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. 2024 May 1;16(6):1374–1380. doi: 10.1111/os.14059

Clinical Study of a Four‐Step Program for the Treatment of Plantar Fasciitis with Bone Spurs

Lu Jiang 1, Tianyu Liu 2, Zhenyi Li 2, Zihui Tang 1, Xin Zhou 3,4,5, Bin Xiong 2, Lei Zhang 3,4,5,✉
PMCID: PMC11144503  PMID: 38693719

Abstract

Objective

The most common causes of plantar and heel pain are plantar fasciitis and calcaneal spurs, and they often co‐exist. Surgery is a recognized treatment for refractory plantar fasciitis. However, few studies have proposed treatment options for patients with metatarsophalangeal fasciitis with bone spurs. Accordingly, this study's purpose was to propose a four‐step surgical regimen, and to improve the surgical outcome of plantar fasciitis with osteophytes and to establish a procedure for surgical treatment.

Methods

Retrospective analysis of 45 patients suffering from plantar fasciitis with bone spurs from 2020 to 2023. All patients underwent a four‐step procedure, including plantar fascia release, calcaneal spur grinding, inflammatory tissue removal, and calcaneal burr decompression. The imaging parameters and functional scores were recorded before and after the operation. The objective evaluation included the measurement of calcaneal spur length on radiographs. Clinical evaluation included the American Orthopaedic Foot and Ankle Society (AOFAS), the Visual Analog Scale (VAS), and the Foot and Ankle Outcome Scale (FAOS). Measurement data that conformed to normal distribution were expressed as (x 2 ± s), and pre‐and postoperative AOFAS, FAOS, and VAS scores were compared using repeated‐measures ANOVA, and preoperative and postoperative spur lengths were compared using paired t‐tests.

Results

The 45 patients were followed up for 3 to 30 months, (17.72 ± 8.53) months, at final follow‐up, the patient's AOFAS score improved from preoperative (74.93 ± 5.56) to (94.78 ± 3.98), FAOS score increased from preoperative (76.42 ± 3.37) to (96.16 ± 2.74), the VAS score decreased from (3.18 ± 0.54) to (1.07 ± 1.20) (p < 0.05), the length of spur decreased from (0.72 ± 1.81) cm to (0.23 ± 1.19) cm, and there were significant differences before and after operation (p < 0.05).

Conclusion

The four‐step surgical regimen is an appropriate and effective surgical procedure to treat plantar fasciitis with bone spurs.

Keywords: Bone Spur, Calcaneal Spur Grinding, Four‐Step Regimen, Plantar Fascia Release, Plantar Fasciitis

The four‐step surgical regimen is an appropriate and effective surgical procedure to treat plantar fasciitis with bone spurs.

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Introduction

One of the main causes of heel pain is plantar fasciitis, and the prevalence of plantar fasciitis with pain is estimated to be about 0.85%. 1 Plantar fasciitis pain is characterized by “one‐step pain”, a condition that severely impairs a patient's ability to move. Most patients recover after conservative treatment such as non‐steroidal anti‐inflammatory drugs, plantar injections, and radiation therapy. 2 , 3 , 4 However, for patients with refractory plantar fasciitis who do not respond to conservative treatments, surgical treatment can be effective in relieving their symptoms in the short to medium term, 5 and therefore may be a better option for patients with refractory metatarsophalangeal fasciitis.

Calcaneal spurs are bony protrusions of the root trochanter, and Menz et al. 6 reported that heel spurs and plantar fascia thickening often co‐occur in patients with heel pain. Surgery plays an important role in patients with plantar fasciitis and bone spurs that fail conservative treatment, 7 , 8 such as metatarsal fascia lysis, calcaneal spur grinding, calcaneal drilling decompression, gastrocnemius release, and so on. 4 , 9 , 10 , 11 Because bone spurs increase the risk of heel pain, 12 most surgeons remove them as they appear. However, few studies have proposed surgical protocols for plantar fasciitis with bone spurs.

Recent studies have found that endoscopic surgery is a safer and more effective treatment for Plantar fasciitis than open surgery, improving patient satisfaction earlier and returning to work more quickly. 13 But there is no “gold standard” to treat plantar fasciitis with a bone spur. In a meta‐analysis, due to the unstandardized nature of the surgical protocol, the available evidence does not demonstrate that endoscopic plantar fascia release is safe and effective for the treatment of plantar fasciitis. 14 Therefore, it is important to propose a suitable and effective surgical program. At the same time, in the existing research that focuses on treating plantar fasciitis with a bone spur, most scholars only choose one or two treatment methods, and few studies pay attention to comprehensive treatment. To our knowledge, no studies have explored surgical procedures for plantar fasciitis with spurs.

