Heel Spur Surgery: Everything You Need to Know
- Updated on: 2020-11-03
- Read original article here
Calcaneal spur reduction is a procedure used to remove heel spurs—painful outgrowths on the heel bone (calcaneus) that cause pain, inflammation, and swelling. Heel spur surgery is done when conservative therapies fail to provide relief. There are two approaches to the surgery: one that targets inferior spurs on the bottom of the heel and another that targets posterior spurs on the back of the heel.
Heel spur surgery can be highly effective, but it may take up to three months for some patients to fully recover.
What Is Heel Spur Surgery?
Heel spur surgery describes two different procedures that can be performed as either open surgery (involving a scalpel and large incision) or endoscopic surgery (using "keyhole" incisions with a narrow scope and operating tools).
Inferior heel spur resection: Inferior heel spurs typically develop in the presence of plantar fasciitis (inflammation of the plantar fascia ligament, located on the bottom of the foot) and are often referred to as plantar fasciitis bone spurs.1 In many cases, the removal of spurs will immediately follow plantar fasciotomy (also known as plantar fasciitis release surgery). Once the ligament is partially or fully severed ("released"), the surgeon will remove any large or suspect spurs.
Posterior heel spur resection: This less common approach targets posterior heel spurs located near the Achilles tendon on the back of the foot. Posterior heel spurs, also referred to as Achilles bone spurs, generally develop at the point where the tendon attaches to the heel bone. In addition to the heel, it is not uncommon for spurs to develop in the tendon itself. Simple spurs on the bone are relatively easy to remove, but those imbedded deep in the Achilles tendon may require the detachment and reattachment of the tendon (Achilles tendon repair), making spur resection more complicated.2
Heel spur surgery is performed on an outpatient basis, allowing you to return home as soon as the surgery is complete. Depending on the aims of the surgery and other factors, the procedure may involve local, regional, or general anesthesia.
According to research, heel spur surgery is effective in around 69% of cases, with another 25% reporting a moderate improvement of symptoms.3
When to See a Doctor About Heel Pain
Contraindications
There are few absolute contraindications to heel spur surgery. The surgery should be approached with caution in people with severe bleeding disorders, diabetes co-occurring with peripheral artery disease, or a history of deep vein thrombosis (DVT). These relative contraindications need to be assessed on a case-by-case basis.4
One absolute contraindication for heel spur surgery is the absence of symptoms. If a spur is accidentally found on an X-ray, it should not be removed just because it is there. Doing so not only exposes the individual to unneeded surgery but may cause serious and potentially permanent injury.
Understanding the Risks of Surgery
Potential Risks
As with all surgeries, there are risks associated with heel spur surgery, including the use of anesthesia. Common complications specific to this procedure include:
Temporary or permanent heel pain
Temporary or permanent nerve injury (including foot numbness)
Acquired pes planus (fallen arches) and flat-footedness
Tendinitis (tendon inflammation)
Metatarsalgia (pain in the ball of the foot)
Foot cramps
Foot instability
Development of hammertoes or claw toes (due to the contraction of the plantar fascia ligament)
Heel fractures5
Complications from heel spur surgery are more common with open surgery, occurring a 3.7-fold increased rate compared to endoscopic surgery. With that said, open surgery is better able to remove the entire spur compared to an endoscopic approach.6
What Could Be Causing My Foot Pain?
Purpose of Heel Spur Surgery
Heel spurs are essentially the abnormal accumulation of calcium, most commonly caused by repetitive foot strain. Repeated injury can lead to changes in the foot as scar tissue develops and calcium released from microfractures and bone degeneration begins to accumulate into bony outgrowths.7
The size or shape of a spur has nothing to do with the incidence or severity of symptoms. Large spurs can often cause no pain, while tiny ones can cause excruciating pain and extreme loss of mobility.8
Heel spur surgery is not used because a bone spur is large—or simply because it's there—but rather because it is causing refractory (treatment-resistant) pain.
