We have previously considered risk factors and treatment of plantar fasciitis (PF for short, though we should really call it fasciopathy). Over the years I have talked to many people (patients, and otherwise) who have plantar fasciopathy and they tell me that their doctor said that it was caused by a bone spur. I have heard the same logic with rotator cuff tears at the shoulder. This logic is often used to recommend surgery to patients that have “failed” conservative treatment. This logic brings two thoughts to my mind:

Did the physical therapist treat and dose correctly? How does this affect your doctor’s recommendation?

First, what do you define as “failed”? To answer that, I think we should consider a couple of sub-questions: Is this the right treatment, has it been appropriately dosed (time, amount, etc). In many cases, it’s important to remember that there may be multiple types of ‘conversative’ (I.e., non-surgical) treatments available. Some gold standard treatments may offer short- or medium-term relief, whereas others provide long-term relief. These should be the go-to treatments, and need to be used for a long enough period to allow true healing. However, in a 24/7 society, we are often impatient and want quick results (even if only short-term). It is common for doctors to prescribe conservative treatment for a patient, with a follow-up in 4 or 6 weeks. If the symptoms have not resolved in that time, surgery is offered as the only remaining option. But in many cases, the pain has been developing over the course of many months prior to the patient seeing the doctor, and for problems such as PF and tendinopathy, we know that healing has to occur at a tissue level, and they will take time. As such, I do not feel it makes sense for a patient to return to their doctor after only four weeks of conservative care like we often see. The reality is that any relief seen in that short space might not last (might be from a quick fix or even placebo effect), or we might not be seeing far enough along to see the greater relief that comes in the mid to late term. If this is the case there is the potential for people to be classed as having “failed” rehab when they have hardly scraped the surface, leading to surgery, when appropriate conservative (and low risk)  treatment could have helped if given enough time.

An x-ray from case study of a bone spur in the 1910 Cleveland Medical Journal. This guy had plantar heel pain and they removed this big hook of a bone spur. It mentioned he had some relief, but as far as I know we do not know the long term result. Does the evidence support removing these bone spurs, and does the size matter?

Secondly, we should ask, “Does the bone spur really cause problems?” I come to this point having seen people recover from plantar fasciopathy and rotator cuff tendinopathy without anything being done to the spur. Some people will say that the treatment (strengthening, or whatever else) has taken load off the spur, but no studies have shown this to be the case. Instead, it increasingly appears that bone spurs should be classed as anatomical variation. The fact that your healthcare provider finds a spur on your x-ray when you are in pain is relatively meaningless, as it could have been existing uneventfully for the past 20 years. Counter to previous opinions, a new study¹ found that people who had larger (>5mm) bone spurs had better outcome from conservative care on their pain and function than those will smaller spurs. They also found that shape of the spur did not affect the outcome. This is in disagreement with patients being told that the spur is hooked and that is why they have the problem. These two facts suggest that just the presence of a bone spur should not lead to a rush to surgery, but supports the opinion that surgery should only be considered in patients where pain persists for for an extended period of time. I have met many patients over my career who have wished they did not have surgery, or worse felt railroaded into it, as the removal has not given them either relief or resolution.

Recommendations:

• Don’t be afraid to ask your provider what the evidence is for a treatment. Their answer may help you to know if they are the right provider for you.
• If the treatment seems plausible, and has evidence, make sure you give it the time the provider recommends, not an arbitrary time based on your next follow up.
• Bones spurs, much like disc bulges in the spine, are considered to be variations of normal anatomy. This is one reason to avoid imaging unless really necessary so this is not in the back of your mind or the front of the provider’s mind! Do not let these findings direct you towards an unnecessary surgery.

Reference:

1. Ahmad J, Karim A, Daniel JN. Relationship and Classification of Plantar Heel Spurs in Patients With Plantar Fasciitis. Foot Ankle Int. 2016;37(9):994-1000.

Photo credits:

1. Internet Archive Book Images via Foter.com / No known copyright restrictions
2. Army Medicine via Foter.com / CC BY