have been used successfully to treat plantar fasciitis. All of these devices focus on changing the biomechanical properties of the CT Band. Remember, the key to treating plantar fasciitis is addressing the entire CT Band and not just the plantar fascia. Stretches and heel lifts are quite often all that is needed for complete resolution of symptoms. Arch supports can be used on a daily basis to maintain good support of the arch and help to decrease recurrence of plantar fasciitis.

Anti-inflammatory medications can be used to help control the pain associated with plantar fasciitis. Anti-inflammatories include steroid injections, oral anti-inflammatory medications such as aspirin, prescription strength medications called NSAID's, ultrasound, massage, topical medications and a host of other methods to reduce inflammation. When using anti-inflammatory to treat plantar fasciitis, bear in mind that plantar fasciitis is a mechanical problem. Knowing this fact, it's important to recognize that anti-inflammatories alone cannot cure plantar fasciitis. Anti-inflammatories are only helpful in treating inflammation. Anti-inflammatories will not typically address the sharp tearing pain we call post dystatic pain but rather address the pain we develop as the day progresses (see the symptoms tab for more information on symptoms of plantar fasciitis). That's why it's important to combine mechanical methods of care with an anti-inflammatory medication. The two methods of treatment work together to address the two different types of pain that are experienced with plantar fasciitis.

Extracorporeal shock wave therapy has been used recently as a tool to break the re-injury cycle associated with plantar fasciitis. The initial studies on shock wave therapy were performed on renal (kidney) and biliary (gall bladder) stone patients. Due to the initial success of treating renal and biliary stones, researchers began to look for new applications for shock wave therapy. Animal experiments began in 1986 to study the effects on bone growth when stimulated by shock wave therapy. In 1991, High Medical Technologies (HMT) of Switzerland developed and clinically tested the OssaTron®. The OssaTron® is the first shock wave therapy device designed for orthopedic/podiatric use. The OssaTron® received FDA approval for treating plantar fasciitis in 2000. Other applications for shock wave therapy, which are now under investigation, include tennis elbow, non-healing bone and tendonitis.

Shock wave therapy employs an acoustic wave that results in an explosion of energy at the point of focus. Shock waves differ in amplitude and are 'tuned' for a specific purpose based upon the desired amplitude and medium that is crossed to reach a target tissue. The effect of the shock wave in cases of plantar fasciitis is not fully understood. It is believed that the effect of the shock wave stimulates an intense focused inflammatory reaction that promotes healing at the insertion of the plantar fascia.

Shock wave therapy can be painful to perform and therefore requires that the procedure be performed in an outpatient setting with deep sedation. The procedure takes about 15 minutes to complete and does not require a local anesthetic (only sedation). Patients are able to walk on the foot the same day. Complication are minimal. Most doctors will require continued stretching and limited activity for 4 weeks following shock wave therapy. The long term success or failure of shock wave therapy is yet to be seen, but recent studies have had short term success rates of 65-95%. For additional information on shock wave therapy refer to The International Society for Musculoskeletal Shock Wave Therapy.

Neuroablation is a technique used to treat heel spur syndrome that focuses on deadening nerve pain. Neuroablation doesn't actually treat the mechanical component of heel spur syndrome, but instead destroys nerve that supplies sensation to the bottom of the heel. Neuroablation can be performed with a cold probe (cryoablation, thermoablation) with a hot probe (radiofrequency surgery) or with injectable chemicals (alcohol, phenol). Neuroablation is an appropriate procedure for select patients who have not responded to conservative care.

Surgical correction for plantar fasciitis has come a long way over the past several decades. Although the intent of the procedure has remained the same, the methods of completing the surgery have changed dramatically. Endoscopic surgical methods have become the standard of care for plantar fasciitis. The procedure, called an endoscopic plantar fasciotomy, or EPF for short, was developed by Steve Barrett, DPM. Dr. Barrett developed instrumentation that enabled the procedure to be performed through two small 1/4 incision. Most patients are able to return to their shoes in just a matter of days. Dr. Barrett deserves credit for making such improvements in not only the knowledge pertaining to plantar fasciitis but also revolutionizing the ways in which the procedure is performed. The older methods of surgical correction included resection of the heel spur or partial resection of the heel bone. We now merely release, or make a cut through the fascia, leaving any spur in place. Once again, it's important to realize that we are treating a soft tissue problem. Dr. Barrett's efforts have resulted in a vast improvement in surgical care, sparring many patients the complications and disability associated with the older surgical methods.

