Classification of Calcaneal Spurs and Their Relationship With Plantar Fasciitis

doi:10.1053/j.jfas.2014.11.009

The Journal of Foot and Ankle Surgery

Volume 54, Issue 4, July–August 2015, Pages 594-600

https://doi.org/10.1053/j.jfas.2014.11.009 Get rights and content

Abstract

Calcaneal spurs, as a cause of plantar fasciitis, are currently debatable. A prospective study was performed to classify calcaneal spurs according to the findings from an investigation of the relationship between calcaneal spurs and plantar fasciitis. Thirty patients with calcaneal spurs and plantar heel pain underwent calcaneal spur removal and endoscopic plantar fasciotomy. The relationship between the classification of calcaneal spurs and plantar fasciitis was evaluated by endoscopic findings, clinical symptoms, radiographic images, and biopsy findings. The visual analog scale for pain and the American Orthopedic Foot and Ankle Society ankle-hindfoot scores for functional evaluation were used preoperatively and postoperatively, respectively. The mean follow-up period was 24 months. Two separate types of calcaneal spurs were recognized. Type A calcaneal spurs were located superior to the plantar fascia insertion, and type B calcaneal spurs were located within the plantar fascia. Magnetic resonance imaging results showed a more severe plantar fasciitis grade in type B calcaneal spurs preoperatively. Histologic examination showed that the numbers of granulocytes per image in type B spurs were significantly increased compared with those in type A spurs. Statistically significant improvements were found in the mean visual analog scale and American Orthopedic Foot and Ankle Society scores and magnetic resonance imaging results in both groups. The amount of change in the visual analog scale score and American Orthopedic Foot and Ankle Society score, the number of granulocytes per image, and calcaneal spur length showed a high association with the classification of the calcaneal spurs. Calcaneal spurs were completely removed and did not recur in any of the patients on radiographic assessment during the follow-up period. Calcaneal spurs can be classified into 2 distinct types that are indicative of the severity of plantar fasciitis.

Section snippets

Patients and Methods

The ethics committee of the Third Military Medical University Affiliated Southwest Hospital (Chongqing, People's Republic of China) approved the present study, and the participants provided written informed consent. From January 2009 to March 2012, the senior author (K.L.T.) performed an endoscopic calcaneal spur removal and plantar fasciotomy procedure in 30 patients (38 feet in total). All participants has been diagnosed with calcaneal spurs (M77.31 and M77.32, international classification of

Results

We identified 2 types of calcaneal spurs on the preoperative radiographs. Type A spurs were superior to the plantar fascia insertion, and type B spurs stretched forward from the plantar fascia insertion to extend distally within the plantar fascia. These spur configurations are illustrated in Fig. 3.

All 30 patients completed a minimum of 12 months of follow-up after surgery, and the mean follow-up duration was 24 (range 12 to 36) months. At 12 months postoperatively, the type A calcaneal spur

Discussion

The etiology of plantar heel pain is complex and multifactorial. Plantar fasciitis is considered to be the most common pathogenesis of a painful plantar heel 13, 19. Plantar fasciitis has been associated with increased intraosseous pressure of the os calcis and the presence of calcaneal spurs 20, 21. However, whether inferior calcaneal spurs have a true association with plantar fasciitis has been debated 1, 22, 23. Our study has shown that calcaneal spurs can be classified into 2 types and that

Acknowledgments

We thank Journal Prep and Dr. Mark Hardy for their assistance in writing our report.

