Conway McLean, DPM, Journal columnist
Heel spurs get a bad rap. How much pain and suffering has been laid at the feet of the dreaded “heel spur.” They certainly don’t sound pleasant, do they? And where exactly are these mysterious creatures? The heel is a large region, so is it referring to something on the bottom of the heel, or is it found in back, or maybe at a joint? Although the term is generally referring to pain on the bottom of the heel, the more symptomatic structure is the spur at the back of the heel.
An individual presented to my office recently, describing a typical history for someone suffering from this condition. He was mildly overweight and relatively inactive. His pain had developed gradually, progressing slowly, subtly, without a history of any trauma or injury to the area. This fellow had noted the area behind the heel enlarging gradually, making shoe use painful. His primary care provider had recommended use of an anti-inflammatory medicine, naproxen, which had helped with his discomfort. But it didn’t provide any benefits when he stopped taking it. Besides, the list of potential complications was significant.
Any discussion of these bony prominences must also involve the Achilles tendon itself since these two structures are intimately related. Our example, the gentleman mentioned earlier, had discovered on his own that walking more caused more pain. He sometimes had greater discomfort during the activity, but always had more afterwards. The reason: how do you walk anywhere without putting stress on the attachment of this, the largest tendon in the body.
Whenever problems of the Achilles tendon are mentioned, it is critical to understand this tendon crosses three distinct joints, all of which are vital to gait and stance, i.e. walking and standing. When the tendon is diseased and painful, an effective gait type becomes difficult. Part of the mystery of these are why the bone proliferates within the tendon for some and not for others. But we are certain of several contributing conditions.
When the Achilles tendon has shortened over the years, numerous problems can develop. The list of potential issues is too lengthy for this article. From knee degeneration to chronic low back pain, recurrent plantar fasciitis to bent toes, all these and more may result from an excessively tight Achilles. Obviously, there will be greater tension on the tissues where it attaches. This tissue stress sets up the potential for chronic inflammation, leading to abnormal bone production in some people, but not in others. We remain uncertain what specific differences exist, leading to bone growth inside the tendon, but only some of the time.
Numerous factors can contribute to spurring in this location. A higher arched foot means the heel bone is pitched at a more acute angle, throwing the back of the heel against the tendon, step after step, day after day. Again, chronic inflammation is at play, with this recurrent irritation of the tendinous tissues resulting in bony proliferation. In contrast, Achilles micro-trauma can be caused by a foot that flattens too much in gait. The heel moves too much, side to side, in this foot type, irritating the tendon once again.
The spur that is formed in this pathology is encased by the tendon, completely enclosed. To remove these spurs, which is sometimes necessary, the tendon must be reflected from the surface of the heel bone, which means it must be reattached following spur removal. But healing of this structure is a slow process with many opportunities for complications. Exhausting conservative therapies prior to considering surgery is essential.
Treatment of injured or diseased tendons is challenging, with neither conservative nor surgical approaches reliably providing full recovery. And important limitations to healing need to be considered. Tendon tissue has poor inherent regenerative potential. Healing of tendons will typically lead to repaired tissue that is different from before, and not as strong.
Is the spur actually the cause of pain? There have been many cases where removing the spur didn’t resolve the pain. Every physician practicing musculoskeletal medicine can relate to patients receiving only conservative care and achieving complete resolution of their pain. Conservative approaches can’t possibly remove or diminish the spur, and yet the individual achieves relief. Clearly, the presence of the abnormal bone alone is not always the cause of pain.
The usual recommendations for care have been around for years, having withstood the test of time. Achilles stretches can help to reduce the degree of tension, but can take months to be of benefit. Use of a wedge of material under the heel, termed a lift, can also serve to decrease this tension. Physical therapy can also be of benefit, but newer technologies are proving to be “game changers” altering radically how we approach these difficult conditions.
In particular, shock wave therapy has proven to be less of a secondary option and now recommended as an initial therapy. The lack of complications and reliable benefits to many musculoskeletal conditions means it’s popular with physicians, while the lack of downtime or recovery time makes it a hit with patients. The technology is a derivative of the lithotripsy millions have had their kidney stones treated with, non-invasively, safely.
The newest game changer is certainly the regenerative medicine techniques that have been developed. Only a few decades in existence, the use of amniotic tissue products have produced eye-opening results. Although no living cells are administered, the growth factors present trigger the body to recruit stem cells to the area. The “holy grail” of regenerative medicine, stem cells can form any kind of tissue. With this simple, comfortable injection, healthy tendon can be produced by the body. A healthy tendon is a stronger tendon.
Heel spurs are blamed for significant pain and disability. Yet they behave very differently when they are in back of the heel versus on the bottom. Naturally, this means they are treated very differently. Spurs at the back of the heel deserve a bad reputation, plaguing some sufferers for years. Without proper care, these bony lesions can be resistant, making life painful. More specialized care usually means faster paths to relief. Don’t live with heel pain; life is tough enough in these uncertain times.
Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula. Dr. McLean’s practice, Superior Foot and Ankle Centers, has offices in Marquette and Escanaba, and now the Keweenaw following the recent addition of an office in L’Anse. McLean has lectured internationally, and written dozens of articles on wound care, surgery, and diabetic foot medicine. He is board certified in surgery, wound care, and lower extremity biomechanics.