Luckily, more than 90% of people with heel spurs experience spontaneous recovery without surgery.7 By committing to a holistic, non-surgical treatment plan, you may find that your heel spur symptoms resolve on their own. It's when they don't that surgery can play a role in treatment.
Heel spur surgery is generally considered a last resort, and the American College of Foot and Ankle Surgeons (ACFAS) recommends it be considered if symptoms fail to resolve with non-surgical treatments after 12 months.
In some cases, the pain is not associated with the spur itself but the condition that gave rise to it. Heel spurs associated with plantar fasciitis do not point downward but rather forward toward the toes. Because of this, the pain in the heel is usually not caused by the spur but rather the persistent inflammation of the ligament at its attachment point at the heel.1 Such heel spurs may be removed anyway when a surgeon suspects that they could be (or become) problematic.
How Heel Spurs Are Treated
Pre-Operative Evaluation
Heel spurs are most easily detected on X-ray while standing. Even if spurs are identified, every effort should be made to ascertain whether the pain is the result of the spurs or an associated condition. Heel spur surgery is not only difficult to recover from but can cause more problems than it solves if not used appropriately.
The presence of a spur, even a large one, doesn't necessarily mean that it is the cause of the pain. Consulting with an experienced podiatric surgeon or foot and ankle orthopedist is essential to getting a correct diagnosis. Either one of these specialists can perform the surgery, if needed.
Heel spur surgery is often considered when heel spurs are accompanied by severe plantar fasciitis or Achilles tendinitis (both of which may benefit from surgery).9
On the other hand, there may be "clues" that cast the viability of heel spur surgery into doubt. One such example is bilateral heel pain, in which the pain in both heels may be the result of systemic diseases or infections rather than any spurs the doctor may find.10
To this end, doctors will typically conduct a differential diagnosis to exclude other possible causes before heel spur surgery is recommended. These may include:
Achilles tendon rupture
Bone tumor
Bursitis (joint inflammation)
Haglund's deformity (protrusion of the heel bone)
Osteomyelitis (a bone infection)
Paget's disease of bone
Reactive arthritis (caused by a systemic infection)
Rheumatoid arthritis (autoimmune arthritis)
Sarcoidosis of bone or joints
How to Prepare
If heel spur surgery is recommended, you will meet with the surgeon to review the lab and imaging reports and discuss how the operation will be performed. You will also discuss pre-operative and post-operative procedures you need to follow to better ensure the intended result.
The surgical approach used will be determined by the underlying cause and location of a spur. Neither procedure is inherently "better" than the other at providing relief, although recovery times tend to be shorter with endoscopic surgery.
Do not hesitate to ask the surgeon why a particular surgery was chosen. While open surgery is associated with a greater risk of complications, there may be reasons why it is a better approach in your case. Keep an open mind and seek a second opinion if needed.
Important Questions to Ask Before Surgery
Location
Heel spur surgery is performed in the operating room of a hospital or specialty surgical center. The operating room will be equipped with standard surgical equipment, including an anesthesia machine, surgical table, an electrocardiogram (ECG) machine to monitor your heart rate, and a mechanical ventilator to deliver supplemental oxygen if needed.
For endoscopic surgery, there will also be a rigid fiberoptic scope called an endoscope that delivers live images to a video monitor. Specialized surgical equipment that can access the foot through tiny incisions will also be there.
What to Wear
Depending on the extent and location of the surgery, your foot may be bandaged, placed in an ankle splint or walking boot, or covered with a cast afterward. To accommodate for this, wear baggy shorts or loose-fitting pants (e.g., yoga or pajama bottoms) that slip easily over the foot. Skirts also work, or you can cut the side seam of an old pair of pants to widen the leg opening.
In addition to changing into a hospital gown before surgery, you will be asked to remove contacts, hairpieces, dentures, hearing aids, and tongue or lip piercings prior to the surgery. Leave any valuables at home, including jewelry and watches.