Therefore, the main purposes of this study are: (i) Combined with plantar fascia release, heel spur grinding, and heel drill decompression to treat plantar fasciitis with spur; and to develop a four‐step plan for the surgical treatment of plantar fasciitis with bone spurs. (ii) Validation of the effectiveness of the surgical protocol of this study for clinical application.

Materials and Methods

Research Target

Inclusion criteria: (i) Physical examination for pain on palpation in the medial plantar region, dorsiflexion pain, and tightness of the Achilles tendon or gastrocnemius muscle. (ii) X‐ray examination suggestive of the presence of heel bone spurs. (iii) No improvement of symptoms after conservative treatment for 6 months or more. (iv) Underwent a four‐step program of surgical treatment.

Exclusion criteria: (i) No previous history of foot and ankle deformity or heel fracture. (ii) Exclusion of other etiologies of pain in the heel region such as posterior heel bursitis, posterior Achilles tendon bursitis, and metatarsal plantar fascial fibroma.

Forty‐five patients with metatarsal plantar fasciitis with bone spurs who were treated surgically by a four‐step regimen were selected for pre‐ and post‐surgical control between 2020 and 2023. We ensured that all procedures were approved by the ethics committee (IRB/IEC No: BY2022029) and that informed consent was obtained from patients.

Diagnostic criteria for metatarsal plantar fasciitis: the pressure point of the heel is located at the medial heel tubercle, and the pain is characterized by “one‐step‐pain”: the pain in the anterior portion of the heel pad is very pronounced in the first step after waking up in the morning or after a long period of sedentary activity. However, the pain is significantly relieved after a few steps. 15 , 16

Surgical Method

Bone spurs in the heel bone, localized soft tissue inflammation, and high pressure within the heel bone can all cause heel pain symptoms. 6 , 8 , 12 So we developed a four‐step program of surgical treatment to address these factors. We first release the metatarsal fascia to expose the spur, and then grind it down after it has been fully exposed. Once the spur was removed, the local inflammatory tissue was exposed to the arthroscopic field of view, and then the local inflammatory tissue could be completely removed, and then the heel bone was drilled and decompressed to reduce the intra‐osseous hypertension.

The patient's preoperative MRI of the foot showed inflammation of the plantar fascia (Figure 1A). Intrathecal anesthesia was administered to the patient. After satisfactory anesthesia, the patient was placed in the supine position, the patient's affected limb was tied with a tourniquet, routinely disinfected and surgically draped. Taking the affected heel bone arthroscopic medial and lateral approach incision, inserting arthroscopic examination saw: the affected foot plantar fat pad hyperplasia hypertrophy, metatarsophalangeal fascia tension increased, and hypertrophy, metatarsophalangeal fascia at the heel bone attachment point of the osteophyte (Figure 1C).

  1. Metatarsal plantar fascia release (Figure 1B): Two‐thirds of the metatarsal fascia is released from the inside out using a planer knife and low‐temperature plasma, then the metatarsal fascia is checked for proper tension and low‐temperature plasma stops the bleeding.

  2. Bone spur grinding (Figure 1D): A bone micro power grinder was used to completely remove the endoscopically visible protruding bone spurs, and the grinding of hyperplastic bone spurs was visualized by C‐arm fluoroscopy.

  3. Metatarsal plantar fascia inflammatory tissue removal (Figure 1E): Complete removal of all inflammatory tissue visible to the endoscopic naked eye.

  4. Metatarsal plantar fascia heel bone drilling decompression (Figure 1F): In the metatarsal fascia at the stopping point of 1.5 mm Kirschner's needle heel bone drilling until the fat droplets overflowed, the line of heel bone drilling decompression, low‐temperature plasma electrocoagulation hemostasis, myofascial blood seepage at the electrocoagulation to stop bleeding difficulties, two Bionin wet compresses without obvious blood exudation, with resorbable collagen sutures to close the deep fascia, using silk sutures to close the skin, with a medical adhesive glue incision, and the incision was glued with 1 medical adhesive, and the wound was bandaged with pressure using a sterile dressing. Postoperatively, apply a pressure bandage and elevate the affected limb.

FIGURE 1.

FIGURE 1

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A case of plantar fasciitis with bone spur treated by four‐step program (A) Patient, female, 54 years old, left plantar fasciitis with a bone spur, MRI shows the plantar fascia's inflammation. (B) Release the metatarsal fascia. (C) Exposure to the bone spur. (D) Grinding of the heel spur. (E) Cleaning of inflammatory tissue. (F) Drilling and decompression of the heel bone. (G) Postoperative wound size. (H) Preoperative radiograph of the patient showing the heel spur. (I) Postoperative review of the patient with a cleared heel spur.

