Plantar Calcaneal Spurs: Is Surgery Necessary?
For example, O’Malley observed that 12 of 19 patients with symptomatic plantar fasciitis had no spur present.14 When Surgery Is Indicated There remains a small subsection of patients who ultimately require surgical intervention when all else fails. Partial plantar fasciotomy has remained a mainstay with good long-term outcomes when such patients need a more aggressive treatment approach. When considering surgery for recalcitrant heel pain, one must ensure a careful and comprehensive differential diagnosis in addition to a thorough history and physical exam. When heel pain is associated with radiographic presence of enthesopathy, the differential should include a history of trauma, degenerative disease, inflammatory joint disease, crystal deposition disease, endocrine disorders (including diabetes mellitus) and infection (such as Reiter’s).8 What The Literature Reveals One may release a portion of the proximal plantar aponeurosis either openly, percutaneously or endoscopically. Regardless, controversy remains as to the necessity of concomitantly resecting the calcaneal heel spur. As it is technically challenging to resect the spur alone while leaving the plantar fascia inviolate, very few such studies have been reported. Steindler noted that less than half (7/16) of patients with isolated spur resection had good outcomes.15 Anderson found that 11 out of 72 patients had only fair or poor clinical results when the spur was resected alone.16 On the other hand, Ward and Clippinger found that seven out of eight patients had excellent results while one patient had 75 percent improvement with a partial fasciotomy without resecting the spur.17 Snider, et. al., reported that 10 of 11 such procedures among runners also yielded excellent results.18 Brekke and Green found those with minimal incision fasciotomy alone experienced greater pain reduction when they compared them to those who had open procedures with or without heel spur resection.19 In fact, many other studies have also confirmed good postoperative results while the calcaneal spur was left intact.20-26 What You Should Know About Potential Complications While surgery is generally successful, one must consider potential postoperative complications.27 These complications include recurrent heel pain, permanent local numbness, painful nerve entrapment, wound dehiscence, infection and hypertrophic scar formation. Furthermore, any procedure involving plantar fascial release can also lead to instability, foot pain, cramping, metatarsalgia, metatarsal stress fractures, tendonitis and sinus tarsitis. These complications are not unique whether clinicians perform the surgery by minimal incision, open or endoscopically. Additionally, these complications are irrespective of whether one performs the fasciotomy with or without plantar heel spur resection. Of particular concern is whether one should combine the fasciotomy with osseous work to remove the heel spur. Two of the more serious complications following heel spur surgery are a calcaneal fracture, presumably from stress risers following minimal bone removal, and deep infection in the surgical area. Manoli, et. al., observed three calcaneal fractures following a fascial release and spur resection for chronic plantar fasciitis.28 One patient developed displacement with nonunion and arthritis, and ultimately required a subtalar joint arthrodesis. The authors treated another patient successfully with a short leg cast. Both cases resulted in calcaneal fractures with weightbearing before the patients even left the surgery centers. A third patient required an open reduction and internal fixation through a conventional posterolateral approach when she fractured the os calcis 10 days after primary heel spur resection. A fourth patient ultimately required a below knee amputation secondary to painful nonunion after she underwent plantar bone debridement. This particular situation was complicated by diabetes, neuropathy and local osteomyelitis.28 Hoffman and Thul reported two cases of calcaneal fractures following subcalcaneal spur resection. They treated both patients successfully with casting and offloading.29 The patients fell two days and two weeks respectively after their primary heel surgery. Donohue, et.