Heel Spur Surgery
The heel spur is a radiographic sign; it is not a pathology in itself. Some patients may experience pain at the insertion of the plantar fascia without a spur, while others may show spurs on the X-ray without any associated pain in that area.
What does heel spur mean?
Definition
The calcaneal spur is an ossification at the base of the calcaneus where the plantar aponeurosis inserts. It is a radiographic sign. The calcaneal spur is therefore not a pathology. Pain coming from this area does not originate from the spur, but from excessive tension of the plantar aponeurosis at this location. The calcaneal spur is a potential radiological sign of a condition called plantar fasciitis.
Causes
The main cause of plantar fasciitis, and of the calcaneal spur, is the retraction of the Suro Achilleo Plantar system. The Suro Achilleo Plantar system corresponds to the triceps surae with the twin muscles, or gastrocnemius and the soleus muscle, the Achilles tendon, its fibrous expansion, and the plantar aponeurosis.
This is a retraction of the posterior muscle chains that can cause pain in the calves, at the level of the Achilles tendon, at the level of the fibrous insertion of the Achilles tendon on the calcaneus, and at the level of the plantar aponeurosis which extends from the base of the calcaneal tuberosity to the base of the toes. The calcaneal spur is located at the calcaneal insertion of the plantar aponeurosis.
In cases of high-arched foot, the tension of the plantar aponeurosis is increased, which can lead to excessive tension at the insertion of the plantar aponeurosis on the calcaneal tuberosity, and provoke the creation of an ossification called a calcaneal spur. It is probable that excessive tension of the plantar aponeurosis causes repeated micro lesions at its calcaneal insertion, leading to the development of a bony spur as a form of healing. While the spur itself is not pathological, it may probably cause further stiffening of the system.
Wearing shoes that are not suitable for the physical activity performed is also an important risk factor for painful plantar fasciitis and therefore for calcaneal spur.
Symptoms
The main symptom of the calcaneal spur, and thus of plantar fasciitis, is pain. This pain can be located along the plantar aponeurosis, over its entire length. During clinical examination, stretching the plantar aponeurosis is generally uncomfortable, and palpation is then painful, reproducing the patient's pain.
The pain of plantar fasciitis is mechanical pain; in general, patients experience pain when getting up during the first few steps. This pain tends to disappear or improve as the tissues warm up. Then, during the day, it is enough to stop for a few minutes to feel the pain again when starting to walk. Pain from plantar fasciitis disappears completely at rest.
In cases of plantar fasciitis persisting for some time without improvement, the differential diagnosis of tarsal tunnel syndrome should be considered. In general, the pain is mixed, corresponding to pain from plantar fasciitis associated with pain from compression of the posterior tibial nerve. The pain of tarsal tunnel syndrome is pain that increases progressively throughout the day, which may then cause insomnia and is associated with neurological sensations such as electric shocks or burning...
What treatments are available?
Conservative management
Conservative treatment is always recommended in cases of plantar fasciitis, whether or not a calcaneal spur is present on X-ray. Functional treatment yields very good results, with a 90 % cure rate at one year when patients comply with the treatment. If plantar fasciitis pain occurs quickly and becomes disabling, the effectiveness of the treatment usually starts to be felt after 2 or 3 months of treatment. Patience and compliance are therefore necessary.
It is only after a clinical examination, with radiographic analysis of the feet under load, that functional treatment will be recommended and adapted to each patient. This involves performing stretches of the posterior muscle chains, massaging the plantar fascia, correcting poor footwear habits, and adapting sporting activities.
Surgical management
Surgical management is offered in the event of failure of conservative management, and therefore if functional treatment is insufficient, provided it has been correctly implemented.
The goal of surgical treatment is to relieve the tension of the plantar fascia by selectively lengthening it. We do not perform resection of the calcaneal spur.
In cases of plantar fasciitis in a patient with a flat foot, surgical treatment carries a risk of decompensation of the flat foot if the plantar fascia is lengthened.
Overview of Heel Spur Surgery
Purpose of the operation
The purpose of the plantar fascia operation, and indirectly of the heel spur, is to relieve the painful tension of the plantar fascia. In our opinion, it is not necessary to perform resection of the heel spur.
Preparation for the operation
This is a genuine surgical procedure, requiring a preoperative consultation with a surgeon and then with an anesthetist.
The surgical technique
For painful plantar fasciitis that is resistant to functional treatment, we offer a selective percutaneous lengthening of the plantar fascia at the base of the heel pad. This is a selective percutaneous plantar fasciotomy.
The procedure is performed on an outpatient basis, with discharge the same day from the clinic. A dressing is left in place for about ten days, and walking is allowed from the day after the procedure with a postoperative shoe for a period of one month.
Recovery and restricted activities
One month after the procedure, walking is possible with a pair of comfortable sneakers, and the resumption of driving is considered. In the case of surgery on the left foot, driving an automatic car can be resumed as early as the next day.
One and a half months after the procedure, cycling without resistance and swimming are permitted.
Three months after the procedure, the plantar fascia has healed, and resumption of all sporting activities may be considered.
Possible complications
General surgical complications are always possible, although the percutaneous technique helps to minimize them. These may include residual pain, hematoma, infection, or phlebitis.
More specifically, during the procedure, there is a neurological risk, as the sole of the foot is richly innervated.
The healing of the plantar fascia may be retractile, which is why it is necessary to resume rehabilitation exercises to stretch the plantar fascia postoperatively, generally one month after the surgical procedure.
Heel Spur Surgery FAQ
Functional treatment of plantar fasciitis, with or without a heel spur, gives very good results in 90% of cases. Surgical treatment can be considered as a selective lengthening of the plantar fascia, allowing for increased effectiveness of the subsequent functional treatment.
The main risks of selective plantar fasciotomy for plantar fasciitis, with or without a heel spur on X-ray, are neurological complications and retractive scarring of the plantar fascia, which may potentially cause recurrence of symptoms.
Heel spur surgery generally lasts between 15 and 30 minutes. It is performed under regional anesthesia, often as an outpatient procedure, which means that the patient can go home the same day. The exact duration of the surgery may vary depending on the surgical technique used, such as minimally invasive surgery or endoscopic fasciotomy, as well as the specific details of the patient's case.
Conclusion
The heel spur is therefore not itself responsible for the pain; it is a radiological sign that can be found in cases of plantar fasciitis. Functional treatment, although lengthy, allows for pain relief in the vast majority of cases. Surgical treatment involving lengthening of the plantar fascia, without touching the heel spur, is proposed as a last resort.