Special Operations Forces Medical Handbook

5-1

PART 5: SPECIALTY AREAS

Chapter 9

Podiatry: Heel Spur Syndrome

(heel spur, heel bursitis, plantar fasciitis)

CDR Raymond Fritz, MSC, USNR

Introduction: Heel spur syndrome is one of the most common foot problems seen in the special operations
community. The term "heel spur syndrome" refers to any to heel pain with or without a spur that typically
develops from excessive repetitive strain on the plantar fascia. The plantar fascia is loaded when weight
is applied (standing), causing pain along the plantar fascia, particularly where the fascia connects to the
heel tubercle. This condition is often a tolerable nuisance but it may be painful enough to make ambulation
difficult. Chronic conditions may last for years if not properly treated. More than 90% of the cases in military
personnel are due to faulty foot mechanics and increased activity demands.

Subjective: Symptoms
Insidious onset of heel pain, most severe in the morning or when standing up; may acutely follow an injury;
pain can be bilateral.

Objective: Signs
Using Basis Tools: Point tenderness over medial tubercle of the calcaneus at the level of the plantar fascial
attachment, which may radiate distally causing pain and swelling in the arch; more common in pronated
foot type but heel pain can present in a high-arch foot type; distant symptoms due to compensatory gait
changes; tight Achilles tendon.
Using Advanced Tools: X-rays: Spur presents 60% of the time; fracture, bone cyst or arthritic changes
may be noted to explain symptoms.

Assessment:
Differential Diagnosis
Bursitis - palpate tenderness (inflamed bursa) directly below the calcaneal tubercle.
Nerve entrapment - point tenderness over nerve; pain radiating into heel; positive Tinel’s sign.
Tarsal tunnel syndrome - compression of the posterior tibial nerve; positive Tinel’s sign.
Referred pain from low back - L-4 L-5 extends to the heel as part of the area of distribution for this nerve root
level; EMG/nerve conduction studies are helpful for diagnosis of nerve related heel pain.
Stress fracture - diagnose on x-ray; not common in calcaneous
Foreign body - usually an entrance portal visible
Arthritis (Reiter’s, psoriatic, ankylosing spondylitis, rheumatoid) - See Symptom: Joint Pain section.

*Tinel’s sign is pain radiating distally along the course of a nerve.

Plan:
Treatment
Primary:

1. Conservative: Ice (not heat) massage, Achilles stretching, heel pad (foreign body, bursitis, arthritides).
   a. Ice massage: Use ice directly on heel and arch but limit to 8-10 minutes 4-6 x day; use Dixie cup
   technique or frozen plastic water bottle or gel pack if available.
   b. Dixie cup technique when freezer available: Fill cup with water and freeze. Keep several ice cups on
   hand. Tear cup down to expose ice and use as an applicator to heel area.
   c. Achilles tendon stretching: Any limitation in ankle dorsiflexion increases force on plantar fascia.


2. Rest strap: Tape the foot to support the arch


3. Remove any splinter, glass or metal when the operational tempo permits.