Postoperative Management and Functional Exercises

Active ankle dorsiflexion and extension exercises were performed on the first postoperative day and partial weight‐bearing walking was started on the third day, and full weight‐bearing walking was started on the 10th postoperative day. To find out the pain relief and foot function after discharge from the hospital, regular follow‐up visits were made by telephone, outpatient follow‐up was used for the last follow‐up.

Postoperative Follow‐Up and Evaluation Indicators

Patient efficacy was assessed using AOFAS, FAOS, and VAS scores preoperatively, immediately postoperatively, 1 month postoperatively, 3 months postoperatively, and at the final follow‐up (25.3 ± 8.9 months). Followed up with all patients by phone, outpatient follow‐up was used for the final follow‐up.

Surgical efficacy was assessed by measuring the length of the heel spur on preoperative and postoperative foot radiographs of the patients. Bone spur length measurement: the distance from the spur's tip to its base on the lateral foot radiograph (Figure 2). Lateral foot radiographs were taken by an experienced radiographer, and double‐blind measurements were performed by two senior diagnostic imaging physicians, respectively.

FIGURE 2.

FIGURE 2

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Measurement of bone spur length. Blue Line: marking the base of the spur along the medial calcaneus through the midpoint of the base of the spur. Red Line: make a horizontal line to the right from the vertex of the spur, intersect with the Blue Line, and measure the length of the spur.

Statistical Analysis

IBM SPSS Statistics for Windows, Version 20.0 (Armonk, NY: IBM Corp.) was applied for statistical analysis. Measurement data that conformed to normal distribution were expressed as (x 2 ± s), and pre‐and postoperative AOFAS, FAOS, and VAS scores were compared using repeated‐measures ANOVA, and preoperative and postoperative spur lengths were compared using paired t‐tests, and the difference was statistically significant when p < 0.05.

Results

Patients' AOFAS, FAOS, and VAS Scores

The surgery went smoothly in 45 patients, and there were no postoperative complications such as tendon, nerve, and vascular injuries. The postoperative incisions all healed in one stage and recovered well. The average age at surgery was 55.3 ± 9.3 years. As shown in Table 1, there were significant differences in FAOS, AOFAS, and VAS scores between preoperative, postoperative, and 1 and 3 months postoperative and at the last follow‐up (25.3 ± 8.9 months) (p < 0.05), and the average FAOS and AOFAS scores at the follow‐up were statistically significantly higher (Figure 3A) and the average VAS scores were statistically significantly lower (Figure 3B) than those at the preoperative level (p < 0.05).

Table 1.

Pre‐ and postoperative clinical scale assessment.

Preoperative Postoperative 1 month post‐operative 3 months post‐operative Final follow‐up F p
FAOS 76.4 ± 3.4 84.5 ± 4.6 88.6 ± 3.7 93.5 ± 3.6 96.2 ± 2.7 665.5 0.0
AOFAS 74.9 ± 5.6 82.0 ± 5.1 87.0 ± 4.2 92.1 ± 3.8 94.8 ± 4.0 408.1 0.0
VAS 3.2 ± 0.5 2.5 ± 0.7 2.2 ± 0.8 1.8 ± 0.8 1.1 ± 1.2 105.0 0.0
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n = 45, two‐by‐two comparisons of FAOS scores, AOFAS scores, and VAS scores at different time points were significant (all p < 0.05).

FIGURE 3.

FIGURE 3

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Patients' clinical and objective assessments improved at postoperative follow‐up compared to preoperative. (A) American Orthopaedic Foot and Ankle Society (AOFAS) and Foot and Ankle Outcome Scale (FAOS) scores were constantly improving at postoperative, 1 and 3 months postoperative, and final follow‐up compared to preoperative. (B) Visual Analog Scale (VAS) scores were constantly decreasing at postoperative, 1 and 3 months postoperative, and final follow‐up compared to preoperative. (C) Bone spurs were significantly eliminated postoperatively compared to preoperatively.

Comparison of Bone Spur Length in Patients before and after Treatment

The length of bone spurs in postoperative (0.00 cm) patients was reduced compared with preoperative (0.72 ± 0.18 cm) (Figure 3C), and the difference was statistically significant (p < 0.05). There was only one spur in each case.

