Heel Spur Syndrome

HEEL SPI-]R SYNDROME PLANTAR ST]RGICAL APPROACH Donald R. Green, DPM Heel Spur Syndrome is really a misnomer, as the fascial accommodation or grooves often must be plantar spur itself is generally not the cause of built into the orthoses. the primary symptom complex. Plantar fasciitis The shelf-like spuring on the inferior distal may be a more accurate description. The mecha- surface of the calcaoeal tuber is generally not the nism of pain has been attributed to plantar fasci- cause of the patient's pain. Many times, very itis, adventitious bursa, vascular engorgement large plantar calcaneal spurs can be identified on and/or neuroma/neuritis. Plantar fasciitis is con- standard lateral radiographs of patients that are sidered to be the most common etiology for a totally asymptomatic. (Fig. 1A). Not infrequently, number of reasons. Most commonly, the pain is there is a complete absence of radiographic evi- Iocalized to the medial plantar tuber. The pain is dence of a calcaneal spur in a patient with acute generally of a post-static dyskinetic type (tempo- plantar heel pain or fasciitis. (Fig. 18) And finally, rary pain occurring when weight is born on the when conserwative therapy is effective in resolv- foot after resting, ie. weightbearing first thing in ing the symptoms of plantar fasciitis, the asymp- the morning.) In more significant cases, the pain tomatic spur does not resorb but universally also occurs after prolonged or vigorous remains radiographically visible. weightbearing. In the past, surgical intervention for heel Although systemic arthropathies can cause spur syndrome was a common form of treatment heel pain and should be ruled out, it is very even before exhaustion of more conservative unusual for these symptoms to manifest primarily forms of therapy. \7hen surgery was performed, in the anterior medial tuber area. The symptoms the usual technique included complete release of can be commonly seen in the mechanically the plantar fascia at its calcaneal insertion and uncontrolled pes cavus foot and the pronated removal of the plantar spur from the calcaneal foot. In approximately 950/o of the cases, symp- tuber. Rare but significant complications such as toms can be controlled by conserwative means. fracture of the calcaneus and delayed healing or The inflammation is generally controlled with infection are described. (Fig. 2A, B) These com- NSAIDs, local cortisone injections, and/or physi- plications were generally attributed to the amount ca1 therapy modalities such as ultra sound, of bone removed during the procedure or other H-wave, or ice massage. Strapping and padding aberrations of surgical technique. Nerve entrap- (such as low dye rest strap and whale's taii ment, protracted pain and failure to resoive the padding), and/or heel cups are used for tempo- primary complaint are other sequelae that have rary support. Functional orthoses are usually nec- lead many surgeons to refrain from eady surgical essary for more long term control to neutralize intervention. the mechanically abnormal fooi structure. In the ca\.us foot with a prominent medial fascial band, 89 Ftg. 1A. Plantar calcaneal spur in an asymptomatic patient Fig. 18. Absence of calcaneal spur in a symptomatic patient. \Wound Fig. 2A. Calcaneal fracture following resection of plantar spur and Fig. 28. dehiscence and infection following plantar fascioto- drilling. my and calcaneal spur resection. THE AUTHOR'S TECHNIQUE In the past 5-6 years, the author has successfully employed a singular plantar fzrsciotomy technique to reiieve the primary symptoms of the common Heel Spur Syndrome. Functional orthoses are still generally requirecl postoperatiyely. The technique is performecl through a small stab incision placed plantarly or directly over the fascial insertion into the calcaneal tuber. (Fig 3A, 3B). A hemostat is used to spread through the subcutaneous tisslles. The medial and lateral bor- ders of the plantar fascia and the specific attachment of the fascia to the calcaneal tuber are iclen- tified with the blunt spreading technique (Fig. 3C). Any neuro-vascular bundles are also mobi- lized and preserued. Once the fascial insertion has been identified, a +67 Beaver blade is used to identify the Ftg. 3.{. Demonstration of the plantar fascia bone of the calcaneai tuber (Fig. 3D). The toes and the primary calcaneal attachments. 90 fig. 3n. Incision placement for the author's Fig. 3C. Hemostat dissection and identification technique. of the plantar fascia bl direct instrlrment palpation. Fig. 3D. #67 Beaver blade utilized for Fig. 3E. Transection of the plantar fascia at its fasciotomy. insertion into the calcaneal tuber. 91 are dorsiflexed, tightening the fascia. The fascia is and nerve with this approach, howevet, this has then sectioned at its insertion (Fig. 3E). The knife not been identified as a complication of this tech- blade is carried from medial to lateral across the nique to date. anterior margins of the calcaneal tuber to release Follow-up care is similar to that seen with the entire attachment of the plantar fascia. Upon neuroma surgery. However, the patient usually release, the fascia can be felt to move freely from feels an aching and fatigue in the plantar arch its primary attachment to the calcaneus. There are region for a short time. This sensation is due to muscle attachments which may remain intact and the release of the plantar fascia. Occasionally, the the surgeon, when performing the procedure for patient may develop a temporary increase in pain the first time may mistake these muscle fibers for at 3 to 4 weeks postoperatively. It can be neuritic residual fascial attachments. If there is a question, or aching in nature. Occasionally, the neuritic a hemostat can be reintroduced to make sure that pain is located in the lateral or lateral plantar there is a complete release of the fibers from the aspect of the rearfoot. Once the patient is sup- medial and lateral margins of the calcaneal tuber. ported (the author uses a Berkemann forefoot The skin incision can be closed with two simple ace wrap and a long metatarsal pad in the shoe), interrupted sutures. the symptoms will resolve. \Xlithin 3 months, the There may be a concern about violating the patient is usually functioning quite weli in calcaneal branches of the posterior tibial artery orthotics with minimal symptoms. o).

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