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Plantar fasciitis is often cause of heel pain, especially in sporting-related activities. Different conservative measures for the management of plantar fasciitis were compared in several researches. The purpose of this retrospective study was to evaluate and compare clinical outcomes of chronic plantar fasciitis treated with ultrasound-guided platelet-rich plasma (PRP) and focal ultrasound-guided extracorporeal shockwave therapy (ESW). Secondarily, results on subpopulation of athletes were recorded. Fifty-five patients treated for plantar fasciitis were included, 24 among them were competitive or recreational athletes. Treatment outcomes were assessed using Visual Analog Scale and Foot Function Index before and after treatment. Time to return to sport among patients practicing sporting activities was recorded. Before treatment, no differences were observed between groups in terms of age, gender, body mass index, and months of follow up. From baseline to final follow-up assessment, significant improvement was observed in all the outcomes measures. The subgroup analysis showed no differences between patients stratified for type of treatment and sport/nonsport practitioners. The overall failure rate was higher, although not significant, in patients who underwent ESW therapy and they required a higher number of orthopedic visits. Among sports practitioners the mean time to return to sport (months) was faster in PRP group than ESW group (p = .044). PRP and ESW represent both reliable solutions for plantar fasciitis leading to good results in terms of patients’ satisfaction, pain, and clinical outcomes. However, after treatment with PRP injections less recurrences in overall population and faster return to sporting activities in sports practitioners were observed.
Plantar Fasciitis/Fasciosis
2021, Clinics in Podiatric Medicine and Surgery
The clinical outcome of endoscopic plantar fascia release: A current concept review
2020, Foot and Ankle Surgery
Citation Excerpt :
As already mentioned, Cottom et al. carried out an endoscopic plantar fascia debridement with or without heel spur resection [17]. Zhou et al. conducted a prospective clinical trial to classify the calcaneal spurs in two different types according to their correlation to plantar fasciitis [22]. The endoscopic findings showed that the anatomy of the calcaneal spurs was consistent with the classification made using the preoperative radiographs.
To clarify whether endoscopic plantar fascia release is safe and effective in the treatment of chronic plantar fasciitis. Secondary goals were a. to compare the clinical outcome between EPFR and non-operative treatment and b. to describe the various EPFR surgical approaches and their outcomes.
Two reviewers (MM and EBC) independently conducted the search using the MEDLINE/PubMed database. This database was queried with the terms ‘endoscopic plantar fascia release’ and ‘endoscopic plantar fasciotomy’. To maximize the search, backward chaining of reference lists from retrieved papers was also undertaken.
From the initial 63 studies we finally chose and assessed 15 studies which were eligible to our inclusion-exclusion criteria. A total number of 535 patients (576 feet) were reported, with a slightly higher female rate. The vast majority of the studies were case series (66.7% of all), while two papers were randomized controlled trials (13.3%), two were case control studies (13.3%), and one was cohort study (6.7%). The overall quality of the studies included in this review, as it was evaluated according to the GRADE Working Group guidelines, was low, while it ranged from very low to high. All studies showed that the postoperative clinical and functional subjective scores were significantly improved with the use of EPFR. Overall, the postoperative complications’ rate was 11.0%. The most common complications which were recorded were persistent heel pain (5.6%), paresthesias or numbness (4.3%), soft tissue healing problems (1.7%), and superficial infection (0.4%).
There was weak evidence to support that endoscopic plantar fascia release was safe and effective for the treatment of chronic plantar fasciitis.
Endoscopic plantar fasciotomy for plantar fasciitis: A systematic review and network meta-analysis of the English literature
2019, Foot
Currently, there is limited evidence on outcomes for endoscopic plantar fasciotomy.
An evidence-based literature review for outcomes of endoscopic plantar fasciotomy for the treatment of plantar fasciitis is provided.
A comprehensive evidence-based literature review of PubMed and Cochrane databases was conducted on 9th March 2019, which identified 12 relevant articles assessing the efficacy of endoscopic plantar fasciotomy. The studies were then assigned to a level of evidence (I–IV). Individual studies were reviewed to provide a grade of recommendation (A–C, I) according to the Wright classification in support of or against endoscopic plantar fascia release.
Based on the results of this evidence-based review, there is poor evidence (grade C) to support endoscopic plantar fascia release. Release of the medial 2/3 of the plantar fascia in endoscopic plantar fasciotomy was associated with higher AOFAS score.
Although the majority of the level of evidence was low (level IV) and grade of recommendation was poor (grade C), there seemed to be good outcomes for endoscopic plantar fasciotomy. There is a need for more high quality level I randomized controlled trials with validated outcome measures to allow for stronger recommendations to be made.
Plantar fasciitis treated with endoscopic partial plantar fasciotomy—One-year clinical and ultrasonographic follow-up
2019, Foot
Endoscopic operations for plantar fasciitis generally have good clinical outcome. The aim of this study was to record the effect of endoscopic partial fasciotomy and heel spur removal and evaluate by ultrasonography whether the fascia regenerates and the heel spur reforms.
Eleven consecutive patients were evaluated before and 3, 6 and 12 months after surgery. Operations were performed endoscopically using a deep fascial approach with a medial and a lateral portal. Bony spurs were removed and the medial half of the plantar fascia was transected. All patients followed a standardized rehabilitation program.
Median Foot Function Index values decreased from 119 pre-surgery to 69 and 12 (p = 0.004), at 3 months and 1 year post-operatively respectively. Median VAS-score for first step pain was likewise reduced from median 71 mm to 29 mm and 7 mm (p = 0.004), respectively. Median fascial thickness at the medial insertion was 6.0 mm (range 4.6–6.8 mm) pre-operatively. A heel spur was present in 9 cases. One year postoperatively a well-defined fascia in the area of resection was demonstrated in 8 cases. In the rest of the cases scar tissue made it impossible to clearly outline the fascia. Nine of the feet showed good medial fascial tensioning. There was no evidence of recurrence of the bony spur.
Endoscopic partial plantar fascia resection reduced pain symptoms and increased function significantly 3 months after operation, with additional effect achieved 12 months after surgery. Based on ultrasonography the resected fascia regenerated/healed, and a calcaneal spur did not recur.
Management of Symptomatic Plantar Fasciitis
2018, Operative Techniques in Orthopaedics
Citation Excerpt :
Radiographic evaluation should include lateral and axial weight-bearing views of the hindfoot. Calcaneal spurs have anecdotally been considered a risk factor for plantar fasciitis; however, they were evident in 30% of an asymptomatic cohort studied by Zhou et al.6 Patients may have plantar fascial thickening cortical or fat pad abnormalities on plain radiography that correlate significantly with plantar fasciitis.7,8 An increased plantar fascia thickness can also be observed on MRI, along with increased signal on both delayed (T2) and short tau inversion recovery images (Fig).7,9
Plantar fasciitis is one of the most common causes of heel pain. Plantar fasciitis occurs from increased stress on the plantar aponeurosis as a result of progressive, repetitive microtears, and degeneration. Plantar fasciitis is largely a clinical diagnosis based on clinical examination; thus using history and physical examination findings. Initial therapy involves addressing of possible modifiable disease factors. Surgical management of plantar fasciitis is considered after an unsuccessful course of nonoperative management, with open or endoscopic release. This article reviews the diagnostic and treatment management for patients with symptomatic plantar fasciitis.

