From the Guidelines
The presence of calcaneal spurs and an os trigonum requires a treatment approach that prioritizes conservative management, including rest, ice, stretching, and NSAIDs, with consideration for corticosteroid injections or surgical intervention if symptoms persist beyond 6-8 weeks. The radiographic findings indicate the presence of calcaneal spurs at both the posterior attachment of the Achilles tendon and the plantar aspect of the calcaneus where the plantar fascia originates. Additionally, an os trigonum, which is an accessory bone located posterior to the talus, is present. These findings are relatively common and often incidental, as noted in the American College of Foot and Ankle Surgeons' guidelines for diagnosis and treatment of heel pain 1.
For symptomatic calcaneal spurs, initial management includes:
- Rest
- Ice application
- Stretching exercises
- Appropriate footwear with cushioning
- Over-the-counter NSAIDs like ibuprofen (400-600mg three times daily with food) for pain and inflammation, as suggested by the American College of Foot and Ankle Surgeons 1 Physical therapy focusing on stretching the Achilles tendon and plantar fascia can be beneficial. Night splints and orthotic inserts may provide additional relief. If conservative measures fail after 6-8 weeks, consider corticosteroid injections or, rarely, surgical intervention, such as resection of the prominent posterior superior aspect of the calcaneus and inflamed bursa, as indicated in the guidelines 1. The os trigonum typically requires no treatment unless it causes posterior ankle impingement syndrome, particularly in dancers or athletes who frequently point their toes. These bony formations develop as a response to chronic tension at tendon or ligament attachment sites, representing the body's attempt to strengthen these areas under repetitive stress.
From the Research
Calcaneal Spurs and Os Trigonum
- Calcaneal spurs are bony projections that form around the calcaneal bone, and their development is often associated with heel pain, also known as talalgia 2.
- The presence of calcaneal spurs can be related to various factors, including gender, age, occupation, and lifestyle, and they are often seen in association with diseases such as plantar fasciitis, arthropathies, gout, pes cavus, and pes planus 2.
- Os trigonum, on the other hand, is an ossicle that can cause symptoms in individuals who require repetitive plantarflexion of the ankle, and it is often associated with posterior ankle impingement and hindfoot pain 3, 4.
Relationship between Calcaneal Spurs and Plantar Fasciitis
- The relationship between calcaneal spurs and plantar fasciitis is debatable, but studies have shown that calcaneal spurs can be classified into two distinct types, type A and type B, which are indicative of the severity of plantar fasciitis 5.
- Type A calcaneal spurs are located superior to the plantar fascia insertion, while type B calcaneal spurs are located within the plantar fascia, and magnetic resonance imaging results have shown a more severe plantar fasciitis grade in type B calcaneal spurs 5.
Treatment Options
- Treatment options for calcaneal spurs and os trigonum syndrome include conservative management, such as corticosteroid injections, as well as surgical options, including endoscopic and open excision 3, 6, 4.
- A tier-wise follow-up procedure has been proposed, where the response to a particular treatment is recorded, and if it does not resolve the spur, the treatment progresses to the next tier 2.