The conundrum of calcaneal spurs: do they matter?

Ossification of the posterior longitudinal ligament is linked to heterotopic ossification of the ankle/foot tendons

INTRODUCTION

Systemic osteogenesis has been speculated to be involved in the pathogenesis of ossification of the posterior longitudinal ligament (OPLL). Our purpose was to compare the radiologic prevalence and severity of heterotopic ossification in foot tendons of Japanese patients with OPLL and to determine their association with systemic heterotopic ossification.

MATERIALS AND METHODS

Clinical and radiographic data of 114 patients with OPLL were collected from 2020 to 2022. Control data were extracted from a medical database of 362 patients with ankle radiographs. Achilles and plantar tendon ossification were classified as grades 0-4, and the presence of osteophytes at five sites in the foot/ankle joint was assessed by radiography. Factors associated with the presence and severity of each ossification were evaluated by multivariable logistic regression and linear regression analysis.

RESULTS

The prevalence of Achilles and plantar tendon ossification (grade ≥ 2) was 4.0-5.5 times higher in patients with OPLL (40-56%) than in the controls (10-11%). The presence of Achilles tendon ossification was associated with OPLL, age, and coexisting plantar tendon ossification, and was most strongly associated with OPLL (standardized regression coefficient, 0.79; 95% confidence interval, 1.34-2.38). The severity of Achilles and plantar tendon ossification was associated with the severity of ossification of the entire spinal ligament.

CONCLUSIONS

The strong association of foot tendon ossification with OPLL suggests that patients with OPLL have a systemic osteogenesis background. These findings will provide a basis for exploring new treatment strategies for OPLL, including control of metabolic abnormalities.

Clinical Study of a Four-Step Program for the Treatment of Plantar Fasciitis with Bone Spurs

OBJECTIVE

The most common causes of plantar and heel pain are plantar fasciitis and calcaneal spurs, and they often co-exist. Surgery is a recognized treatment for refractory plantar fasciitis. However, few studies have proposed treatment options for patients with metatarsophalangeal fasciitis with bone spurs. Accordingly, this study's purpose was to propose a four-step surgical regimen, and to improve the surgical outcome of plantar fasciitis with osteophytes and to establish a procedure for surgical treatment.

METHODS

Retrospective analysis of 45 patients suffering from plantar fasciitis with bone spurs from 2020 to 2023. All patients underwent a four-step procedure, including plantar fascia release, calcaneal spur grinding, inflammatory tissue removal, and calcaneal burr decompression. The imaging parameters and functional scores were recorded before and after the operation. The objective evaluation included the measurement of calcaneal spur length on radiographs. Clinical evaluation included the American Orthopaedic Foot and Ankle Society (AOFAS), the Visual Analog Scale (VAS), and the Foot and Ankle Outcome Scale (FAOS). Measurement data that conformed to normal distribution were expressed as (x2 ± s), and pre-and postoperative AOFAS, FAOS, and VAS scores were compared using repeated-measures ANOVA, and preoperative and postoperative spur lengths were compared using paired t-tests.

RESULTS

The 45 patients were followed up for 3 to 30 months, (17.72 ± 8.53) months, at final follow-up, the patient's AOFAS score improved from preoperative (74.93 ± 5.56) to (94.78 ± 3.98), FAOS score increased from preoperative (76.42 ± 3.37) to (96.16 ± 2.74), the VAS score decreased from (3.18 ± 0.54) to (1.07 ± 1.20) (p < 0.05), the length of spur decreased from (0.72 ± 1.81) cm to (0.23 ± 1.19) cm, and there were significant differences before and after operation (p < 0.05).

CONCLUSION

The four-step surgical regimen is an appropriate and effective surgical procedure to treat plantar fasciitis with bone spurs.

Are enlarged peroneal tubercle and accessory anterolateral talar facet associated with calcaneal spur?

BACKGROUND

As the anatomical variations of the foot, enlarged peroneal tubercle (EPT) and accessory anterolateral talar facet (AALTF) have attracted the attention of foot surgeons in recent years. However, EPT and AALTF have not been examined for a relationship with calcaneus spur (CS) as a common osteophyte.

METHODS

The subjects were 369 individuals who died in northeastern Thailand and were preserved as skeletal specimens. The authors examined for the presence of left and right EPT, AALTF, and calcaneus spur (CS). We divided the EPT (+) group with EPT and the EPT (-) group without it and also divided the AALTF (+) group with AALTF and the AALTF (-) group without it. The age at death and the presence of CS were compared statistically between the EPT (+) and EPT (-) groups and between the AATLF (+) and AALTF (-) groups.

