The cool, dark west Texas night sky was nearly silent. It was almost like I had been placed into some type of surreal soundproof chamber. There was a big silence, except for the occasional coyote howl, and of course the regular cracking and popping of the roaring campfire. But that was like white noise. You never heard it unless you really concentrated. There is nothing like being out on a roundup, resting by the flickering fingers of the orange and yellow flames of the fire, being bone aching tired from herding cows all day. Then the silence ended.
From the other camp I heard: “I’ve got spurs that jingle, jangle, jingle.” The campfire songs had started.
Somehow, between trying to remember if it was Gene Autry or Tex Ritter who sang the song (actually both of them did), and what that song really meant, I had a flashback into my day job as a heel pain terminator. I was with a couple of colleagues on this drive and I knew that they were trying to forget about their day jobs as well. However, the song kept playing in my mind: “I’ve got spurs that jingle, jangle, jingle.”
“What does that really mean?” I silently asked myself. “Spurs” means something completely different to cowboys. Cowboys wear them with pride. In fact, they have to earn them. To us wannabe cowboy heel pain terminators, spurs are hated and reviled. Cowboys want to put spurs on and wear them with pride, and most of us want to take them out or at least fixate them a little. But should we? What has that heel spur done to you and, most importantly, what has it done to your patient?
Now we had gone there. Yes, sir and madam, I could not shut out work even on our first day out on this adventurous cattle drive. Call mothers against ADD. We have got a violator here.
Spitting a piece of gristle from my steak into the fire (cowboys are supposed to spit and do stuff like that), I cleared my throat, slapped my chaps (another real cowboy maneuver), and broke the rules of Man-cation. “Dudes, let’s talk about heel spurs,” I proffered.
“Let’s talk about which one of my ischial tuberosities is sorest and then you can kiss it,” my esteemed colleague John (going by Curly this week in honor of City Slickers fame) fired back with annoyance.
“No, seriously. I think there is merit (nobody says merit around a campfire and nobody proffers, for that matter) in discussing this,” I protested.
By now, they knew I was not going to give it up. Both of them looked at each other and then at me, and said in unison: “He’s disturbed.”
Damn right, I am disturbed, my fellow vacation cowboys. “Curly, you especially should listen up. You’re still takin’ ‘em out, aren’t you?” I accused.
“Maybe but what’s it to ya?” he sassed back like a little third-grade school boy.
I sighed. “And what about you, Duke?” (Robert wanted his trail ride name to be “Duke” even if there was not a “Duke” in City Slickers. Since that violated the City Slicker theme, I as the terminator decided I was to be henceforth known as Arnold.) “Are you still taking them out?”
“Hell no. Stopped doin’ that years ago,” he said with his eyes downturned in an apologetic look.
“OK,” I shifted around so that I could see them better without being blocked by the flames. “Let me ask this first: how did this little “trabeculous” piece of bone become public enemy number one? Surgeons for over a hundred years have focused on it and patients have too.”
Curly responded quickly: “You can see it. It looks like they have to hurt and when I remove ‘em, I can hold up the post-op film with pride showing the patients that the spurs are gone and that I really did something. They like that.”
“Nice. You are treating the X-ray and paying homage to the almighty view box rather than optimally helping the patient. Do they like not being able to walk without pain for weeks?” I shot back.
Curly got up, dusted off his sore hindquarters, and kicked at the fire. “All right, Arnold, since we can’t get you to shut up anyway, why don’t you enlighten us about the spur?”
Now I had my opening. They were actually requesting a soliloquy. I began with great animation. “OK, boys, the spur is a protective mechanism from shearing forces that occur on the plantar aspect of the calcaneus, and is not due to a tensile force as always believed. It is the body’s way of dispersing force. Remember, pressure is predicated on area, right?”
I was warming up and getting in the zone. “Sit down, Curly, you are making me nervous.” For some reason, Curly followed my direction and sat back down, groaning while the ground hit his inflamed tuberosities.
“See, Curly, your derriere hurts because pressure is being put on your bony little butt. I want you to think of the spur as a cantilever, a beam that is anchored only at one end. The inferior calcaneal exostosis is just that — a beam. It gives the inferior aspect of the heel bone more surface area, thereby diminishing pressure.” I could now see the disbelief on Duke and Curly’s faces.
“Where did you come up with that cow pie philosophy?” Duke asked.
“I didn’t. Li and Muehlman did in their 2007 article,” I replied, admittedly a bit smugly.1 “They determined that the trabeculae of the spur are perpendicular to the ground and not aligned with soft tissue traction. The bone reacts to the force put on it and, gentlemen, bone doesn’t lie. The heel spur is a protective physiological response and not a pain generator.”
“Huh?” they responded in unison.
“Want more? How about this: Where is the highest tensile force at the Achilles tendon insertion? Don’t answer. Posterior, that’s right.” (Neither of them knew that but they were now lower than a rattlesnake’s belly in a wagon rut, and I wanted to spare them any further ignominy.) “In fact, that force is 10 times higher than in the anterior tendon, where you almost always see the degeneration of the tendon. So that further supports shearing force over tensile ones.”2 Curly was now shifting his saddle-sore heinie more than Little Richard did when performing “Tutti Frutti.”
Lifting up my boot (no spurs yet as cowboys have to earn them) to illustrate my next point, I asked them: “What about foot type and heel pain? Does foot type really play a role in the development of heel pain?”
Duke popped off immediately: “Pronated.” Curly followed right after him: “Cavus.” I slapped my raised boot and said “Aha.”
“Which is it? A cavus foot or a pronated foot?” The fire crackled as I asked them again. “Don’t humiliate yourselves. There is no relationship, my friends.”
“Arnold, that’s bull — you know what, pure and simple,” Duke bellowed.
“Yah, Arnold, Duke’s right,” Curly added.
“Well, which foot type is it in your practice, boys?”
“Cavus,” Curly said. “Pronated,” Duke said. Then they started arguing between themselves about how the other was wrong because they each had decades of clinical observation. I let them go on for a few minutes while I ate as this was great theatre in the open west, and my steak was getting cold.
“See, you guys can’t even agree to what foot type most likely causes a heel spur,” I interjected, my steak properly masticated and swallowed. “How about this? Menz and colleagues studied 76 men and 140 women 62 to 94 years of age, and 55 percent of them had spurs. They reported that the highest odds ratio to risk factor was obesity at 7.9, previous or current heel pain at 4.6 and osteoarthritis at 2.6. However …” I paused for dramatic effect, “they also found that there was no relationship to foot type!”3
Curly and Duke were clearly disturbed by my soliloquy. “Arnold,” Duke said in a defeated and a whisper of a voice, “could we have been wrong all these years?”
“Yes, Duke, we could.” I quickly came back to the majesty of the campfire and the cattle round-up when I heard that last lyric of the song:
“So I’ll go jingling, a-jangling, a-jingling along.”
1. Li J, Muehleman C. Anatomic relationship of heel spur to surrounding soft tissues: greater variability than previously reported. Clin Anat. 2007; 20(8):950-955.
2. Lyman J, Weinhold PS, Almekinders LC. Strain behavior of the distal achilles tendon: implications for insertional achilles tendinopathy. Am J Sports Med. 2004; 32(2):457-461.
3. Menz HB, Zammit GV, Landorf KB, Munteanu SE. Plantar calcaneal spurs in older people: longitudinal traction or vertical compression? J Foot Ankle Res. 2008; 1(1):7.