Heel spurs, just like the name implies, are boney outgrowths (spurs) that occur on the back and/or bottom of the heel bone - both of which can cause heel pain. They are generally developed at the interface where a tendon or ligament attach to the heel bone. Heel spurs on the back of the heel are associated with the Achilles Tendon and are best described as Achilles insertional bone spurs. Those on the bottom of the are best described as plantar fasciitis bone spurs.1 While the Achilles and plantar fascia bone spurs both qualify as heel spurs, most people think of the latter when using the term heel spurs.
1. The Achilles Insertional Bone Spur
The Achilles tendon is the largest and strongest tendon in the body. It is formed from two leg muscles (gastrocnemius and soleus) combining together, forming the Achilles tendon, and attaching to the back of the heel.2 It is the main tendon that is responsible for moving the foot downward and to lift oneself on their tiptoes.
Achilles bone spurs generally occur directly at the insertion point of the tendon on the heel bone, exactly where the edge of the shoe meets the heel bone. There are a variety of reasons that Achilles bone spurs form, but three common reasons are overuse, injury and genetics.2 The bone spurs may small or large. They can develop largely within the tendon as well. The size of the bone spurs doesn’t necessarily correlate with pain. Large bone spurs can be completely asymptomatic whereas small ones can be excruciatingly painful.
Treatment for Achilles bone spurs first begins with alleviating pressure from the shoes on the heel bone. This can be done by spot stretching shoes, placing gel pads on the area and/or by wearing open back shoes. In some cases, heel lifts may be useful to elevate the heel bone so that the back part of the heel is elevated above the edge of the shoe. Pain medication, especially anti-inflammatories, can be really helpful if the area has a bursae (inflammatory fluid filled area between the skin and bone). Physical therapy can be useful for stretching and use of ultrasound to alleviate inflammatory.2
Achilles bone spur surgery can be performed to remove the heel bone spurs, however depending on the extent of the surgery, the procedure can become involved.3 Simple bone spurs on the periphery can be easily excised. Bone spurs that are enveloped within the tendon often require surgical detachment and reattachment. In some cases, tendon transfers may need to be performed to augment the repair. The recovery generally involves casts and crutches for 6-8 weeks, followed by physical therapy rehabilitation.
2. Plantar Fasciitis Bone Spur
Bone spurs on the bottom of the heel bone develop around the insertion point of the plantar fascia, the thick ligamentous band that supports the arch. Inflammation of this ligament is known as the common condition called plantar fasciitis. Heel spurs do not always occur in conjunction with plantar fasciitis but are common in patients with plantar fasciitis. Heel spurs of plantar fasciitis do not point downward towards the ground, rather they point forward, towards the toes - so the pain in the heel is generally not directly from the bone spur.1 With plantar fasciitis (+/- heel spur), the pain is associated with inflammation at this ligamentous insertion, and in some cases microtears of the ligament.
Treatment for plantar fasciitis with or without bone spurs generally involves rest, arch supports to stabilize the ligament, anti-inflammatory medications, icing and a stretching program.2 Physical therapy is useful in patients with plantar fasciitis. Steroid injections are used to rapidly decrease inflammation. Some intense cases may involve casting and crutches.
Most plantar fasciitis will resolve within several months of treatment. Plantar fasciitis that persists for year or so may be treated with plantar fasciitis surgery.2 The mainstay of surgical treatment involved partially cutting the plantar fascia ligament to allow for a surgically controlled lengthening. When a heel spur is present, the heel spur is commonly removed at the same time. The recovery generally involves casts and crutches for several weeks, followed by physical therapy rehabilitation.