RESULTS

Out of the total 369 cases, EPT was found in 117 cases (31.7%), AALTF was positive in 91 cases (24.7%), and CS was found in 194 cases (52.3%). In comparison between EPT (+) and EPT (-) groups, CS was significantly higher (p < 0.0001) in the EPT (+) group, but there was no significant difference in age at death. In comparison between AALTF (+) and AALTF (-) groups, there was no significant difference in age at death or CS.

CONCLUSION

This study showed a strong relationship between EPT and CS, and the prevalence of EPT and AALTF by age in Thailand was first reported. We believe it helps to know the pathogenesis and biomechanism of EPT and AALTF.

TRIAL REGISTRATION

Not applicable.

Common Painful Foot and Ankle Conditions: A Review

Importance

Morton neuroma, plantar fasciitis, and Achilles tendinopathy are foot and ankle conditions that are associated with pain and disability, but they can respond to nonoperative treatment.

Observations

Morton neuroma, consisting of interdigital neuronal thickening and fibrosis, is characterized by burning pain in the ball of the foot and numbness or burning pain that may radiate to the affected toes (commonly the third and fourth toes). First-line nonoperative therapy consists of reducing activities that cause pain, orthotics, and interdigital corticosteroid injection; however, approximately 30% of patients may not respond to conservative treatment. Plantar fasciitis accounts for more than 1 million patient visits per year in the US and typically presents with plantar heel pain. Fifteen years after diagnosis, approximately 44% of patients continue to have pain. First-line nonoperative therapy includes stretching of the plantar fascia and foot orthotics, followed by extracorporeal shockwave therapy, corticosteroid injection, or platelet-rich plasma injection. Midportion Achilles tendinopathy presents with pain approximately 2 to 6 cm proximal to the Achilles insertion on the heel. The primary nonoperative treatment involves eccentric strengthening exercises, but extracorporeal shockwave therapy may be used.

Conclusions and Relevance

Morton neuroma, plantar fasciitis, and Achilles tendinopathy are painful foot and ankle conditions. First-line therapies are activity restriction, orthotics, and corticosteroid injection for Morton neuroma; stretching and foot orthotics for plantar fasciitis; and eccentric strengthening exercises for Achilles tendinopathy.

Do the presence, size, and shape of plantar calcaneal spurs have any significance in terms of pain and treatment outcomes in patients with plantar fasciitis?

BACKGROUND

: The purpose of this study was to determine the effect of the presence, size, or type of calcaneal spurs on pain or the outcomes of extracorporeal shock wave therapy (ESWT) therapy in patients with plantar fasciitis.

METHODS

Seventy-four patients with unilateral plantar fasciitis who had no pain in the contralateral foot, either currently or in the past, were included in the study. The length, base width, type, and presence of plantar calcaneal spurs in both heels of the patients were determined using radiography. A total of five sessions of ESWT (3 bar, 2000 shocks/session, 12 Hz frequency) with an interval of 3 days were performed on the painful sides of the patients. Symptom duration and numerical rating scale (NRS) scores were recorded pretreatment and 1 week and 12 weeks after treatment.

RESULTS

: Spurs were detected in 85.1% of painful feet and 71.6% of painless feet, this difference was statistically significant (p = 0.046). There was no significant correlation between the type of the spurs and whether the foot was painful. Patients with spur sizes of >5 mm or with horizontal and hooked spurs had a higher NRS decrease than patients with spur sizes of ≤5 mm or with a vertical spur. Symptom duration, spur length, and base width were found to be correlated with pretreatment NRS scores.

DISCUSSION

The presence and size of calcaneal spurs are associated with pain. However, it should be kept in mind that a high rate of spurs can also be found in painless feet, so spur is not the only factor that causes pain. Patients with a spur size of ≤5 mm or a vertical spur have less pain relief with ESWT.

The Prevalence and Risk Factors of Plantar Fasciitis Amongst the Population of Jazan

Background

Plantar fasciitis develops as a consequence of irritation of the plantar fascia, which is responsible for supporting the arches and absorbing shock. Multiple factors can contribute to plantar fasciitis, but the most common factor is overuse stress. The classical presentation is a sharp pain that is felt at the plantar aponeurosis (near the area of its insertion on the medial process of the calcaneal tuberosity), and it is possible to find a heel spur (osteophyte) in some cases. Most treatments for plantar fasciitis are ineffective and unsatisfactory for patients.

