Heel spurs

A heel spur is when the tendon insertion point (enthesis) on the heel is ossified.

Ossification (bone formation) usually occurs on the heel bone under the heel. On rarer occasions, it also affects the Achilles enthesis, which connects the heel bone to the calf muscles.

The heel spur itself is often asymptomatic. The accompanying heel pain is usually triggered by wear and aging of the plantar fascia. This is the tendon plate that spans the longitudinal arch of the foot, similarly to how a tendon spans its bow. Each time the foot rolls, the bone insertion point is subjected to particularly high strain.

If the foot is subjected to excessive strain, plantar fasciitis occurs. This can also occur in old age without excessive strain. This refers to heel pain caused by minor injuries (micro injuries) in the area of the tendon enthesis. About half of people with plantar fasciitis have a heel spur.

Heel pain caused by plantar fasciitis is unpleasant and can make it difficult to walk. It is most common among long-distance runners and the elderly.

Treatment generally takes a long time and the pain often comes back. However, surgery is not usually required.

A heel spur can occur with or without heel pain. If the heel spur is painful, this is often due to plantar fasciitis, i.e. small injuries to the tendon enthesis caused by excessive strain.

The pain typically occurs under the heel and can be triggered by localized pressure. The same pain occurs when the toes and front of the foot are bent upwards with the hand. Severe heel pain can also spread into the lower leg.

The heel pain is particularly prominent after longer rest periods, for example in the morning when first getting up. It generally improves over the course of the day or while subjected to strain. It often gets worse again toward the evening, after long periods standing up or after carrying weights.

If the pain affects the entire heel and occurs after going barefoot for a long time or in parallel with additional sensory disorders such as tingling and numbness, it has other causes that need to be determined by a doctor.

The longitudinal arch of the foot is held in place by the muscles and a fixed tendon plate (plantar fascia). This tendon plate connects to the bony heel bone and the front of the midfoot (anterior metatarsal). If ossification of the tendon tissue occurs at the enthesis on the heel, a heel spur forms. Plantar fasciitis, which causes heel pain, is often also present.

Plantar fasciitis is caused by repeated excess strain on the enthesis, causing tiny tears in the fascia. These micro injuries can sometimes also occur as a result of a foot injury.

About 11 to 15 percent of all foot issues can be attributed to plantar fasciitis, i.e. to minor injuries to the enthesis caused by excess strain.

About 10 in every 100 people experience such heel pain at some point in life, primarily between the ages of 40 and 60. In one third of these, the pain occurs on both sides.

Women are affected slightly more often than men. The painful signs of wear and tear of the enthesis are particularly common among runners.

However, people who stand up or walk around a lot while working as well as those who practice sports such as tennis on hard floors are also more prone to wear-induced heel pain.

It can take anything from a few weeks to several months for the heel pain to completely subside. Most people are pain free after a year.

Depending on how much strain they exert during work or sport, some people need to take breaks every now and again. They may be temporarily unable to walk, stand for a long time or carry weights. Only about 5 in every 100 patients require surgery.

Long-distance runners in particular can prevent heel spurs by:

• wearing running shoes that absorb the impact well when their foot strikes the ground
• regularly changing their shoes

Training should also be adjusted to include regular stretching exercises, less intensive training sessions and shorter distances.

Heel spurs in the enthesis area can usually be detected by a physical examination. As such, no further investigations are required.

If the symptoms don’t improve after a certain time, imaging procedures may help:

• A heel spur can be detected on an x-ray and by means of an ultrasound examination.
• Magnetic resonance imaging (MRI) is used to detect stress fractures or cartilage damage.
• An ultrasound examination can be used to examine both tendons and muscles in order to detect thickening or calcium deposits.

If connective tissue or joint diseases are suspected to be triggering the heel pain, this can be proven by taking a blood sample.

An in-depth neurological examination will show if nerve problems are triggering the pain.

The heel spur itself, i.e. the ossified enthesis on the heel bone, will not go away again.

If heel pain occurs, it can be treated as follows:

• If a particular form of sport or exercise is triggering the pain, the person should take a break from it. Applying an ice pack to the area after subjecting it to strain can sometimes alleviate the pain.
• Exercises to stretch the sole of the foot and the calf, especially before physical activity, reduce the pain.
• Silicone heel pads can provide relief.
• Shoes with thin leather soles and walking barefoot should be avoided. On the other hand, it can help to wear shoes with a footbed, padded soles or orthopaedic insoles. Insoles are particularly important if the person also has a foot misalignment.
• Painkillers in tablet form can effectively combat pain but should not be taken for more than 2 to 3 weeks.
• Injecting the enthesis area with anti-inflammatory agents such as cortisone and local anaesthetics is also very effective in the short term. If cortisone injections are used more frequently, however, they can potentially damage the tendons.
• Anti-inflammatories can also be externally applied to the skin together with a mild electrical current. The medical term for this method is “iontophoresis”.
• Wearing foot splints at night is particularly effective if the pain primarily occurs first thing in the morning after getting up.
• Foot tapes can sometimes alleviate the pain at first. Here, the mechanics of the foot are supported by specially attached adhesive strips.

Surgery should only be considered if all other measures have not resulted in an improvement after 6 to 12 months.

In the event of persistent pain, further therapies are often recommended. To date, however, the efficacy of these has not yet been proven. These include:

• shockwave therapy
• injections with the body’s own blood components or botulinum toxin, a neurotoxin produced by bacteria
• applying cortisone ointments or herbal active ingredients
• treatment with X-rays
• cryotherapy
• laser therapy
• treatment of trigger points with acupuncture needles, also known as dry needling