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A heel spur is often used to describe the bony extension on the undersurface of the heel bone (inferior calcaneum). Sometimes it is used to describe the bony growth at the back of the heel (posterior calcaneum). The latter is due to insertional Achilles tendinopathy.
Patients often come to The London Foot and Ankle Clinic having been told that they have a heel spur which is the cause of their heel pain.
This was in the past thought to be the cause of plantar fasciitis but has now been disproven. A large proportion of the population has a “heel spur” and it is now seen as an incidental finding and nothing else.
No treatment is required for an inferior calcaneal heel spur.
Please visit insertional achilles tendinopathy for information regarding treatment of posterior calcaneal heel spurs.
A – Normal x-ray of the foot and ankle B – x-ray of a patient with a posterior and inferior calcaneal heel spur
Heel pain pain is a very common presentation at The London Foot and Ankle Clinic.
It can cause severe discomfort, restrict sports and exercise and significantly affect quality of life.
While plantar fasciitis and Achilles tendon problems account for most cases of heel pain, there are many other conditions that can result in similar symptoms.
Many patients with chronic symptoms who fail to respond to treatment may have other pathology present as well. At The London Foot and Ankle Clinic we make sure to make the right diagnosis.
The following are causes of “heel pain”:
For symptoms, investigations and treatment please find further information under the specific condition page.
Common causes of heel pain
Hammer toe is the commonest type of lesser toe deformity.
Before describing the deformity, you may wish to read about the normal anatomy of the lesser toes here.
In a hammer toe the normal anatomy is distorted.
There is flexion of the PIP joint, with an extension deformity at DIP and MTP joint. With severe deformity the toe can also be dislocated at the MTP joint.
Hammer toe deformity
In the early stages of the condition the toe may still remain flexible and the deformity correctible on passive manipulation of the toe. As the condition progresses the deformity becomes fixed.
Hammer toe deformity in both 2nd and 3rd toes
It is most common in elderly females and affects usually the second toe. It can however affect male and female of any age. It often is associated with a bunion deformity.
Hammer toe deformity in a patient with a bunion
A number of mechanisms have been implicated in the formation of hammer toe deformity. As with claw toe deformity there is an imbalance in the muscles that control toe movement. The powerful extrinsic muscles (in the leg) that straighten (extensor) and bend (flexor) the toe are not balanced by the intrinsic muscles (in the foot) which are too weak or under active.
Wearing tight shoes and high heels may be a risk factor. Having a long 2nd metatarsal may alter the normal foot biomechanics causing 2nd MTP joint overload with synovitis (inflammation of the joint) and subsequent joint deformity. Hammer toe is also associated with rheumatoid arthritis and diabetes. Wearing shoes that are too short for the toes in particular a long 2nd toe, high heels and a narrow toe box resulting in crowding of the toes can also be a risk factor for developing hammer toe deformity.
Problems with the big toe such as a bunion (Hallux Valgus) or 1st MTP joint arthritis (Hallux Rigidus) are also associated with 2nd MTP joint overload and subsequent instability which can result in a hammer toe deformity. This occurs in the latter two because the big toe joint (1st MTP) does not work properly. In a normal foot the 1st MTP joint takes roughly 40-50% of the load as you walk. This load is transferred to the 2nd MTP joint and to varying degrees the other lesser toes. As the 2nd toe joint is not designed to take this load, damage can occur at the 2nd MTP joint with synovitis initially. There then follows joint capsule distension, plantar plate and collateral ligament attenuation. Please read about 2nd metatarsal instability for more details.
Tight calf muscles (gastrocnemius) are not known to cause hammer toe deformity, however we mention it as it can exacerbate the problem. Tight calf muscles result in an increase load across the front of the foot, this puts more strain on already damaged structures such as the plantar plate ligament. Addressing calf tightness is important in the treatment of hammer toe.
In summary the following are associated with the development of a hammer toe deformity:
Pain is the main symptoms. It can arise due to a number of reasons:
Pain is by far the commonest symptom of hammer toe deformity. Pain may be felt in the “ball” of the toe (MTP joint), on the plantar (sole) aspect of the foot. Pain may also be felt across the dorsum (top) of the foot at the MTP joint. People with hammer toe may also have corns or calluses on the top of the middle joint (PIP) of the toe or on the tip of the toe where there is rubbing or pressure against shoes. They may also feel generalised pain in their toes or feet and have difficulty finding comfortable shoes.