Objective

To estimate the prevalence and assess risk factors for plantar fasciitis among the population of the Jazan region.

Methods

A cross-sectional online survey was conducted on the population of the Jazan region. An online Google form questionnaire was prepared and distributed to the study population. Data was then entered and analyzed using IBM SPSS (Statistical Package for the Social Sciences) Statistics, version 21.0.

Results

A total of 695 participants were enrolled in the study. Out of that, 350 (50.4%) of the participants were males, while 345 (49.6%) were females. About the age of the participants, 507 (72.9%) were younger than 40 years of age. Participants with hypertension were 43 (6.2%), and 37 (5.3%) participants had diabetes. In terms of occupation, 120 (17.3%) worked in healthcare, 187 (26.9%) taught, and 43 (6.2%) served in the military. A great quantity of standing or walking was necessary for the jobs for 127 people (18.3%), while moderate amounts were recorded for 273 people (39.3%). The most commonly reported lower limb conditions were: pes planus (low arches) in 26 (3.7%) participants; and weakness of the gastrocnemius, soleus, and intrinsic foot muscles. The most commonly reported exercises were walking for 499 (71.8%) participants and jogging for 97 (14%) participants. The prevalence of plantar fasciitis was found to be 37% of the participants. Regarding the Foot and Ankle Outcome Score (FAOS) survey, the mean symptoms subscale score was 57.81 + 11.28, the mean pain subscale score was 72.87±20.84, the mean daily living subscale score was 72.73 ± 22.25, the mean sports and recreation subscale score was 76.83 ± 23.06, and the mean quality of life subscale score was 70.23 ± 25.17. Multivariate logistic regression was done and the following factors predicted a higher rate of plantar fasciitis: being 40 to 55 years old (p < 0.001, odds ratio = 2.15), being 56 to 65 years old (p = 0.037, odds ratio = 3.58), being obese (p = 0.031, odds ratio = 2.16), having weakness of the gastrocnemius, soleus, and the intrinsic foot muscles (p = 0.003, odds ratio = 7.39), jobs requiring a great amount of time standing or walking (p < 0.001, odds ratio = 3.17), and jobs requiring a moderate amount of time standing or walking (p = 0.012, odds ratio = 1.83). Being male predicted a lower rate of plantar fasciitis (p < 0.001, odds ratio = 0.52).

Conclusion

Plantar fasciitis is a prevalent and disabling condition with considerable effects on quality of life. Jobs that require long hours of walking or standing were associated with an increased risk of developing plantar fasciitis. Middle age, prolonged exercise, and gastrocnemius muscle tightness were also associated with plantar fasciitis. Efforts should be directed towards health education of the population regarding the risk factors and management of plantar fasciitis.

Endoscopic Plantar Fascia Release Combined With Calcaneal Spur Resection: A Case Series of 40 Patients

PURPOSE

To review the cases of patients treated using endoscopic plantar fascia release (PFR) with calcaneal spur resection (CSR) and examine why the combined procedures cause complications.

METHODS

The medical records of patients treated with endoscopic PFR with CSR from November 2017 to December 2019 with a follow-up of >2 years were reviewed.

RESULTS

A total of 40 feet in 40 patients (22 females, 18 males) were enrolled. The mean age and body mass index were 51.1 years and 24.7 kg/m2, respectively. The mean follow-up duration was 5.7 years. The visual analog scale for pain improved from 80.7 to 8.8 mm, and the Japanese Society for Surgery of the Foot score improved from 44.7 to 95.6 points (Wilcoxon signed rank test, P < .001 for both). Complications occurred in 8 patients (20%): 3 had flatfoot, 3 had an injury to the first branch of the lateral plantar nerve, 1 had scar pain, and 1 had a wound infection.

CONCLUSION

The 40 patients treated with endoscopic PFR with CSR for plantar fasciitis had good outcomes with a high complication rate; the invasiveness of creating the working space for the combined procedures was thought to be responsible.

LEVELS OF EVIDENCE

Level IV: Case series.

Fluoroscopic and Endoscopic Calcaneal Spur Resection Without Plantar Fascial Release for Recalcitrant Plantar Fasciitis

Background

Studies on endoscopic calcaneal spur resection (CSR) without plantar fascial release (PFR) are limited. This study aimed to review the data of patients who underwent fluoroscopic and endoscopic CSR without PFR for plantar fasciitis with a calcaneal spur to assess the effectiveness of CSR.