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: Financial Disclosure: This research was supported by grants from the National Natural Science Foundation of China (grant 81230040) and the China Scholarship Council has sponsored Binghua Zhou. No additional external funding was received for the present study.

: Conflict of Interest: None reported.

: Binghua Zhou and You Zhou contributed equally to this study.

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Original ResearchClassification of Calcaneal Spurs and Their Relationship With Plantar Fasciitis

Abstract

Section snippets

Patients and Methods

Results

Discussion

Acknowledgments

J Sci Med Sport

Foot Ankle Surg

J Bodywork Movement Ther

Foot

Arthroscopy

J Foot Ankle Surg

Foot

J Foot Ankle Surg

Foot

Clin Podiatr Med Surg

Manual Ther

Orthop Trauma

J Sci Med Sport

Clin Podiatr Med Surg

Foot

J Foot Ankle Surg

Diagnostic imaging for chronic plantar heel pain: a systematic review and meta-analysis

J Foot Ankle Res

Plantar fasciitis: a concise review

Permanente J

Drilling of the os-calcis for painful heel with calcanean spur

Acta Orthop

Endoscopic plantar fasciotomy for chronic plantar fasciitis/heel spur syndrome: surgical technique—early clinical results

J Foot Surg

Plantar fascia release and calcaneal spur excision for sub-calcaneal heel pain

J Med Assoc Thailand

Original Research
Classification of Calcaneal Spurs and Their Relationship With Plantar Fasciitis