Another recent theory regarding heel spur syndrome is that of plantar fasciitis vs plantar fasciosis. Several papers in the literature have shown that over a period of several months, plantar fasciitis changes from an acute inflammatory condition to a non-inflammatory condition. Tissue biopsy actually shows a decrease in the total count of inflammatory cells at the insertion of the fascia. As a result of these findings, a school of though has arisen that suggests that treating plantar fasciitis necessitates restarting the inflammatory process at the insertion of the plantar fascia. A number of methods have been used to accomplish this. These techniques include needling the fascia, injections of medications and Topaz surgery. The fasciitis vs fasciosis argument is still fresh, therefore many doctors will opt for EPF surgery as a procedure with a more definitive or proven track record.

So what's the best method of treatment for your heel pain? That decision should be made by you and your doctor together. Essentially, the most important issue is the duration of your symptoms. How long has your plantar fasciitis been present? The use of the biomechanical methods of care and anti-inflammatories may help and are a necessary part of a complete treatment plan but do not always work. If your symptoms have been present for more than a year or if you've tried 4 months of conservative care with no change in your symptoms, you are probably a good candidate for EPF surgery. Consider the conservative measures of care as a means to help the body heal itself or make the necessary change to become pain free. Surgery on the other hand is the physical change required when conservative care has failed.

While 90% of EPF cases are completed without complication, 10% do have problems that can vary in severity. One complication specific to plantar fasciotomies, regardless of how they are performed, is later column syndrome (LCS). LCS is sometimes a very difficult complication to understand, diagnose and treat. If we think of other endoscopic surgical procedures, such as a cholecystectomy (gall bladder) we tend to think of the first week or two as the time when we would have complications. The surgery is completed, we heal and move on. The complications of LCS do not occur in the first week or two after surgery but rather 2-4 month after a plantar fasciotomy. As a patient gets 4 weeks or so out on their plantar fasciotomy, they start to feel more able to return to their normal activities. As they progressively increase their activities they begin to add an increase in load to the foot. Although the surgical site no longer is sore from the surgery, the biomechanical impact, or change to the joint structure of the foot requires 4-6 months to heal following surgery. Early symptoms of LCS are a dull ache of the lateral (outside) of the foot and the top of the arch. This ache is a stiffness that if left untreated will result in small stress fractures if the lateral and dorsal aspects of the foot. LCS is a manageable complication of this procedure and should be thoroughly discussed before surgery so that patients are aware of the symptoms of LCS and can make their doctor aware should they experience problems.

The terms heel spur syndrome, heel spur and plantar fasciitis are used interchangeably to describe a set of symptoms which include pain in the bottom of the heel. Heel spur syndrome is the older of the two terms but has remained as a common description of these symptoms. Plantar fasciitis is a relatively newer term that is more descriptive of the condition and is becoming the definition used by most medical professionals.

‘Plantar’ refers to the bottom of the foot. ‘Fascia’ is a component of the musculoskeletal system that is found through-out the body. Fascia helps to support the function of the bones and joints and often acts as an anchor for structures such as muscles. ‘Itis’ refers to the inflammation found in a structure and is used in other familiar words such as arthritis (inflammation in a joint).

The combination of plantar + fascia + itis results in the descriptive term, plantar fasciitis, or inflammation of the plantar fascia.

Enthesiopathy - pain that results from a ligament or tendon pulling away from its' insertion on a bone.

EPF - endoscopic plantar fasciotomy.

Lateral column - All osseus and soft tissues of the foot including the calcaneus, cuboid, 4th and 5th metatarsals.

Lateral Column Syndrome - a complication post EPF surgery due to abrupt loading of the lateral column of the foot

The plantar fascia is a strong, inelastic ban that originates on the bottom of the heel and spans the length of the foot, inserting into the toes.  The plantar fascia can easily be felt in the bottom of the foot, particularly when the toes are dorsiflexed (towards the shin).  The plantar fascia consists of three slips; a medial, a central and a lateral slip.  The medial slip of the plantar fascia is the band that most commonly becomes symptomatic in cases of plantar fasciitis.

When we stand and apply our body weight to the foot, the arch drops and the plantar fascia becomes tight. In cases of plantar fasciitis, the tension applied to the fascia is so great that the fascia is literally trying to pull off of the heel bone.  Understanding this simple biomechanical principle is at the heart of understanding plantar fasciitis.  Plantar fasciitis is not due to a sharp spur.  Plantar fasciitis is due to the fascia trying to pull away from the heel bone when load is applied to the foot. 

When discussing biomechanical properties of plantar fasciitis, it’s important to understand the mechanical definition of load. The amount of load, the frequency of load and the duration of load are just a few of the different loading issues that can contribute to plantar fasciitis. Loading issues will vary in each person affected by plantar fasciitis. For instance, for a long distance runner, the frequency of loading may be the primary issue that contributes to the onset of plantar fasciitis. For a factory worker who stands for long periods of time, the duration of load may be the primary issue. Typically, those who suffer from plantar fasciitis don’t have just one of these loading issues but a number of them combined.