Methods

Medical records of consecutive patients with plantar fasciitis with ≥2 mm calcaneal spur who underwent endoscopic CSR without PFR from November 2017 to December 2019 were reviewed. Patients with ≥2 years of follow-up were included, whereas those who underwent another surgery on the operated foot were excluded. Age, body mass index (BMI), follow-up duration, calcaneal spur length, duration to full weightbearing postoperatively, Japanese Society for Surgery of the Foot (JSSF) score, visual analog scale (VAS) score for pain, and complications were assessed.

Results

The mean follow-up duration was 2.7 years. A total of 47 patients (31 female, 16 male; mean age, 56.4 years; mean BMI, 25.5) were included. The mean calcaneal spur length was 5.7 mm. The VAS score improved from 79.6 ± 12.9 mm preoperatively to 5.3 ± 7.3 mm postoperatively. The JSSF score improved from 54.0 ± 19.1 points preoperatively to 97.5 ± 5.7 points postoperatively (Wilcoxon signed-rank test, P < .001, respectively). The mean duration to full weightbearing postoperatively was 4.4 ± 4.2 days. Two patients presented with tenderness, and one presented with hypesthesia at the portal site.

Conclusion

Endoscopic CSR without PFR resulted in good outcomes, early return to full weightbearing, and few complications in patients with plantar fasciitis with ≥2 mm calcaneal spur. The results suggested that CSR was sufficient to relieve symtoms and improve function. PFR may not be necessary for treating plantar fasciitis with calcaneal spur.

Level of Evidence

Level IV, retrospective case series.

The levels of 25-hydroxy vitamin D, parathyroid hormone, calcitonin and lipid profiles in patients with calcaneal spur

Objectives

The aim of this study was to investigate the 25-hydroxyvitamin D (25(OH)D), parathyroid hormone (PTH), and calcitonin levels and lipid profiles in patients with calcaneal spurs.

Patients and methods

Between March 2018 and June 2019, a total of 50 patients (30 males, 20 females; mean age: 39.8±8.1 years; range, 24 to 54 years) admitted to our clinic with heel pain and diagnosed with heel spurs based on radiographic images were included. The control group consisted of 50 age- and sex-matched healthy volunteers (32 males, 18 females; mean age: 35.7±9.6 years; range, 20 to 56 years). Blood samples were collected from all participants. Total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), triglyceride, phosphate, and calcium levels were measured using the colorimetric method. The PTH and 25(OH)D levels were measured using the chemiluminescent microparticle immunoassay. Calcitonin levels were detected using the chemiluminescent immunometric assay.

Results

In the patients with calcaneal spurs, 25(OH)D and HDL-C levels were significantly lower (p<0.001), while LDL-C, triglyceride, and PTH levels were significantly higher (p<0.05, p<0.002 and p<0.001, respectively). There was no significant difference in the calcium, phosphate, body mass index, and calcitonin levels between the groups.

Conclusion

Our study results suggest that calcaneal spur formation is associated not only with weight-related pressure, but also with lipid levels and hormonal alterations involved in calcium metabolism. Based on these findings, hormonal alterations and lipids should be considered in patients with calcaneal spurs.

Age, Body Mass Index, and Spur Size Associated with Patients’ Symptoms in Plantar Fasciitis

Background

Plantar fasciitis is a common cause of heel pain affecting 10% of the general population. This study aimed to investigate the specific symptoms in patients with plantar fasciitis using the Foot and Ankle Outcome Score (FAOS) questionnaire and their relationship with demographic and radiographic factors.

Methods

We retrospectively analyzed 73 consecutive patients (mean age, 53.8 ± 10.0 years; 20 men and 53 women) with plantar fasciitis who had visited our foot and ankle clinic and undergone weight-bearing foot X-ray examinations. Their demographic data, anteroposterior and lateral talo-first metatarsal angles, intermetatarsal and hallux valgus angles, and responses to the FAOS questionnaire were recorded.

Results

The quality-of-life subscale showed the lowest score of all FAOS subscales. Age was significantly correlated with quality of life (r = 0.297, p = 0.011), and body mass index was correlated with the function in sports and recreational activities (r = –0.251, p = 0.032). Age and body mass index were statistically significantly correlated with calcaneal spur size (r = 0.274, p = 0.027 and r = 0.324, p = 0.008, respectively). The calcaneal spur size was significantly correlated with pain (r = –0.348, p = 0.004), function in daily living (r = –0.410, p = 0.001), and function in sports and recreational activities (r = –0.439, p < 0.001).

