0198-0211/92/1306-0352$03,00/0 FOOT
&
ANKLE
Copyright © 1992 by the American Orthopaedic Foot Society, Inc,
Calcaneal Spurs in a Black African Population Bezarel M. Banadda, M.D.: Ophelia Gona, M.D.:·t Raquel Vaz, M.D.: and Dumisani M. Ndlovu, M.D.:f: Harare, Zimbabwe and Newark, New Jersey
ABSTRACT The radiological incidence of calcaneal spurs in a black African population was studied. Our findings show that spur incidence increased with age and was greater in females than in males. These results, the first from a large, exclusively African population, are similar to those from previous studies of individuals from other continents.
nated, as were radiographs from patients who were not black. The radiographs were examined on a standard view box under subdued lighting conditions. Data were taken concerning patient's name, age, race, diagnosis, and occurrence of calcaneal spurs. Any deviation from the normal rounded configuration of a calcaneal tuberosity to a sharp and pointed structure, however small, was classified as a spur. Other desirable data, such as reason for x-ray, existence of other foot problems, occupation, and weight, were not taken because they were usually not available. For analysis of data, patient
INTRODUCTION
Calcaneal spurs have been reported to occur in 11% to 16% of normal individuals.4 ,8 ,9 However, prevalence data on these exostoses have come almost exclusively from European and North American populations; apparently, no studies had been done on a black African population. The present retroactive study has addressed this deficit by investigating the incidence of calcaneal spurs among black Zimbabweans. MATERIALS AND METHODS
The data were obtained from the section of the archives of the Casualty (Le., Accident and Emergency) Department of Parirenyatwa Hospital in Harare, Zimbabwe that covered the 11-year period from 1979 to 1990. Parirenyatwa is a referral teaching hospital that, since 1980, has served a predominantly black African population. The Casualty Department was selected because, compared with most other departments, its patients were less likely to have presented with chronic medical problems and because its archives were readily accessible to us. Slightly more than 1500 radiographs of feet showing the calcaneus in lateral view (Fig. 1) were retrieved according to alphabetical order. Radiographs from patients with known rheumatological disease were elimi-
Fig. 1. Radiograph of heel of an adult female black African shOWing both posterior and inferior calcaneal spurs (arrows). TABLE 1 Incidence of Inferior Calcaneal Spurs in Sample Black Population from Parirenyatwa Hospital, 1979-1990 Age (years)
+
No. of inferior spurs
Male
Female
Male
Female
50 60 84 47 22 13 137
0 4 21 14
0 1 10
9
7
14 44
9
Adult
66 114 186 87 46 33 283
37
Totals
815
413
106
73
0-10 11-20 21-30 31-40 41-50 51+
• Department of Anatomy, University of Zimbabwe, Harare, Zimbabwe. t Department of Anatomy, UMDNJ-New Jersey Medical School, Newark, New Jersey. To whom requests for reprints should be addressed at Department of Anatomy, UMDNJ-New Jersey Medical School, 185 South Orange Ave., Newark, New Jersey 07103. Department of Radiology, University of Zimbabwe.
No. of patients
352
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9
Foot & AnklejVol. 13, No. 6/July/August 1992
CALCANEAL SPURS
353
50
50
40
% F r
30
e Fig. 2 Percentage of frequency of calcaneal spurs in entire population.
q u
e
n 20
c y 10
0+,----,0-10
11-20
21-30
31-40 Years of Age
41-50
51+
Adutt
70
60
%
50
F r 40
e
q u
e
Fig. 3 Sex frequency distribution of calcaneal spurs.
30
n C
y 20
10
0-10
11 - 20
21 - 30
31 - 40
41 - 50
51+
Adult
Years of Age
records were grouped by 10-year age intervals. Because of the small number of patients in each decade for the older ages, all patients above age 50 were placed in a single group. A separate grouping was used for cases in which the patient's age was given simply as "adult." In the few cases where images of both feet were available, data were only used for the left foot. RESULTS
The results, obtained from 1228 patients and summarized in Table 1 and Figures 2 and 3, show that although three-fourths of the total patient pool was above 20 years of age, 97% of the calcaneal spurs
were found in adult patients. Spur frequency increased with increasing age, peaking after the fifth decade of life (Fig. 2). The vast majority of spurs (N = 179) were of the inferior type, although three instances of posterior spurs were observed, with two of these appearing simultaneously with inferior spurs. Interestingly, two thirds of the patients were males, yet spurs were present more frequently among females of all adult age groups (Fig. 2). This sex difference became more apparent with increasing age. Among the adults of unspecified age, the incidence of calcaneal spurs in females was approximately twice what it was in males. Overall, 13.0% of the males presented with spurs compared with 17.7% of the females. The sex
Downloaded from fai.sagepub.com by guest on April 16, 2016
354
BANADDA ET AL.
