Plantar Calcaneal Spurs: Is Surgery Necessary?
al., performed closed reduction with Steinman pin fixation after a patient fractured her right calcaneus two months following heel spur and plantar fascia surgery.30 The senior author of this article has also observed at least two cases of calcaneal fractures in the immediate post-op period following heel spur resection with no history of additional trauma to the area. Stress fractures arise from excess repetitive fatigue on normal bone (fatigue fractures) or from nominal weightbearing forces on insufficient bone stock (insufficiency fractures).31 They generally do not arise from direct impact but can propagate from a region where focal integrity has been compromised (i.e. stress riser). Gordon described this notion from a material science perspective and also cited other works that showed fracture progression from small holes and cracks within structures that grossly appeared undisturbed macroscopically.32 Smith, et. al., outlined four progressive stages of “standard” calcaneal fatigue fractures before surgical intervention, describing the fatigue perturbation emanating from the plantar tubercle region.33 This is noteworthy given the fact that calcaneal fractures following heel spur surgery have arisen from this same region of apparent weakness in the os calcis.28-30 Deep infections can be very difficult to eradicate when they occur at this surgical site. Some surgeons have suggested rasping the spur down using either hand or power instrumentation to minimize the risk of creating heel stress risers. However, increased potential still exists for creating local infection or even osteomyelitis by violating the periosteal and cortical structures, or by burring. In Conclusion Accordingly, resection of the plantar heel spur is seldom a necessary adjunct to partial plantar fasciotomy. There is no significant anatomic correlation of the plantar heel spur with the plantar fascia. The vast majority of plantar fasciitis cases will resolve with conservative care even in the face of plantar heel spur. In these cases, the asymptomatic spur remains. One may often see asymptomatic plantar heel spurs in patients without any symptoms of plantar fasciitis. Conversely, many patients with fasciitis are devoid of infracalcaneal heel spurs. Therefore, it is hard to make a case that the plantar heel spur is directly correlated to plantar fasciitis at all. Plantar fasciotomy may be an option for appropriately selected candidates who have recalcitrant plantar heel pain. The literature supports releasing part of the plantar aponeurosis at its most proximal medial attachment to the os calcis without spur resection as the partial release yields good clinical outcomes. There is a small but devastating potential for calcaneal fracture and an increased potential for deep infection following spur resection. Consequently, we find no evidence to support “routine” surgical resection of bone spurs during the course of plantar fascial release. Dr. Green is the Director of Podiatric Surgical Residency at the Scripps Mercy Medical Center in San Diego. He is a Clinical Professor at the California School of Podiatric Medicine at Samuel Merritt College, and is a Fellow of the American College of Foot and Ankle Surgeons. Dr. Green is also a Clinical Assistant Professor at UCSD Medical School, a faculty member of the Podiatry Institute and has a private practice in San Diego. Dr. Kim is a second-year resident within the Scripps Mercy Kaiser Residency Program in San Diego. Dr. Burks is a Fellow of the American College of Foot and Ankle Surgeons and is board-certified in foot and ankle surgery. Dr. Burks practices in Little Rock, Ark.