Rubbing against shoes often causes pain in the second toe and breakdown of the skin (ulcer formation)
Thickening of the skin (callosity) under the MTP joint is typically a manifestation of increased load and forces going through the joint. The callosity maybe painful and attempts to remove it will be temporary as the skin will thicken again in response to the abnormal load.
Clinical picture of a focal callosity under the 2nd MTP joint and at the tip of the 3rd toe
Investigations are not necessary to make the diagnosis.
Radiographs will be arranged at your initial clinic consultation. These will help confirm the diagnosis, the severity of the deformity and aid in pre operative planning.
Lateral foot radiograph (x-ray) demonstrating severe hammer toe deformity with dislocation at the MTP joint
Hammer toe is a condition that can get worse over time.
The deformity can be flexible and passively correctible in the early stages but with time it can become fixed. The deformity can also increase and the toes finally dislocate at the MTP joints.
Complications include painful callosities and ulcers (a break in the skin) which can become infected.
Infected ulcer on the dorsum of the toe caused by rubbing against shoes
A painful callosity
Non-operative management aims at relieving pain and limiting deformity progression. It is likely to be most effective in the early stages of the condition. It should always be the first line treatment. Options include:
Made of silicon can be worn over the toe to protect from direct pressure and rubbing against footwear.
Position the toe in neutral alignment using cross over taping or toe straps. Provide stability to the joint and alleviate symptoms. If the deformity is of recent onset, one can use pads over the corns.
A custom insole with plenty of padding can take some of the pressure off the joint and alleviate the pain. A metatarsal bar insole may also provide symptomatic relief.
Hammer toe splints are commercially available that can help maintain the toes in a corrected position.
The use of non-steroidal anti-inflammatory drugs (NSAIDs) can decrease discomfort from an inflamed synovitic MTP joint.
The use of stiff soled shoes that do not bend and therefore protect the MTP joint. Wearing a shoe with a wide and deep toe box.
Stretching tight calf muscles will help reduce the forces going across the forefoot. This will help reduce pain in the MTP joint.
Dynamic intrinsic muscle exercises. These exercises may limit the progression of claw toe deformity. For details regarding intrinsic foot muscle exercises please click here.
Surgical management is reserved for patients who have failed to respond to non operative treatment.
Patients should understand that the decision to undergo surgery should not be taken lightly.
Any intervention is considered in a step wise manner, with the least invasive procedure carried out first.
A variety of surgical options exist which need to be tailored to the individual and the stage of the disease. Often a combination of procedures is performed. Because the deformity results from a muscle imbalance, tendon transfer or lengthening may be needed in order to achieve a correction and minimise the risk of recurrence. When planning surgery it is important to note whether the deformity is fixed or flexible.
A bunion must be corrected prior to correction of the hammer toe deformity. The bunion can be thought of as the “cause” and the hammer toe the “effect”. Not correcting the bunion will most likely result in a less successful outcome or recurrence following surgery.
The most common procedures that may be used in combination with others include:
The aim of surgery is to correct the deformity, alleviate pain and return a patient to full function.
Before (left) and after (right) radiographs of a bunion and hammer toe deformity correction with temporary K-wire
Hammer toe deformity being corrected using MIS technique
Before (left) and after (right) radiographs demonstrating a hammer deformity correction, note the 2nd toe is no longer elevated
It should be borne in mind that complications can result from a condition with or without surgery.
Clinical photograph of an ulcer that developed over the PIP joint after a patient with hammer toe deformity opted for non operative treatment
Complications can occur as with any type of surgery. Please see Complications for more detailed explanation of post surgical complications.
Please read the information regarding what to expect post surgery on this website.
Remember that below is a guide to recovery and that everyone heals at different rates and some people do take longer. Use this information to help you understand your condition, possible treatment and recovery. The timeframes given below are a minimum, it is important that you appreciate this when considering surgery as your healing and recovery may take longer.
