Injection Technique for Calcaneal Spurs

Indications and Clinical Considerations

Calcaneal spurs are a common cause of heel pain. When symptomatic, they usually are found in association with plantar fasciitis. Calcaneal spurs are most commonly formed at the insertion of the plantar fascia on the medial calcaneal tuberosity but can occur anywhere along the calcaneal tuberosity ( Figs. 190.1 and 190.2 ). Calcaneal spurs usually are asymptomatic, but when they cause pain, it is usually a result of an inflammation of the insertional fibers of the plantar fascia at the medial tuberosity. As with plantar fasciitis, calcaneal spurs can occur alone or can be part of a systemic inflammatory condition, such as rheumatoid arthritis, Reiter syndrome, or gout. In some patients, the cause seems to be entirely mechanical, and often such patients exhibit an abnormal gait with excessive heel strike. High-impact aerobic exercise also has been implicated in the evolution of calcaneal spurs ( Fig. 190.3 ).

The pain of calcaneal spurs is most severe on first walking after not having borne weight and is made worse by prolonged standing or walking. Characteristic radiographic changes are lacking in both calcaneal spurs and plantar fasciitis, but radionuclide bone scanning may show increased uptake at the point of attachment of the plantar fascia to the medial calcaneal tuberosity in both painful conditions.

On physical examination, the patient exhibits point tenderness over the plantar medial calcaneal tuberosity ( Fig. 190.4 ). The patient also may have tenderness along the plantar fascia as it moves anteriorly. The pain of calcaneal spurs is increased by weight bearing and relieved by padding of the affected heel.

Plain radiographs are indicated for all patients with pain thought to be emanating from calcaneal spurs to rule out occult bony disease and tumor ( Fig. 190.5 ). On the basis of the patient’s clinical presentation, additional testing may be indicated, including complete blood cell count, prostate-specific antigen, sedimentation rate, and antinuclear antibody testing. Magnetic resonance imaging of the foot is indicated if calcaneal spurs, occult mass, or tumor is suggested ( Fig. 190.6 ). Radionuclide bone scanning may be useful to rule out stress fractures not seen on plain radiographs. The injection technique described later serves as both a diagnostic and a therapeutic maneuver.

Clinically Relevant Anatomy

The calcaneus is the largest of the tarsal bones ( Fig. 190.7 ). The main function of the calcaneus is to transfer the weight of the body to the ground and to serve as a lever for the muscles of the calf. The plantar surface of the calcaneus is elevated posteriorly to form the calcaneal tuberosity, which is depressed centrally with a lateral and medial process. It is at the medial process that symptomatic calcaneal spurs most commonly occur. The plantar fascia is made up of thick connective tissue tightly attached to the plantar skin. The plantar fascia attaches to the medial calcaneal tuberosity and then runs forward, dividing into 5 bands, 1 going to each toe.