Food and Drink
You will be advised to stop eating at midnight the night before your procedure. On the morning of the surgery, you can take a few small sips of water to take your morning medications. Within four hours of surgery, you should not consume any food or liquid.
Medications
Your doctor will advise you to stop taking certain medications that promote bleeding and slow wound healing, including anticoagulants (blood thinners) and nonsteroidal anti-inflammatory drugs (NSAIDs).
You may need to stop taking certain drugs for anywhere from one day to two weeks before surgery and discontinue use for up to a week or two after surgery.
Among the drugs commonly avoided prior to surgery:
Aspirin
Advil or Motrin (ibuprofen)
Aleve (naproxen)
Celebrex (celecoxib)
Coumadin (warfarin)
Herbal remedies like garlic tablets, ginkgo biloba, and dan shen
Mobic (meloxicam)
Plavix (clopidogrel)11
To avoid drug interactions and complications, always let your doctor know about any medications you are taking, whether they are prescription or over-the-counter. The same goes for herbs and supplements.
What to Bring
You will need to bring your driver's license (or some other form of government ID), your insurance card, and an approved form of payment if copay or coinsurance costs are required upfront. (Be sure to call the office beforehand to confirm that they accept your insurance and are in-network providers.)
You will also need to bring someone to drive you home and, ideally, to stay with you for a day or two to help you out and monitor for any adverse symptoms.
What to Expect on the Day of Surgery
Depending on the scope of the operation, the surgeon may be accompanied by an anesthesiologist, operating nurse, endoscopic technician, and surgical scrub.
How to Find the Best Podiatrist
Before the Surgery
Upon your arrival at the hospital or surgical facility, you will register, fill out medical information forms, and sign consent forms confirming that you understand the aim and risks of the surgery. You will then be led to the back to change into a hospital gown.
A nurse will take your weight, height, vital signs, and a sample of blood to check your blood chemistry. An intravenous (IV) line is then inserted into a vein in your arm to deliver medications and fluids. (Even if the procedure is performed under local anesthesia, an intravenous sedative is typically used to induce "twilight sleep.")
In addition, EGC leads are attached to your chest to monitor your heart rate, while a pulse oximeter is clamped to your finger to monitor your blood oxygen levels.
During the Surgery
Once you are prepped, you are wheeled into the operating room. The appropriate form of anesthesia will be administered:
If general anesthesia is used, the medications are delivered through the IV line to put you completely to sleep.
If regional anesthesia is used, the anesthetic may be injected in the spine (spinal epidural block) or a shallow bundle of nerves behind the knee called the popliteal fossa. An intravenous sedative, also known as monitor anesthesia care (MAC), typically accompanies the regional block.
If local anesthesia is used, it is delivered by injection in and around the surgical site. MAC is also commonly used.
You will be positioned on the surgical table in either a supine (downward-facing) or lateral decubitus (sideways-facing) position, depending on how the heel spur(s) are best approached.12
The open or endoscopic procedure is then performed:
Open reduction: An incision is made either along the bottom of the foot (to access a plantar bone spur) or down the back of the heel (to access an Achilles bone spur). If plantar fasciotomy or Achilles tendon repair is needed, it is performed first. The heel spurs can then be cut away in a secondary procedure, flush to the bone.8
Endoscopic reduction: For this procedure, a tiny incision (usually about an inch in length) is made on the side of the heel to insert the endoscope. A second incision is made to insert a cutting instrument to reduce the spur. Because endoscopic surgery does not remove as much of a spur, it is generally reserved for combination surgeries in which heel spurs are involved.13
Finally, the incision is closed with sutures or adhesive strips, and the foot is bandaged. An ankle splint, walking boot, or a cast may be used to immobilize the foot and/or ankle if needed.
After the Surgery
After the surgery is complete, you are wheeled into recovery and monitored by a nurse until you awaken. This can take anywhere from 10 minutes for local anesthesia with IV sedation to 45 minutes for general anesthesia. Food and drink are usually provided when you are fully awake.
