Sunday, July 17, 2005

Is the calcaneal spur in the plantar fascia?

In a Yahoo Groups Discussion on manipulation, a question was asked:

"What is the best treatment for plantar fascitis induced heel spurs... " to which I replied:

"Since when did heel spurs have anything to do with the plantar fascia?"

Needless to say there was some interesting comments that followed, mostly based on what people were taught as students, and NOT on a reading of the research evidence.At the end of the day, all the published evidence I have seen, is that the spur is not in the plantar fasica, so how can plantar fasica "traction" cause heel spurs?One poster (Peter Morgan) did back up what I said with this:

"McCarthy DJ, Gorecki GE. The anatomical basis of inferior calcaneal lesions. JAPMA 1979;69:527This is quoted as finding the spur in the origin of the flexor digitorum brevis. ALSO, they asserted "the origin of flexor digitorum brevis, quad. plantae, long plantar ligament, abductor hallucis muscle and abductor digiti minumi are all sites of potential spur formation."

THIS WAS PUBLISHED IN 1979!!!! -- why do people still talk about the calcaneal heel spur as being due to traction of the plantar fascia. Now, I finally found one of the other more recent references showing the same thing:

"Heel Spur Formation and the Subcalcaneal Enthesis of the Plantar Fascia TSUKASA KUMAI and MIKE BENJAMIN Objective. To describe the structure and significance of subcalcaneal heel spurs associated with the plantar fascia. Methods. The enthesis of the plantar fascia was removed from 17 elderly cadavers by sagittal saw cuts either side of the medial tuberosity, radiographs were taken, and the tissue was processed for routine histology. Sagittal sections were stained with toluidine blue, Masson's trichrome, or alcian blue, and sections were matched with the corresponding radiographs. Results. Spurs develop on the deep surface of the plantar fascia but their formation is heralded by degenerative changes that occur within it. According to differences between small and large spurs, we propose that there are 3 stages in their development: (1) an initial formation of cartilage cell clusters and fissures at the plantar fascia enthesis; (2) thickening of the subchondral bone plate at the enthesis as small spurs form; (3) development of vertically oriented trabeculae buttressing the proximal end of larger spurs. The spurs grow by a combination of intramembranous and chondroidal ossification. Conclusion. Contrary to popular belief, subcalcaneal heel spurs cannot be traction spurs as they do not develop within the plantar fascia itself. They are thus fundamentally different from heel spurs in the Achilles tendon. We suggest instead that they develop as a consequence of degenerative changes that occur in the plantar fascia enthesis. (J Rheumatol 2002;29:1957-64) "

That was 3 yrs ago. There are other references, I just don't have them handy. Is it not time to "put this one to bed"? What say you? Discussion

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