What is the recommended x-ray positioning for a calcaneal (heel bone) spur?

X-ray Positioning for Calcaneal Spur Evaluation

For optimal visualization of calcaneal spurs, a standard three-view radiographic study of the foot is recommended, with particular emphasis on the lateral view which best demonstrates calcaneal spurs. 1

Standard Radiographic Views for Calcaneal Spur Evaluation

Primary Views

• Lateral view - Most important for calcaneal spur visualization
• Anteroposterior (AP) view
• Oblique view

Patient Positioning

• For lateral view: Patient in prone position for dorsal scan 1
• For AP view: Patient in supine position for ventral scans 1
• For oblique view: Patient in supine position with foot rotated appropriately 1

Special Considerations

For Posterior Calcaneal Spurs

• Posterior longitudinal scan is particularly important as it best visualizes the relationship between the Achilles tendon and calcaneus 1
• Position patient prone with hip and knee joints in neutral position 1

For Inferior/Plantar Calcaneal Spurs

• Lateral non-weight bearing view is the first choice for investigation of plantar fasciitis and associated calcaneal spurs 2
• This view effectively demonstrates plantar fascia thickness and fat pad abnormalities, which have 85% sensitivity and 95% specificity for plantar fasciitis 2

For Complex Cases

• Axial calcaneal view can be added when detailed evaluation is needed, as it increases specificity in diagnosing calcaneal fractures 1
• The AP calcaneal profile view may provide more accurate assessment of calcaneal alignment in cases where fracture of the spur is suspected 3

Clinical Relevance

• While calcaneal spurs are commonly seen in patients with heel pain (85% of plantar fasciitis patients), they are also present in 46% of asymptomatic individuals 2
• The key radiological features that differentiate symptomatic from asymptomatic individuals are not the spurs themselves but rather changes in soft tissues (plantar fascia thickness and fat pad abnormalities) 2

Imaging Algorithm

1. Initial imaging: Standard three-view radiographic study (AP, lateral, and oblique) 1
2. If plantar fasciitis is suspected: Emphasize lateral non-weight bearing view 2
3. If spur fracture is suspected: Consider additional axial calcaneal view 1, 4
4. If radiographs are negative but clinical suspicion remains high: Consider advanced imaging such as MRI or CT 1

Pitfalls to Avoid

• Relying solely on the presence of a calcaneal spur for diagnosis, as they are common in asymptomatic individuals 2
• Overlooking soft tissue changes which are more specific indicators of pathology 2
• Using inappropriate positioning which may obscure the spur or related pathology 1
• Failing to obtain additional views when standard views are inconclusive 1

By following these positioning recommendations, clinicians can optimize visualization of calcaneal spurs and associated pathology, leading to more accurate diagnosis and appropriate management of patients with heel pain.