Almost all surgical procedures for hammer toe deformity will be undertaken as a day case.
You will have a bandage applied similar to this during the operation.
Post operative bandage of the foot
Please do not remove your bandages until you are seen by your surgeon Mr Malik at the two week post operative clinic appointment. You will also be provided with a stiff soled black post operative shoe. Please ensure you wear this whenever you are weight bearing.
Post operative stiff soled shoe
For the first 48 hours you will be allowed to touch weight bear using two crutches. After 48hrs you can weight bear as tolerate. The physiotherapist will guide you after your operation and before your discharge from hospital with the use of crutches and mobilising.
For the first two weeks following your surgery please keep your foot elevated to the level of your heart for 95% of the time. It is recommended you stay at home during this period.
High elevation of the foot and ankle
Naturally most people do not have a hospital bed at home. The same effect can be achieved by lying in a bed or lengthways on a sofa, with pillows behind your back and under your foot. You cannot have your leg elevated sitting in a chair. It is strongly advised that during the first two weeks you are house bound.
To minimise risk of infection keep the foot dry and cool. Avoid humid and hot environments. Keep the foot dry and when showering wear a Limbo bag.
To minimise the risk of blood clots please move your foot and ankle at regular intervals. Please ensure you are well hydrated. If you have a risk of blood clots please notify Mr Malik who may organise for you to have blood thinning injections as a precaution.
You will be reviewed at the clinic and your dressings removed. Your wound will be checked and your toe taped or strapped.
At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position (50-75% of the time). You will require to wear the special post operative shoe for another 4 weeks. Short trips can be made outside, within limits of pain and swelling.
Driving will be permitted for short trips if the left foot has been operated on and you drive an automatic. If the right foot has been operated on it will be at least 8 weeks before any driving is advisable.
Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area.
Commence exercises of the lesser toes 3 weeks after surgery and continue for 3 months. These exercises included active resistive and passive toe flexion and extension. They also include intrinsic foot muscle strengthening exercises.
You will have radiographs taken just before you are seen in clinic. You will go over these with Mr Malik and compare the before and after images. If you have had a bony procedure, it will take a minimum of 6 weeks to heal.
At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably, although expect some degree of swelling for at least 3 to 4 months.
You will be able to start wearing normal footwear (swelling permitted), although stiff soled shoes are advisable. Continue to do the lesser toe exercises for another 6 weeks.
Final clinical examination. Discharge if satisfactory.
I had hammer toes which were becoming more and more painful. I was getting repeated ulcers on my toe joints where they rubbed against my shoes and I could no longer wear “normal” shoes at all. I was also getting pain in the balls of my feet making walking increasingly painful.
I have bi-polar disorder and going for long walks with my dogs in the countryside is not only my passion but also my main coping strategy to alleviate depression and mood swings.
I went to see Mr Malik because I couldn’t face becoming less and less able to walk without pain and the adverse effect this would have on my mental well-being (there is scientific evidence that time spent outdoors exercising in the countryside is great for alleviating stress and lifting mood).
Both procedures (first proximal medial gastrocnemius releases and then a second staged second hammer toe deformity correction) were successful and the outcome has been excellent.
I had the gastrocnemius release procedure on both knees to release my tight calf muscles (the underlying cause of the toe problems). As a result my mobility improved and even my gym trainer commented on my flexibility.
A month later Mr Malik performed hammer toe correction surgery on both my feet at the same time to minimise recovery time. I built up my walking very gradually and although my fitness had reduced considerably it has now, 6 months post op, returned to pre-op level. I am now able to walk up to 14 miles a day without pain which is all I hoped for.
Have them both done at the same time provided you have someone who can look after you during the 6 weeks recovery (cooking, cleaning etc).
Follow Mr Malik’s exercise instructions to the letter, particularly the calf stretches after the gastrocnemius and sit ups, leg scizzors, arm exercises with a resistance band and light weights (several times a day).
When you resume “normal” activity, build up slowly. When I started walking normally again my right hip and knee were painful particularly when going upstairs but as I built up the amount of exercise I was doing each day my muscles got stronger and the pain subsided to the extent that I am now pain free.
