In a rare case, these authors discuss the diagnosis and treatment of a 60-year-old patient, who fractured his left infracalcaneal heel spur when he missed a step on the stairs.
When it comes to calcaneal fractures, the classifications of these injuries, the mechanism of action, protocols for diagnosis and treatments are well documented in the literature.1-10However, a fracture of a plantar heel spur is rare and not often documented. Accordingly, clinicians may misdiagnose such an injury, resulting in a patient having prolonged pain. This case report illustrates a previously unreported injury.
A 60-year-old male presented to our clinic after “missing a step” while descending stairs in his home, impacting heavily on his left foot one week priorto presentation. The patient reported "sever out of ten" pain localized to the medial tubercle of the left calcaneus, making weightbearing difficult. Mild localized edema was present over the medial and plantar aspects of the left heel. No open wounds, ecchymosis or erythema were present. The patient’s neurovascular status was intact. We obtained three plain radiographic views of the involved foot. The lateral view demonstrated a complete fracture of the distal aspect of the left infracalcaneal spur (see Figure 1).
The patient had a medical history of well-controlled type 2 diabetes mellitus (since 2017) without peripheral neuropathy and denied any surgical history. He denied any tobacco, alcohol or illicit drug use. The patient took metformin and reported no allergies. He did not have a history of plantar fasciitis or heel pain prior to the fracture. We did not order a computed tomography (CT) scan as the patient’s pain was localized to the medial calcaneal tubercle and we did not suspect a fracture extending into the body of the calcaneus.
Formulating An Initial Treatment Plan
We initially attempted non-surgical treatment and instructed the patient on non-weightbearing with crutches and a removable cast walker. The patient started taking prescribed ibuprofen 600 milligrams every six hours and we recommended rest, ice, compression and elevation (RICE) therapy. We saw the patient at our podiatry clinic every three weeks for up to three months and obtained serial radiographs to monitor osseous changes.
Due to his schedule, it was difficult for the patient to remain completely non-weightbearing to the fracture site. He refused to transition to a below-knee cast and was not adherent with other recommended pressure relief modalities. After three months, the fracture showed signs of delayed healing and continued to cause pain(see Figure 2). We decided to surgically excise the calcaneal spur.
A Closer Look At The Surgical Technique
After ensuring supine positioning of the patient, intravenous sedation and a local ankle block, we padded the left ankle with Webril and used an Esmarch bandage as a tourniquet11
Directing our attention to the plantar medial aspect of the foot, we made an approximately two cm incision overlying the medial calcaneal tubercle, perpendicular to the longitudinal axis of the foot. This placement allows for easier access to the spur while avoiding branches of the medial calcaneal nerve.
We proceeded to release approximately one cm of the medial plantar fascial band with a #15 scalpel blade. Subsequent use of fluoroscopy enabled us to locate the avulsed fragment of the infracalcaneal spur, which we carefully and completely removed. After copious irrigation of the surgical site with normal sterile saline, we completed deep closure with 2-0 polyglactin 910 (Vicryl®, Johnson & Johnson) suture. Then we reapproximated the skin edges with 3-0 nylon suture in a simple interrupted technique, dressed the incision with povidone-iodine-soaked Adaptic (Acelity) and covered it with a sterile compressive dressing. This consisted of 4x4 gauze, roll gauze, Webril, an ACE bandage and a posterior splint (see Figure 3).
We instructed the patient to remain non-weightbearing with crutches. Although he did not comply with post-operative weight bearing advice, the incision site did remain intact without dehiscence. The patient transitioned to weightbearing in a removable cast boot walker and we removed the sutures three weeks after surgery. Four weeks postoperatively, the patient began tolerating regular shoe gear and returned to normal activity two weeks later. The patient noted no pain or related symptoms upon follow up one year after the initial injury.
Examining The Etiology, Evaluation And Treatment Of Plantar Calcaneal Spur Fractures
Plantar heel spurs arise from the inferior aspect of the calcaneus, typically at the origin of the plantar fascia. Howevercalcaneal exostoses may occur above or within the plantar fascia, between the fascia and the abductor digiti minimi, or between the abductor hallucis and flexor digitorum brevis.12
This case demonstrates that patients can fracture plantar heel spurs with direct trauma and this should be among the differential diagnoses of heel pain. In theory, a sudden pull of the underlying soft tissue structures, such as the plantar fascia or flexor digitorum brevis, could also cause such a fracture.13,14The aforementioned patient demonstrated intact neurovascular status. However, physicians should also consider compartment syndrome in one or more pedal compartments with any fracture of the calcaneus.15
Initial radiographs may demonstrate a displaced bony fragment separated from its origin at the inferior surface of the calcaneal tuberosity, or a break in the cortex of the medial process. In some cases, bony sclerosis may be the only finding of note. The use of CT is debatable, but may be considered if a fracture extending into the body of the calcaneus is suspected.15, 16
A conservative care approach seems reasonable as the first step of management prior to attempting surgical intervention. Due to the location of the fracture, clinicians should implement non-weightbearing to prevent occurrence of nonunion.17
Several reports have documented calcaneal body fractures as a complication following surgical resection of plantar calcaneal spurs.18,19 However, a traumatic fracture of the inferior heel spur is rare and underreported. To the best of our knowledge, this is the first documented case of an infracalcaneal heel spur with a surgical workup. The rarity of this fracture and risk of nonunion due to fracture location makes the case worthy of acknowledgement.
Dr. Meneely is a second-year foot and ankle surgical resident at Mount Sinai/Captain James A. Lovell Federal Health Care Center in Chicago.
Dr. Wu is the Associate Dean of Research, a Professor of Surgery at the Dr. William M. Scholl College of Podiatric Medicine, and Professor of Stem Cell and Regenerative Medicine at the School of Graduate Medical Sciences at the Rosalind Franklin University of Medicine and Science in Chicago. She is also the Director of the Center for Lower Extremity Ambulatory Research (CLEAR) in Chicago.
Dr. Lucas is the director of the Podiatric Surgical Residency at Mount Sinai/Captain James A. Lovell Federal Health Care Center in Chicago. He is a Fellow of the American College of Foot and Ankle Surgeons.
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