Conclusions

Demographic factors were associated with specific symptoms in patients with plantar fasciitis. Calcaneal spur size was the only radiographic parameter correlated with symptoms. These findings help communicate with patients, set appropriate treatment goals, and evaluate treatment effectiveness.

Radiologic and Demographic Characteristics of Patients With Plantar Calcaneal Spur

Many people with heel pain in the general population are often diagnosed with plantar calcaneal spurs (PCS). The aim of this study was to evaluate the radiological and demographic characteristics of PCS patients and to compare the differences with the control group. In 2018, 420 patients with weightbearing lateral ankle X-ray images were included in the study. The patients were divided into 2 groups as PCS group and control group. Groups were compared age and age group (20-29, 30-39, 40-49, 50-59, 60-69, 70 and over) weight, height, body mass index (<25, 25-30, >30), chronic diseases as demographically and were also compared radiologically as calcaneal inclination angle (CIA), lateral talocalcaneal angle (LTCA), Bohler angle and Gissane angle. A statistically significant relationship was found between gender and PCS. Plantar calcaneal spur is more common in females than in males (X²:8.101, p < .03). PCS was less common in patients with BMI <25 and 25-29.9, whereas PCS is more common in patients with BMI >30 (X²:7.698, p < .021). Although the CIA angle was within normal limits in both groups, it was significantly lower in patients with PCS than in the control group(p < .05). There was no statistically significant difference between the 2 groups in terms of age, chronic disease, LTCA, Bohler angle, Gissane angle. Female gender and obesity are among the risk factors for PCS formation. CIA may have an important role in PCS formation. In order to clarify the etiology and pathophysiology of PCS, further studies with radiological features are needed.

Long-term effect and prognostic factors of a low-dose radiotherapy of painful plantar calcaneal spurs : A retrospective unicenter study

PURPOSE

To estimate the long-term effect of low-dose radiotherapy of painful plantar calcaneal spurs, and to verify possible prognostic factors.

PATIENTS AND METHODS

In this retrospective unicenter study, electronic patient files of patients with painful plantar calcaneal spurs treated with low-dose radiotherapy between July 2009 and February 2020 were reviewed. The low-dose radiotherapy consisted of a total dose of 3.0 Gy given with a fraction dose of 0.5 Gy three times a week. The pain reduction was estimated using a patient questionnaire with a visual analogue scale. Kaplan-Meier statistics and Cox regression analysis were used for the statistical analysis.

RESULTS

Altogether, 864 heels of 666 patients were reviewed. The probability of an insufficient pain control 10 years after low-dose radiotherapy was 45.9% (95% confidence interval 39.4-52.4%) in the subset of patients with a minimum follow-up of 3 months (582 heels of 467 patients). Patients with an unsatisfactory pain reduction 3 months after low-dose radiotherapy were offered a re-irradiation. Forty percent of the patients who received a re-irradiation developed good pain reduction. Occurrence of an initial aggravation of pain during or within 3 months after low-dose radiotherapy (p = 0.005), and treatment of bilateral painful plantar calcaneal spurs (p = 0.008) were identified as significant unfavorable prognostic factors on univariate analysis. On multivariate analysis, the initial aggravation of pain remained as independent significant prognostic factor (p = 0.01). No clear radiation toxicity was observed.

CONCLUSIONS

Low-dose radiotherapy is a safe and effective treatment option for patients with painful plantar calcaneal spurs. An initial aggravation of pain during or within 3 months after radiotherapy was identified as unfavorable prognostic factor for the treatment outcome. Re-irradiation of patients with an unsatisfactory pain reduction after low-dose radiotherapy is effective and should be offered to patients.

Plantar fasciitis in patients with type 1 and type 2 diabetes: A contemporary cohort study

OBJECTIVE

Hyperglycemia leads to increase advanced glycation end products (AGEs) in patients with type 1 and type 2 diabetes. Subsequently, formation of AGEs can cause increased plantar fascial thickness (PFT), an imaging feature of plantar fasciitis (PF). This study evaluates the prevalence of PF in a contemporary cohort of type 1 diabetes and type 2 diabetes patients managed according to current standards, compared to patients without diabetes.