Discussion

Main Findings of this Study

The results of this study showed that the mean scores of FAOS and AOFAS were higher than the preoperative level (p < 0.05), the mean VAS was lower than the preoperative level (p < 0.05), and the length of bone spurs was decreased after operation (p < 0.05). These results indicate that the four‐step treatment protocol in this study has achieved good clinical results.

Our proposed four‐step therapy is the most important finding of this study, which seems to be an appropriate approach to treating patients with plantar fasciitis with bone spurs. It led to improvements in both anatomy and function of the foot. This was confirmed by the significant improvement in both our postoperative clinical scale assessment and objective imaging assessment.

Reasons for Bone Spur Grinding

In the current study, the occurrence of heel pain is considered to be closely related to its anatomical structure, and the main cause of heel pain is plantar fasciitis, 17 , 18 while metatarsal plantar fasciitis also stimulates the heel bone to produce heel bone spurs, which aggravates heel pain. 19 Metatarsal fasciitis occurs when the metatarsal fascia becomes tense with too much activity or excessive contraction. The part of the metatarsal fascia that connects to the heel bone stop can have small tears and bleeding, further straining the metatarsal fascia. As a result of the inflammatory stimulus and the body's compensation, the bone at the heel stop increases in size, resulting in a bone spur. In clinical practice, plantar fasciitis and heel spurs often occur together, 6 and 50%–75% of plantar fasciitis is associated with heel spurs, heel spurs are found in 50% of patients with plantar fasciitis and in 19% of the asymptomatic population. 6 , 20 However, most of the current studies have focused on plantar fasciitis treatment, and there seems to be little research on plantar fasciitis with bone spurs’ treatment. Therefore, in this study, a four‐step program was developed for the disease of plantar fasciitis with bone spurs, which not only treated plantar fasciitis but also dealt with bone spurs, to improve the therapeutic effect as much as possible.

In addition, plantar fasciitis is not only closely related to the bone spurs but also related to the curvature of the foot arch. If the curvature of the foot arch decreases, the protection of the plantar neurovascular system decreases, and the cushioning and shock‐absorbing effect also decreases. As a result, the horizontal tension on the plantar fascia during exercise Is significantly higher than in normal people, which may lead to plantar fasciitis. Chronic traction of plantar fasciitis may cause the proliferation of bone spurs, which may cause chronic compression and stimulation to the surrounding soft tissues, causing damage to the plantar fascia and leading to the occurrence of plantar fasciitis, as well as stimulation of the local sensory nerve endings and the production of pain sensation. 21 , 22 Therefore, the enlargement of the presence of bone spurs may cause plantar fasciitis, which is a risk factor for its recurrence. The results showed that the length of bone spur decreased from (0.72 ± 0.18) cm to 0 cm, in the patients after the operation, indicating that the treatment plan in this study solved the problems of bone spurs, and avoided the recurrence of plantar fasciitis due to the influence of the bone spurs in the postoperative period.

FAOS, AOFAS, and VAS Scores Improved Significantly

The results of the final follow‐up (25.3 ± 8.9 months) showed that the scores of FAOS and AOFAS increased to (96.16 ± 0.41) and (94.78 ± 0.98), respectively, after four‐step treatment, indicating that the scores of FAOS and AOFAS were significantly improved to excellent grade, indicating that both the quality of life of the patients and their foot function were significantly improved after treatment. Moreover, the patients' VAS scores were significantly reduced after the treatment, and the treatment program proposed in this study resulted in significant relief of the patient's heel pain condition. However, the preoperative FAOS and AOFAS scores of the patients with plantar fasciitis with bone spurs selected in this study were (76.42 ± 3.37 and 74.93 ± 5.56), which were in the general grade, respectively, and the patients' VAS scores (3.18 ± 0.54) were in the mild–moderate pain category. With the implementation of health care coverage and improvement of people's access to health care, most patients with plantar fasciitis with bone spurs go to the hospital when it is mild to moderate. Therefore, the condition of the patients in this study was not particularly severe, so the results of this study can only show that the four‐step regimen is effective in treating mild‐to‐moderate recalcitrant plantar fasciitis with bone spurs, but the effectiveness of the regimen in the treatment of patients with severe recalcitrant plantar fasciitis with bone spurs is not certain. Nonetheless, these results have clinical significance because they provide a safe and efficacious minimally invasive surgical option to treat recalcitrant plantar fasciitis with bone spurs.

