What are heel spurs?
When discussing heel spurs, we look at two distinct types and the heel spur location. There are the more common bone spurs on the bottom of the heel, and the more difficult to treat bone spurs on the back of the heel.
So, what are spurs? Spurs are additional growths of bone, not just calcium deposits as some patients have asked me about. Bone is made of many minerals like phosphorous including calcium, collagen and matrix of hydroxylapatite and more. Calcium deposits are just calcium and can be found in many areas of the body. BUT bone is NOT just calcium. So, spurs are not just calcium but TRUE bone.
Specifically, this blog will discuss bone growths coming off the calcaneus or heel bone. Bone is a living organism and like all parts of the body will grow larger when there is force or stress on it. (Wolff's law, developed by the German anatomist and surgeon Julius Wolff (1836–1902) in the 19th century, states that bone in a healthy person or animal will adapt to the loads under which it is placed.) In other words, as the heel bone has stress applied to it, it will grow additional bone to handle the stress.
Types of heel spurs
1. Plantar heel spurs
Heel spurs on the bottom of the heel are known as "plantar" heel spurs. Plantar means the bottom of the foot. Heel/bone spurs on the back of the heel are known as "posterior" heel spurs. The theory of plantar heel spurs is that excess force from the plantar fascia, which connects to the heel bone, causes the spur to grow. One theory is that as the foot pronates (when the foot rolls in and the arch lowers), the foot lengthens as the arch drops. This causes the plantar fascia to be stretched and pulls on its insertion on the heel bone. Another theory is that dysfunction of the big toe joint, which is the other end of the plantar fascia, causes the fascia to again pull on the heel when we walk. There are also diseases that can cause heel spurs, such as ankylosing spondylitis which is a type of arthritis.
2. Posterior heel spurs
Heel spurs on the back of the heel, also known as posterior heel spurs, are located where the achilles tendon attaches to the heel bone. The theory is that excess pull on the achilles from its muscle attachments in the leg (gastrocnemius and soleus) causes stress to the heel bone causing heel spur at the achilles/heel bone interface. What is the reason for excess force on the achilles tendon? Here again, pronation of the foot plays is the cause. One major function of the two leg muscles that attach to the achilles (gastrocnemius/soleus) is to decelerate or reduce pronation of the foot when walking or running. When there is excess pronation (which has many causes), the muscles overwork and put extra strain on the achilles causing bone spurs on the back of the heel. Another cause of posterior heel spurs is some types of arthritis.
Heel spur symptoms
Heel spur pain is both common and usually misunderstood.
Posterior heel spurs are often quite painful and include the following:
- • Pain like "a knife cutting into the back of the heel"
- • Soft tissue swelling and inflammation around the area
- • Bursitis, a painful condition that affects the small, fluid-filled sacs that cushion the bones, tendons and muscles near the heel joints.
Unlike posterior heel spurs, plantar heel spurs really aren't the cause of pain on the bottom of the heel. The real culprit of heel pain on the bottom of the heel is either the plantar fascia where it attaches to the heel, or the heel bone at the bottom of the heel at the tubercles. The tubercles are anatomic bumps on the bottom of the heel bone. They are normal anatomy and not associated with spurs. This pain is actually a periostitis which is an inflammation of the periosteum or membrane coating the heel bone and tubercles.
What is quite interesting is that in my over 30 years of practice and thousands of heel pain cases, I have often found that when the feet are x-ray, the foot with the bigger plantar spur is often not the painful one. In many instances there is no correlation between the size of the spur on the bottom of the heel and the pain. I have seen many cases where the painful heel doesn't have a spur at all, while the other heel, which experiences no pain at all is the one with the spur.
Treatment of heel spurs
Your medical provider can diagnose a heel spurs with a simple x-ray. Treatment of heel spurs and heel pain can be frustrating and require multiple features of treatment and time. It requires patience and the need to really follow through on the protocol. The longer the pain has been in existence, the longer it will take to treat and resolve it. Regardless of the cause or location of the pain, I always start with shoes. I have my patients bring in ALL their regular shoes to see what they are wearing and whether the shoes are inappropriate or just old and worn out. Most shoes only are good for about 1 year if used regularly. Over time the materials stretch, deform, and lose stability and cushioning.