RESEARCH DESIGN AND METHODS

This is a five-year prevalence study in a large tertiary health system (approximately 535,000 patients/visits/year) with a single electronic medical record (EMR), applying a cohort discovery tool and database screen (Data Direct) with use of ICD-9 and ICD-10 codes. All patients with a PF diagnosis between 01/01/2011 and 01/01/2016 were included and divided into 3 groups: type 1 diabetes (7148 patients), type 2 diabetes (61,632 patients), and no diabetes (653,659 patients). Prevalence rates were calculated, accounting for other risk factors including BMI and gender using Fisher's exact test.

RESULTS

The overall prevalence of PF in the entire study population was 0.85%. Prevalence rates were higher in patients with diabetes, particularly with type 2 diabetes (42% and 64% higher compared with patients with type 1 diabetes and no diabetes respectively). Individually, PF rates were 0.92% in type 1 diabetes and 1.31% in type 2 diabetes compared with 0.80% in patients with no diabetes (Type 1 vs. no diabetes p = 0.26; Type 2 vs. no diabetes p ≪ 0.0001; Type 1 vs. Type 2 diabetes p = 0.0054). Females in all groups had higher prevalence of PF than males (p ≪ 0.0001 for all), with those patients with diabetes having higher prevalence rates than those without diabetes. Patients with higher BMI levels (BMI ≥ 30 kg/m²) were also more likely to have PF in all categories except males with type 1 diabetes (p = 0.40).

CONCLUSIONS

In this large contemporary population managed in a tertiary health system, prevalence rates of PF were substantially higher in patients with diabetes compared with no diabetes, particularly in type 2 diabetes. Female gender and higher BMI were also associated with higher prevalence of PF in this cohort.

American College of Foot and Ankle Surgeons Clinical Consensus Statement: Diagnosis and Treatment of Adult Acquired Infracalcaneal Heel Pain

Adult acquired inferior calcaneal heel pain is a common pathology seen in a foot and ankle practice. A literature review and expert panel discussion of the most common findings and treatment options are presented. Various diagnostic and treatment modalities are available to the practitioner. It is prudent to combine appropriate history and physical examination findings with patient-specific treatment modalities for optimum success. We present the most common diagnostic tools and treatment options, followed by a discussion of the appropriateness of each based on the published data and experience of the expert panel.

Ultrasonographic Characteristics of the Common Extensor Tendon of the Elbow in Asymptomatic Individuals: Thickness, Color Doppler Activity, and Bony Spurs

Background:

Ultrasonography (US) of the common extensor tendon (CET) of the elbow is often part of the assessment of patients with lateral epicondylitis. This US assessment is currently based on general tendinopathy references and not well-defined US entities.

Purpose:

To describe CET thickness, color Doppler activity, and bony spurs on US in asymptomatic volunteers and to investigate the influence of sex, age, height, body mass index (BMI), weight, and elbow dominance on the measurements.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

Tendon thickness, color Doppler activity, and bony spurs of the CET were measured sonographically in 264 adults (50% women) aged 20 to 96 years. Two different tendon-thickness measuring techniques were applied, labeled the “plateau measure” and the “1-cm measure.” Color Doppler activity was based on a 0 to 4 rating scale (negative, grades 0 and 1; positive, grades 2-4). A bony spur was defined as a bony outgrowth (≥0.3 mm) arising at the insertional site of the CET.

Results:

With both tendon-thickness measuring techniques, the CET in the dominant elbow was thicker than that in the nondominant elbow, and male tendons were thicker than female tendons (all P ≤ .03). In regression analysis, tendon thickness correlated with weight, color Doppler activity, and arm dominance for both measuring techniques in multiple regression analysis. In addition, the plateau measure correlated with height and the presence of bony spurs. No correlations were observed regarding BMI, sex, or age. Positive color Doppler activity was found in 9% of examined elbows, with no difference between the sexes regarding dominant versus nondominant elbows (all P ≥.20). Bony spurs were found to increase with age, from 23% for people in their 20s to 74% in people older than 70 years. Bony spurs were more common in the dominant elbow (P ≤ .01). Women had a higher prevalence of bony spurs than men, but only in the dominant elbow (P = .03).

Conclusion:

This study presents the US characteristics and normal values of the CET. In 264 asymptomatic participants, the CET was found to be thicker in men and in the dominant elbow. No difference in tendon thickness could be demonstrated with regard to different age groups. Color Doppler activity was found to be positive in nearly 1 of 10 asymptomatic subjects. Bony spurs were a common finding; they increased in prevalence with every decade in age and were considered part of the aging process. Normal variations in CET morphologic characteristics should therefore be considered when implementing US in trials and clinical practice.