At the first sign of any problems contact Mr Malik. I experienced some swelling in my toes the day after surgery so I messaged him with photos – he phoned me straight back with advice (remove strapping) and booked me into clinic the next day for him to check it (FOC).
Take great care not to get the pins caught in anything. At night I put pillows either side of my legs so that the covers were not touching my feet. Just before the pins were due to be removed I got one caught on a bed cover which nearly pulled it out. I pushed it back in very carefully but Mr Malik said I could have left it out as it was obviously ready.
Get limbo bags for showering
Buy, beg, steal or borrow a reclining arm chair (I bought mine from an EMAUS charity shop and also slept in it for the first week).
Organise lots of activities you can do lying or sitting down (I alternated between knitting, crochet, reading, Sudoku, puzzle books, TV and radio, catch up on phone calls and invite people round for coffee so you keep up your social contact while laid up.
This depends on your rate of healing and how much pain and swelling you have. For the first 6 weeks we advise you to use the stiff post operative shoe. After 6 weeks it is advised that you wear a stiff soled shoe with a wide toe box while your foot continues to heal.
Please see guidance above and information here. Ultimately it is the responsibility of the patient to decide if they are safe to drive. A good way of knowing is if you can stamp your right foot heavily on the ground to mimic an emergency brake. If you have any hesitation or pain then it should suggest you are not safe to drive. Remember prolonged driving involves keeping your feet in a dependant position. This will worsen the post operative swelling.
This really depends on you and your job. If you have a job that involves a lot of standing, walking and is manual it may be 8 to 12 weeks. If you have a sedentary job, for example in an office and you have a reasonable commute you may be able to go back to work at 2 weeks, although this would be exceptional and not the norm.
Excellent pain relief and deformity correction. Ability to participate in sports by 6 months. Sometimes up to a year before the foot feels “normal” and fully healed.
Haglund’s deformity is a condition where there is a prominent posterosuperior aspect of the calcaneus. Some people have this anatomical variation in their heel bone which predisposes them to problems with the Achilles tendon and the retrocalcaneal bursa.
The normal calcaneum is typically rounded at the top (superior margin). In some patients there is a prominent spur which narrows the space between the back of the heel bone and the front of the Achilles tendon. Activities that involve moving the foot in a downward position narrow the space between the heel bone and tendon resulting in increased rubbing and friction.
The presence of a Haglund’s deformity narrows this space considerbly thereby casuing or exacerbating problems such as retrocalcaneal bursitis.
A – Normal x-ray of the foot and ankle B – X-ray demonstrating a Haglund’s deformity – note reduced space between Achilles tendon (dotted line) and back of the heel bone (solid white line) Haglund deformity in shaded red area in enlarged box
The posterior superior bony prominence is a normal anatomical variation.
It can predispose or exacerbate conditions such as Achilles tendon problems and retrocalcaneal bursitis.
Haglund’s deformity relates to inflammation and damage to surrounding tissues such as the retrocalcaneal bursa and Achilles tendon.
The following can cause or exacerbate symptoms:
Pain
Pain in the posterior heel area is the commonest symptom. The pain may be worse after activity and exercise for example at night or the next morning. Eventually the pain will become more severe and limit exercise and activity. Some patients may find themselves limping.
Patients with bilateral symptoms should be investigated for an underlying inflammatory arthritis.
Examination
Typically patients have tenderness on palpation in a focal areas just above the calcaneum and infront of the Achilles tendon.
Patients also typically have tight calf muscles. There may or may not be associated Achilles tendon problems.
Swelling may be a feature of this condition.
Usually the diagnosis can be made, based on the history and clinical examination.
Radiographs (x-rays) are a useful first line investigation to rule out any other problems in the hindfoot and to confirm the presence of a Haglund’s deformity.
Ultrasound is occasionally employed to assess the state of the retrocalcaneal bursa and Achilles tendon.
Occasionally MRI is useful in confirming the diagnosis and ruling out other causes of heel pain. It provides excellent high definition static images.
It is requested in patients who have failed to respond to conservative treatment and are being prepped and worked up for surgery.
MRI depicting the site of the common problems associated with heel pain
The majority of patients find that their symptoms settle with proper management.
