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Many people claim heel spurs to be an abnormal finding. However, research dating from the early 60’s to late 90’s have reported anywhere from 11-16% of the general population to have some type of heel spur.
It’s debatable if heel spurs are strongly correlated to older age, gender and osteoarthritis. However, the debate linking heel spurs and pain has progressed to treatment involving shock wave therapy, surgical incision and even radiation therapy
The Debate: Traditionally the pathophysiology of spurs forming was based on what was called the longitudinal traction hypothesis.
Why the Traction Theory?: It was thought; the plantar fascia’s insertioncreates traction and thus develops inflammation. Now from this inflammation reactiveossification is formed in the plantar fascia’s enthesis leading to theformation of a spur. Studies started to support this theory with the link offlatfooted people and heel pain. It was believed having a lower longitudinalarch created tension and thus the pain was created. Evidence for a Non TractionTheory:1) Heel spurs have been found to be located deepto the plantar fascia rather than at its insertion point. Heel spurs have also beenshown to be closely related to other muscle insertions such as the quadrates plantae,flexor digitorum brevis and abductor hallucis. Some heel spurs are not evencorrelated to muscle insertions but rather found within fibrocartilage andloose connective tissue.2)Excised plantar fascia doesn’t show histological evidence of inflammation3) Bony trabeculae have not beenfound to align in a direction of traction4) Excised spurs have been shown toreform after a surgical released plantar fascia.The alternative theory:Anothertheory can be one of vertical compressionhypothesis (Kumai & Benjamin) which purposes a heel spur is due tocompressive forces rather than traction. They suggest heel spurs are fibrocartiligenousovergrowths that occur in response to a microscopic stress fracture. Theseovergrowths are simply the calcaneus’s way of protecting itself from microcracks.Support: Heel spurs are more common in subjects which areoverweight and have decreased elasticity in their fat pads. Furthermore, histologicalstudies on cadavers have shown bony trabeculae of spurs to be verticallyaligned as if compensating for a compressive force. Theresearch: A recent study involving 216 subjects foundfurther support for a compressive hypothesis. Subjects were over the age of 62and had either a heel or achilles spur. The spurs were found to be correlatedto obesity (BMI), osteoarthritis and pain. However, there was no significantcorrelation found with foot posture (x-ray measures).Obese and OA findings indicate compressiveforces may be involved. The lack of foot posture being correlated alsostrengthens the argument. If traction was the main culprit all those withflatfeet would have been strongly linked. Torebuttal those studies which also link obesity and a low longitudinal arch thisfactor may be argued to be more so related to the biomechanical properties of pronation. The findings of pain don’t really indicateeither theory. This again strengthens the whole controversy of what actuallycauses the pain from a heel spur. Is it the spur itself or the soft tissuearound it?Whatabout the anatomy? Studies have found almost any variation of wherea heel spur can lie in the foot anatomically. However, the more recent researchsupports a theory of compression where heel spurs are not always found withinthe plantar enthesis. The most recent study inspected 37 spurs in 20cadavers. Multiple variations were found using different forms of imaging. Thisstudy purposed that the cause of a spur isn’t necessarily traction and muchmore complex then probably previously thought. They found spurs to form whensurrounded by loose connective tissue. Furthermore, those spurs aligned withthe plantar fascia’s enthesis didn’t always have a bony trabeculae patternwhich replicated a cause of traction forces. Some heel spurs had a basket weavelike patterns. Thispattern supports wolfs law regarding bony articulation taking on the form ofdynamic stress. In summary, we now have strong implication to believe heelspurs are more so due to compressive forces. The clinical significance of thesefindings is significant. One has to find the cause of a diagnosis before aimingto treat it. If the traction hypothesis is correct one may aim to limit suchforces by releasing the plantar fascia with stretching, aggressive soft tissuetherapy of surgical incision. However, if due to compressive forces one may aimto treat the injury like a stress fracture focusing on relative rest and anorthotic designed to decrease forces. Dr. Wayne Button, BSc, D.CLi, J., & Muehleman, C. (2007). Anatomic relationship of heel spur to surrounding soft tissues: Greater variability than previously reported Clinical Anatomy, 20 (8), 950-955 DOI: 10.1002/ca.20548Li, J., & Muehleman, C. (2007). Anatomic relationship of heel spur to surrounding soft tissues: Greater variability than previously reported Clinical Anatomy, 20 (8), 950-955 DOI: 10.1002/ca.20548Menz, H., Zammit, G., Landorf, K., & Munteanu, S. (2008). Plantar calcaneal spurs in older people: longitudinal traction or vertical compression? Journal of Foot and Ankle Research, 1 (1) DOI: 10.1186/1757-1146-1-7
Evidence for a Non TractionTheory: 1) Heel spurs have been found to be located deepto the plantar fascia rather than at its insertion point. Heel spurs have also beenshown to be closely related to other muscle insertions such as the quadrates plantae,flexor digitorum brevis and abductor hallucis. Some heel spurs are not evencorrelated to muscle insertions but rather found within fibrocartilage andloose connective tissue. 
2)Excised plantar fascia doesn’t show histological evidence of inflammation
Support: Heel spurs are more common in subjects which areoverweight and have decreased elasticity in their fat pads. Furthermore, histologicalstudies on cadavers have shown bony trabeculae of spurs to be verticallyaligned as if compensating for a compressive force. 
Theresearch:
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