Plantar fascia enthesopathy is highly prevalent in diabetic patients without peripheral neuropathy and correlates with retinopathy and impaired kidney function

BACKGROUND

Aim of this study was to evaluate the prevalence of plantar fascia (PF) enthesopathy in Type 2 diabetes mellitus (T2DM) patients without distal peripheral neuropathy (DPN).

METHODS

We recruited 50 T2DM patients without DPN and 50 healthy controls. DPN was excluded using the Michigan Neuropathy Screening Instrument (MNSI). All patients underwent a bilateral sonographicevaluation of the enthesealportion of the PF.

RESULTS

PF thickness was significantly higher in T2DM patients (p<0.0001). T2DM patients presented a higher prevalence of entheseal thickening (p = 0.002), enthesophyte (p = 0.02) and cortical irregularity (p = 0.02). The overall sum of abnormalities was higher in T2DM patients (p<0.0001), as was the percentage of bilateral involvement (p = 0.005). In a logistic regression analysis, retinopathy predicted entheseal thickening (OR 3.5, p = 0.05) and enthesophytes (OR 5.13, p = 0.001); reduced eGFR predicted enthesophytes (OR 2.93, p = 0.04); body mass index (BMI) predicted cortical irregularity (OR 0.87, p = 0.05); mean glucose predicted enthesophyte (OR 1.01, p = 0.03); LDL cholesterol predicted cortical irregularity (OR 0.98, p = 0.02).

CONCLUSIONS

Our data suggest that T2DM is associated with PF enthesopathyindependently of DPN.

The plantar calcaneal spur: a review of anatomy, histology, etiology and key associations

The plantar calcaneal spur (PCS) is a bony outgrowth from the calcaneal tuberosity and has been studied using various methods including cadavers, radiography, histology and surgery. However, there are currently a number of discrepancies in the literature regarding the anatomical relations, histological descriptions and clinical associations of PCS. Historically, authors have described the intrinsic muscles of the foot and/or the plantar fascia as attaching to the PCS. In this article we review the relationship between the PCS and surrounding soft tissues as well as examining the histology of the PCS. We identify a number of key associations with PCS, including age, weight, gender, arthritides, plantar fasciitis and foot position; these factors may function as risk factors in PCS formation. The etiology of these spurs is a contentious issue and it has been explained through a number of theories including the degenerative, inflammatory, traction, repetitive trauma, bone-formers and vertical compression theories. We review these and finish by looking clinically at the evidence that PCS causes heel pain.

High Prevalence of Achilles Tendon Enthesopathic Changes in Patients with Type 2 Diabetes Without Peripheral Neuropathy

BACKGROUND

Metabolic disorders are known to alter the mechanical properties of tendons. We sought to evaluate the prevalence of asymptomatic Achilles tendon enthesopathic changes in patients with type 2 diabetes mellitus (T2DM) without peripheral neuropathy.

METHODS

We recruited 43 patients with T2DM and 40 controls. Neuropathy was excluded with the Michigan Neuropathy Scoring Instrument. Bilateral ultrasonography of the Achilles tendon enthesis was performed.

RESULTS

Patients with T2DM had a higher prevalence of hypoechogenicity (26.7% versus 2.5%; P = .0001), entheseal thickening (24.4% versus 8.7%; P = .007), and enthesophytes (74.4% versus 57.5%; P = .02). No differences were found in the number of patients with erosions (1.2% versus 0%; P > .99), cortical irregularities (11.6% versus 3.7%; P = .09), bursitis (5.8% versus 3.7%; P = .72), or tears (2.3% versus 1.2%; P > .99). The mean ± SD sum of abnormalities was higher in patients with T2DM (1.5 ± 1.1 versus 0.7 ± 0.6; P < .0001), as was the percentage of bilateral involvement (72.1% versus 45.0%; P = .01). Mean ± SD thickness did not differ between patients and controls (4.4 ± 1.1 mm versus 4.2 ± 0.8 mm; P = .07).

CONCLUSIONS

According to our data, there is an elevated prevalence of asymptomatic Achilles tendon enthesopathic changes in patients with T2DM independent of peripheral neuropathy.