Patients with Haglund’s deformity who ignore their symptoms or who are mismanaged may develop chronic pain.
Some patients despite non operative treatment continue to have symptoms.
Non-operative management for retrocalcaneal bursitis aims at relieving pain and return to full activity including sports whenever possible.
It should always be the first line of treatment. Options include:
A short period of rest or reduction from sports and exercise that bring on symptoms. Fitness can be maintained by other non impact activities such as swimming and pool based exercises.
Minimising pressure on the heel will ease the pain. Shoes with soft padding at the heel, using sandals and avoid heel straps. Avoid or minimise the time spent wearing high heels if not already doing so. Wearing shoes with soft heel counters.
The use of non-steroidal anti-inflammatory drugs (NSAIDs) can decrease discomfort in patients with superficial calcaneal bursitis.
The use of paracetamol and other painkillers to help reduce pain levels.
Physiotherapy is important with this condition to hasten the healing process, ensure an optimal outcome and prevent recurrence.
Treatment may comprise:
The following exercises are recommended as part of any physiotherapy program:
Patients with resistent symptoms depsite treatment may benefit from a period of immobilisation in a cast or walking boot.
Any intervention is considered in a step wise manner, with the least invasive procedure carried out first. A number of surgical options are available.
Patients with Haglund’s deformity often have an associated Achilles tendon problem or retrocalcaneal bursitis please read about these conditions as surgery may involve treating these associated conditions at the same time.
Removing (debriding) the posterior superior prominence of the heel bone will remove pressure on the Achilles tendon and the bursa. This can be done through a small open incision or via an arthroscope (keyhole/minimally invasive surgery). Frequently in conjunction with the Haglund’s debridement, an inflamed retrocalcaneal bursa is removed (debrided) as well.
Almost all surgical procedures for Haglund’s deformity will be undertaken as a day case.
You will have a backslab applied post operatively for two weeks to allow the wounds and soft tissues to heal.
A picture of a backslab
Please do not remove your backslab until you are seen by your surgeon Mr Malik at the two week post operative clinic appointment.
You will be non weight bearing for 2 weeks post operatively. The physiotherapist will guide you with the use of crutches after your operation and before your discharge from hospital.
For the first two weeks following your surgery please keep your foot elevated to the level of your heart for 95% of the time.
A picture demonstrating high elevation
You will be reviewed at the clinic and your backslab and dressings removed. Your wound will be checked and if completely healed you will be given advice regarding soft tissue massage and scar desensitisation. Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area. You may shower and get the area wet only if the wound has completely healed and is dry.
At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position whenever possible to minimise swelling. You will require to wear a special walking boot for another 2 to 4 weeks when weight bearing. Please limit your activities within limits of pain and swelling.
Gentle range of motion exercises out of the boot can also commence at this stage.
Driving will be permitted for short trips if the left foot has been operated on and you drive an automatic. If the right foot has been operated on it will be at least 4 to 6 weeks before any driving is advisable.
You may be referred at this stage for physiotherapy for early rehabilitation and Achilles tendon strengthening exercises.
You will be able to start wearing normal footwear (swelling permitted). You will require physiotherapy for approximately 3-6 months. This will help optimise the outcome of your operation.
X-rays may be arranged at this stage.
This is probably the most common question asked of surgeons. Total operation time is different from the actual total surgical time. For example a flight involves not just the flying time, but the time checking in, going through security and boarding the plane for example.
For removal of the bony prominence expect the operation to last 45 to 60 minutes.
This really depends on you and your job. If you have a job that involves a lot of standing, walking and is manual it may be 4 to 6 weeks. If you have a sedentary job, for example in an office and you have a reasonable commute you may be able to go back to work at 2 weeks, although this would be exceptional and not the norm.
Patients with retrocalcaneal bursitis may be expected to return to sports without restrictions once they have:
Excellent pain relief and return to sports by 3 to 6 months in approximately 90% of patients.
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Orthopaedic Outpatient Department 30 Devonshire Street, London, W1G 6PU
tel: +44 (0) 203 7956053
Mon - Fri (8am-8pm) Sat (9am - 5pm)
info@lfaclinic.co.uk