The Effective Treatment Methods of Plantar Fascia

The etiology and pathologic changes of plantar fasciitis have not been fully defined, and there are no ideal treatment criteria. 23 When conservative treatment is ineffective, the most common treatment for plantar fasciitis is surgery. A variety of surgical procedures are available, all of which are designed to restore the normal anatomy and function of the foot and to eliminate pain. Several studies have shown that endoscopic surgery is more effective in the treatment of recalcitrant plantar fasciitis than open surgery, 7 , 13 , 24 , 25 therefore, the four‐step program of therapeutic surgeries carried out in this study was performed endoscopically to ensure its therapeutic efficacy. Several studies have found that endoscopic plantar fascia release is often satisfactory in the treatment of recalcitrant plantar fasciitis. 10 , 26 , 27 Cottom et al. 28 found that AOFAS scores and VAS scores of patients with recalcitrant plantar fasciitis improved significantly during a 5‐year follow‐up period after inflammatory tissue debridement of the plantar fascia. Rizk et al. 29 found that heel drilling and decompression combined with metatarsal fascia laxation was effective in the treatment of recalcitrant plantar fasciitis. El Shazly et al. 30 used a combination of metatarsal fascia laxation, heel drilling and decompression, and bone spur removal in the treatment of plantar fasciitis with bone spurs, and achieved a satisfactory outcome. However, all of the above studies dealt with one or two factors in the occurrence of plantar fasciitis and only proposed a certain surgical method, without proposing a treatment plan and a complete surgical treatment process for plantar fasciitis with bone spurs. Therefore, we addressed the three factors that cause heel pain symptoms, namely plantar fascia soft tissue inflammation, heel bone spurs, and high pressure in the heel bone, and developed a complete surgical program to achieve better results.

The results of the above studies showed that plantar fascia laxation, heel spur debridement, inflammatory tissue debridement, and heel drilling decompression were effective in the treatment of recalcitrant plantar fasciitis, which is the same as the results of this study. However, they only proposed one surgical method or combined several surgical methods to treat patients with plantar fasciitis and did not propose a standardized surgical treatment process for patients with plantar fasciitis with bone spurs. Therefore, this study innovatively combined the above surgical methods and developed a surgical treatment process based on clinical experience, hoping to provide a surgical treatment program for the clinical treatment of plantar fasciitis with bone spurs.

Ultimately, our findings demonstrate the effectiveness and feasibility of the four‐step program of treatment. The proposed four‐step regimen may be an effective treatment option for recalcitrant plantar fasciitis with bone spurs.

Limitations and Prospect

There are still limitations in this study. Firstly, this study was a retrospective case study with a relatively small sample size included, and the results were not very representative. Secondly, this study did not compare with other surgical methods to determine whether the efficacy was better than traditional surgical methods. Finally, the follow‐up period of this study was relatively short, and the long‐term therapeutic effect remains to be observed. Therefore, the generalizability of these findings is limited, so in the future, we need to recruit a larger number of patients for prospective trials as well as include a control group to increase the validity of the results.

Conclusion

The four‐step treatment program provides satisfactory long‐term subjective and objective clinical outcomes, and surgical treatment with the four‐part program is an alternative and effective option for the treatment of recalcitrant plantar fasciitis with bone spurs.

Ethics Statement

The research was complied with protocols approved by the medical ethics committee of The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University (BY2022029).

Author Contributions

Lu Jiang: Conceptualization, Methodology, Investigation, Writing—Original Draft. Tianyu Liu: Methodology, Investigation. Zhenyi Li: Validation, Formal Analysis. Zihui Tang: Investigation. Xin Zhou: Resources, Project Administration. Bin Xiong: Writing—Review & Editing. Lei Zhang: Conceptualization, Resources, Supervision, Funding Acquisition.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding Information

This work was supported by the National Natural Science Foundation of China (Youth Science Foundation Project) [Grant Number: 82004458]; Scientific Research Cultivation Project of The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University [Grant number: 2022‐CXTD‐08]; Sichuan Science and Technology Program [Grant number:2022YFS0609]; General Project of Sichuan Traditional Chinese Medicine Administration Traditional Chinese Medicine Research Special Project (Fundamentals of Traditional Chinese Medicine) [Grant number:2023MS248]; The Southwest Medical University 2023 College Student Innovation Entrepreneurship Training Program [Grant number:202310632079].

Authorship Declaration

All authors listed meet the authorship criteria according to the latest guidelines of the International Committee of Medical Journal Editors. All patients signed a General Consent of the Ethical Committee of The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University for using and publishing their data for scientific use. The content has not been published or submitted for publication elsewhere except as a brief abstract in the proceedings of a scientific meeting or symposium.

Acknowledgements

The authors wanted to show their gratitude to the imaging department at Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University that provided the samples.

Lu Jiang and Tianyu Liu are the authors who contributed equally to this work.

Lu Jiang and Tianyu Liu should be considered joint first authors.

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