The best shoes for heel spurs or for any foot pain are new or almost new shoes to give the best chance for recovery. Here are the most important features in the best shoes for heel spurs:
- • Built in orthotic insole to support the arch and reduce strain on the plantar fascia.
- • Shoes designed with laces or straps that can be adjusted to fit different foot types.
- • Extra depth construction to accommodate any type of custom insert
- • Firm outsole and midsole for increased stability
- • Strong heel counter
- • Wide last design to allow the foot to be in its best anatomical position without being squeezed or bulged.
- • Soft foam uppers and padded interior around the heel area provide comfort for all day wear.
- • Thick multi-layered footbed and sole to cushion the bottom of the heel and disperse shock forces.
Orthofeet, an orthotic footwear company, has many shoes that match these criteria, and in fact my wife and I both wear Orthofeet shoes. They offer some of the best shoes for heel spurs featuring premium orthotic insoles and ergonomic soles to provide anatomical arch support and unsurpassed cushioning. Click here to view the collection.
Now for specifics.
Plantar heel pain treatment:
- • For plantar heel pain which again is really not the spur but either the plantar fascia or the actual heel bone, I start with shoes and an insert usually. For the insert I usually use a BioSole Gel insert from Orthofeet. I have used this particular insert for over 25 years with much success. It has a fairly firm arch support, and a gel pad under the heel, and it molds to the foot over time. The BioSole Gel both reduces pronation which can cause plantar fasciitis, and often unlocks a dysfunctional big toe joint, while it also has a gel pad under the heel for periostitis or tubercle pain on the heel. Click here to view the BioSole Gel inserts.
- • If there is severe pain, a cortisone injection can help but it doesn't really get to the underlying issues.
- • Oral medications can be prescribed if appropriate.
- • Heel spur exercises for plantar heel pain can be helpful and include bringing the foot back into dorsiflexion toward the leg while sitting or lying down. This is especially true first thing in the morning before getting out of bed.
- • If the insert and medication aren't effective over time, I usually consider a custom foot orthotic for maximum pronation control and arch support.
- • In recalcitrant cases, several weeks in a walking boot usually is effective.
- • Surgery is sometimes performed but I have NEVER removed a plantar heel spur in my practice.
Posterior heel spur relief:
Treatment for posterior heel spur relief of pain is much more difficult and debilitating. Patients often complain it is difficult to walk and even experience pain lying down with the back of the heel on the bed. The back of the shoes rubbing can cause even more pain. I have found the key to reducing the pain is to reduce the pronation that causes the leg muscles to over contract pulling on the achilles which irritates and can cause the spurs. Even in cases of arthritic spurs, reducing pronation is effective.
To reduce pronation, it again starts with well-made supportive shoes and an insert. A trial with the BioSole gel is my start point if the in-office test shows it can control enough pronation. If I think they need more control, I dispense a rigid custom orthotic. Medication can be helpful in the short term, but I avoid any "cortisone" as it can damage the achilles tendon. In recalcitrant cases or very severe pain, I recommend a walking boot for a few weeks. Unlike plantar heel spurs, some patients require surgical resection of the spurs. I only recommend this when many months of vigorous conservative treatment and physical therapy in addition to the other treatments I mentioned are not successful. Surgery in these cases can fail and requires a lengthy recovery.
The best way to reduce the risk of heel spur pain is prevention. Prevention starts with always wearing well-made shoes that are not worn out. Never go barefoot or in just socks! Shoes are needed ALL the time when standing or walking. Slippers with the features mentioned above can be worn around the house and they will provide the support and protection needed. Orthofeet also designs these and they work great for heel spurs and heel pain.
So much of the pain I see in the office could have been prevented if the person had paid attention to their feet and worn more appropriate shoes. Unfortunately, many dress shoes, particularly women's, are the cause of many foot problems as they are often narrow, designed with a tight toe box and have a heel. "SENSIBLE" shoes may not be the "IN" look but can save a lifetime of pain. I write these blogs for Orthofeet because I believe in their shoes and as I have often written I wear them myself as I have very problematic feet and no shoes have ever fit as well or been as comfortable. I was a marathon runner for over 35 years and still work out daily. These feet love the Orthofeet shoes and I recommend them to my patients.