It is not uncommon to experience pain and discomfort around the surgical site. You will be given the appropriate painkiller and a nurse will administer anti-nausea medication if you feel ill from the anesthesia.
Once your vital signs normalize and you are steady enough to change into your clothes, you can be taken home by a friend or family member.
The doctor will give you a prescription for a short course of an opioid like Vicodin (hydrocodone plus acetaminophen) to help you manage pain.
Recovery
When you arrive home from surgery, you should relax for the rest of the day with your foot propped up on pillows. Do not bathe or shower for the first day.
If there is any pain, you can either take Tylenol (acetaminophen) or the pain medication prescribed by your doctor. If there is any pain, bruising, or swelling, you can apply an ice pack to the affected area for no more than 15 minutes several times a day. Do not apply the ice directly to the skin.
Stay off your feet as much as possible for the first few days after surgery as well. To avoid placing any strain on the foot, your doctor may provide you with a pair of crutches or a hands-free knee crutch. Use whatever is provided, even if you feel confident without it.
Until the wound is amply healed and the stitches removed, you will need to keep the foot dry. This applies whether you are icing the area or washing yourself. When showering, you can either cover the foot with a plastic bag (secured with a rubber band) or ask your doctor about using a watertight cast cover.
The wound dressing should be changed daily with sterile gauze and an alcohol-free topical antiseptic. Check daily for any abnormal changes in the wound or skin.
When to Call Your Doctor
Call your surgeon if you experience any of the following after undergoing heel spur surgery:
Increasing pain, redness, and swelling around the incision site
High fever (100.5 degrees F) with chills
A yellowish-green and/or foul-smelling ooze from the wound
Nausea and vomiting
Wound dehiscence (an opening incision)
10 Ways to Recover Faster From Surgery
Healing
After seven to 10 days, you will visit your surgeon to have the sutures removed and check on how your wound is healing. An X-ray or computed tomography (CT) scan may also be ordered, especially if other procedures were performed along with heel spur removal.
Based on the findings, the doctor will have a better idea of your prognosis and the appropriate rehabilitation plan. If needed, you may be referred to a physical therapist.
The duration of rehabilitation varies not only by the surgery used but your general health and adherence to the treatment program. Broadly speaking, it takes around six weeks to recover from plantar heel spur surgery and up to three months for Achilles heel spur surgery with tendon repair.14
Most people with office-based jobs can return to work in two weeks with a walking boot or crutches. Those who work on their feet may need to wait for at least four weeks unless their doctor says otherwise.
How Long Will Recovery From Surgery Take?
Coping With Recovery
Your surgeon will want to see you again when it is time to have your cast removed or to step you down from crutches to a walking boot.
As you are gradually stepped down to walking shoes, physical therapy may again be needed to teach you how to walk correctly and how to stretch your arches to compensate for any tissue retraction.
During the recovery period, it is not unusual to feel pain and aggravation as you challenge muscles and tissues that have laid dormant for weeks. With persistence and adherence to your rehabilitation plan, you will improve. Support from family and friends can help this process tremendously.
During follow-up appointments, your doctor will want to check for improvements in your symptoms. Not everyone who undergoes heel spur surgery experience the complete resolution of symptoms, but many do. Be patient with your body as it heals.
Possible Future Surgeries
If you still have pain, inflammation, and swelling after rehabilitation, let your doctor know. In some cases, revision surgery may be needed. At other times, further investigations may be needed to explore other possible explanations for your symptoms.
A Word From Verywell
Surgery is a less common treatment for heel spurs but one that may be necessary if nothing else is able to relieve pain and loss of mobility. Even so, heel spur surgery is not a "quick fix."
Before seeking heel spur surgery, ask your doctor if all treatment options have been explored, including therapeutic ultrasound and extracorporeal shockwave therapy (ESWT). At the same time, ask yourself if you have been adherent to your doctor's treatment recommendations, including routine exercise, weight loss, and the consistent use of night splints and orthotics.