The most important loading issue that contributes to plantar fasciitis is the load applied to the foot by the calf.  The calf is the single most powerful muscle in the human body.  With each step, the calf delivers force via the Achilles tendon to the foot and optimally out to the forefoot where it can most effectively be used for locomotion.  Plantar fasciitis is often the result of an imbalance between the force generated by the calf and the flexibility of the structures that receive that load.  As we age, our tissue flexibility becomes less.  Therefore, with decreased tissue flexibility, we are less able to accommodate load.  Mechanical loads that we used to be able to accommodate and heal in a 24 hour period, become increasingly difficult with age.  The calf delivers and the foot receives.  And in plantar fasciitis, the foot just can't heal quickly enough.

The symptoms of plantar fasciitis classic. The symptoms may be abrupt or develop insidiously over the period of a week or two. As the pain becomes progressively worse, it becomes focused in the bottom of the heel. People describe significant pain in the bottom of the heel when they try to get up out of bed in the morning or try to stand after a period of rest. This post rest pain, called post static dyskinesia, is a sharp pain that seems to subside after being on the feet for 5-10 minutes.

People will also describe a second kind of pain that becomes worse as the day progresses. This pain is described as dull and achy. It's often on the bottom of the heel but also seems to radiate to the inside of the heel.

This picture shows the location of pain found in patients with plantar fasciitis. The red area on the bottom of the heel is where the plantar fascia inserts into the medial tubercle of the calcaneus. This is the location where patients with plantar fasciitis feel pain upon standing after a period of rest or when getting out of bed in the mornings.

Also shown in this picture are the areas where pain is felt with several different nerve entrapments of the heel. The line of red dots symbolizes the path of the posterior tibial nerve. As the posterior tibial nerve descends into the foot, it divides into several different nerves that supply motor function to the muscles of the foot and sensory function to the bottom of the foot. Entrapment of the posterior tibial nerve can result in tarsal tunnel syndrome or Baxter's nerve entrapment.

Baxter's nerve entrapment - entrapment of the 1st branch of the lateral plantar nerve of the posterior tibial nerve

Gout - deposition of monosodium urate crystals (hyperuricemia)

Retrocalcaneal bursitis (Albert's Disease) - this is the formation and inflammation of a bursa at the back of the heel between the heel bone and Achilles tendon

Rheumatoid arthritis

Rheumatic Fever

Septic Arthritis

Sero-negative arthropathies such as Reiter's Syndrome

Sever's Disease - and inflammatory condition typically found in young over weight boys age 10 to 15 years old

Stress fracture of the calcaneus - Achilles tendonitis pain is characteristically different from that of fractures of the calcaneus. Fracture pain begins with the onset of activity and remains painful through the activity.

Tarsal Tunnel Syndrome - also known as posterior tibial nerve neuralgia. Tarsal Tunnel Syn. characteristically has pain that does not decrease with rest. Also has numbness or 'tingling' of the toes

• Achilles Tendonitis

• Calcaneal Fractures

• Tarsal Tunnel Syndrome

• CT Band Syndrome

• Baxters Nerve Entrapment

This article was written by Jeffrey A. Oster, DPM and last updated 2/8/13.

Additional references include;

Brekke MK, Green DR: A retrospective analysis of minimal incision, endoscopic and open procedures for heel spur syndrome. JAPMA 88: 64, 1998

Boike AM, Snyder AJ, Roberto PD, et al: Heel spur surgery: a transverse plantar approach. JAPMA 83:39, 1993

Kitaoka HB, Luo ZP An KN: Mechanical behavior of the foot and ankle after plantar fascial release in the unstable foot. Foot Ankle Int 18: 8, 1997

Barrett SL, Day SV: Endoscopic plantar fasciotomy: two portal endoscopic surgical techniques-clinical results of 65 procedures. J Foot Ankle Surg 32: 248, 1993

Goecker, R.M., Banks, A.S. Analysis of release of the first branch of the lateral plantar nerve J. Am. Podiatric Assoc. 90:6 281-286 June, 2000

Baxter, D.E., Pfeffer, G.B. Treatment of chronic heel pain by surgical release of the first branch of the lateral plantar nerve. Clin Orthop 279:229, 1992

Thordarson, D.B., Kumar, K.J., Hedman, T.P., et al: Effect of partial vs complete fasciotomy on the windlass mechanism. FootAnkle 18: 16, 1997

Anderson, D., Fallat, L., Savoy-Moore, R. Computer assisted assessment of lateral column movement following plantar fascial release: A cadaveric study. J. Foot Surg 40:2, 62-70 2001