Management of plantar fasciitis in the outpatient setting

Plantar fasciitis is a very common cause of inferior heel pain that can be triggered and aggravated by prolonged standing, walking, running and obesity, among other factors. Treatments are largely noninvasive and efficacious. Supportive treatments, including the plantar fascia-specific stretch, calf stretching, appropriate orthotics and night dorsiflexion splinting, can alleviate plantar fascia pain. While local injections of corticosteroids can help with pain relief, the effects are short-lived and must be weighed against the risk of fat pad atrophy and plantar fascia rupture. Ultrasonography-guided focal extracorporeal shock wave therapy is useful for patients with chronic plantar fasciitis and referrals for this treatment can be made in recalcitrant cases. Activity modification to decrease cyclical repetitive loading of the plantar fascia should be advised during the treatment phase regardless of the chosen treatment modality.

Relationship and Classification of Plantar Heel Spurs in Patients With Plantar Fasciitis

BACKGROUND

This study classified plantar heel spurs and their relationship to plantar fasciitis.

METHODS

Patients included those with plantar fasciitis who were treated from 2012 through 2013. Plantar heel spur shape and size were assessed radiographically and correlated to function and pain before and after treatment. Function and pain were scored with the Foot and Ankle Ability Measures and a visual analog scale, respectively. This study included 109 patients with plantar fasciitis.

RESULTS

The plantar heel spur shape was classified as 0/absent in 26 patients, 1/horizontal in 66 patients, 2/vertical in 4 patients, and 3/hooked in 13 patients. The plantar heel spur size was less than 5 mm in 75 patients, 5-10 mm in 28 patients, and greater than 10 mm in 6 patients. Initially, patients with any shape or size to their spur had no difference in function and pain. With treatment, patients with horizontal and hooked spurs had the greatest improvement in function and pain (P < .05). With treatment, patients with larger spurs had the greatest improvement in function and pain (P < .05).

CONCLUSION

Plantar heel spurs can be classified by shape and size in patients with plantar fasciitis. Before treatment, neither the spur shape nor size significantly correlated with symptoms. After treatment, patients with larger horizontal or hooked spurs had the greatest improvement in function and pain. These findings may be important when educating patients about the role of heel spurs with plantar fasciitis and the effect of nonsurgical treatment with certain spurs.

LEVEL OF EVIDENCE

Level III, comparative series.

Isolated Gastrocnemius Recession for Treatment of Insertional Achilles Tendinopathy: A Pilot Study

INTRODUCTION

Many surgeries exist for treatment of insertional Achilles tendinopathy. Another surgical option to consider is an isolated gastrocnemius recession. Recent studies have demonstrated the success of a gastrocnemius recession for noninsertional Achilles tendinitis. We hypothesize that an isolated gastrocnemius recession can be a successful, effective, and less invasive surgery for patients with chronic insertional Achilles tendinopathy.

MATERIALS AND METHODS

This article presents a retrospective review of one surgeon's results of 11 patients (2010-2012), with an average age of 59 years who presented with chronic insertional Achilles tendinopathy. Gastrocnemius recessions, either endoscopic or open, were performed after an average of 6.2 months of conservative treatment. All patients' radiographs were reviewed preoperatively for any calcaneal spurs and divided into groups accordingly. Average follow-up time postoperatively was 13.8 months. Plantarflexion strength, equinus deformity, as well as the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot instrument was assessed.

RESULTS

In all, 10/11 (91%) patients had high patient satisfaction, pain relief, no residual equinus deformity, loss in muscle strength and returned to regular activities successfully at 1-year follow up. All patients and groups had significant improvement in AOFAS scores. The median postoperative AOFAS score was 94.8. All patients and patient groups had significant improvement pre- to postoperatively. Patients without spurs appear to do better than patients with spurs. One patient developed recurrence of insertional heel pain and equinus deformity. Other complications included 2 sural nerve parasthesias, which resolved.

CONCLUSION

An isolated gastrocnemius recession for chronic insertional Achilles tendinopathy can provide high satisfaction, pain relief, and a faster recovery period with few or no complications.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case series.

Targeting the Plantar Fascia for Corticosteroid Injection

Plantar fasciitis is often a difficult condition to treat. It is related to repetitive strain of the fascia at its attachment to the heel bone. This condition quite often appears with the concomitant presence of a plantar calcaneal heel spur. Corticosteroid injection is a popular treatment choice for plantar fasciitis, and accurate localization of the injected medication is essential for successful resolution of symptoms after the injection. In the present brief technical communication, a method for targeting the attachment of the plantar fascia to the medial tubercle of the tuberosity of the calcaneus is described. The targeting method uses the lateral radiograph of the foot to aid in localization of the proximal attachment of the plantar fascia to the calcaneus.