Foot & AnklejVol. 13, No. 6/July/August 1992
difference in the occurrence of calcaneal spurs was significant (x 2 ) at the -P < 0.05 level. DISCUSSION
Development of calcaneal spurs, as well as other bony exostoses, seems to be a part of the aging process. This normal tendency is likely to be accentuated by disease and other processes known to increase in frequency with aging. Hence, it is not surprising that, like other investigators, we observed an increase in the percentage of frequency of calcaneal spurs after age 50 (Fig. 2). The incidence of calcaneal spurs (14.6%) in the study population was within the range reported by other investigators (namely, range 11-16% in normal individuals).2,4,8,9 This finding suggests that, in addition to age, the same factors (e.g., excessive weight4,5; abnormal foot biomechanics 1,3,4,6,7,1o; rheumatological diseases 2,5,8) influence the formation of calcaneal spurs in all human populations. However, two observations that may have bearing on this conclusion need to be made. First, calcaneal spurs are said to be associated with excessive weight,4,5 but this condition is not as common among Zimbabweans as it is among Europeans. Second, foot biomechanics may differ among populations and, thus, may play a varying role in influencing spur formation in different groups of humans. It is noteworthy that despite our study population being composed of an excess of males, heel spurs were more likely to be present in females. A similar finding was reported by Shama et al." We offer no explanation for this finding. Finally, the findings that (1) 20% of the patients with heel spurs were less than 31 years old and (2) within
these younger groups there was a greater tendency for males to have heel spurs should not be ignored. We believe this implies that lifestyle (and perhaps cultural practices) may play an unappreciated role in the development of calcaneal spurs. The possibility of such influences should be borne in mind when evaluating the relationship between disease and the presence of heel spurs.
REFERENCES 1. Appenzeller, 0.: Sports Medicine: Fitness, Training, Injuries, 3rd Ed. Baltimore, Urban & Schwarzenberg, 1988, pp. 471-472. 2. Bassiouni, M.: Incidence of calcaneal spurs in osteo-arthrosis and rheumatoid arthritis, and in control patients. Ann Rheum. Dis., 24:490-493,1965. 3. Doxey, G.E.: Calcaneal pain: a review of various disorders. J. Orthop. Sports Phys. Ther., 9:25-32,1987. 4. DuVries, H.L.: Heel spur. Arch Surg., 74:536-542,1957. 5. Furey, G.: Plantar fasciitis: the painful heel syndrome. J. Bone Joint Surg., 57:672-673, 1975. 6. Giannestras, N.J.: Problems of the tarsal portion of the foot in the adolescent and the adult. In Giannestras, N.J. Foot Disorders: Medical and Surgical Management, 2nd Ed. Giannestras, N.J. (ed.), Philadelphia, Lea & Febiger, 1973, pp. 565-591. 7. Gould, E.A.: Three generations of exostoses of the heel inherited from father to son. J. Heredity, 33:228,1942. 8. Kosmahl, E.M., and Kosmahl, H.E.: Painful plantar heel, plantar fasciitis, and calcaneal spur: etiology and treatment. J. Orthop. Sports Phys. Ther., 9:17-24, 1987. 9. McCarthy, D.J., and Gorecki, G.E.: The anatomical basis of inferior calcaneal lesions. J. Am. Podiatr. Assoc., 69:527-536, 1979. 10. Rubin, G., and Witten, M.: Plantar calcaneal spurs. Am. J. Orthop., 5:38-41,53,1963. 11. Shama, 5.5., Kominsky, S.J., and Lemont, H.: Prevalence of non-painful heel spur and its relation to postural foot position. J. Am. Podiatry Assoc., 73:122-123,1983.
Downloaded from fai.sagepub.com by guest on April 16, 2016
&
ANKLE
Copyright © 1992 by the American Orthopaedic Foot Society, Inc,
Calcaneal Spurs in a Black African Population Bezarel M. Banadda, M.D.: Ophelia Gona, M.D.:·t Raquel Vaz, M.D.: and Dumisani M. Ndlovu, M.D.:f: Harare, Zimbabwe and Newark, New Jersey
ABSTRACT The radiological incidence of calcaneal spurs in a black African population was studied. Our findings show that spur incidence increased with age and was greater in females than in males. These results, the first from a large, exclusively African population, are similar to those from previous studies of individuals from other continents.
nated, as were radiographs from patients who were not black. The radiographs were examined on a standard view box under subdued lighting conditions. Data were taken concerning patient's name, age, race, diagnosis, and occurrence of calcaneal spurs. Any deviation from the normal rounded configuration of a calcaneal tuberosity to a sharp and pointed structure, however small, was classified as a spur. Other desirable data, such as reason for x-ray, existence of other foot problems, occupation, and weight, were not taken because they were usually not available. For analysis of data, patient
INTRODUCTION
Calcaneal spurs have been reported to occur in 11% to 16% of normal individuals.4 ,8 ,9 However, prevalence data on these exostoses have come almost exclusively from European and North American populations; apparently, no studies had been done on a black African population. The present retroactive study has addressed this deficit by investigating the incidence of calcaneal spurs among black Zimbabweans. MATERIALS AND METHODS
The data were obtained from the section of the archives of the Casualty (Le., Accident and Emergency) Department of Parirenyatwa Hospital in Harare, Zimbabwe that covered the 11-year period from 1979 to 1990. Parirenyatwa is a referral teaching hospital that, since 1980, has served a predominantly black African population. The Casualty Department was selected because, compared with most other departments, its patients were less likely to have presented with chronic medical problems and because its archives were readily accessible to us. Slightly more than 1500 radiographs of feet showing the calcaneus in lateral view (Fig. 1) were retrieved according to alphabetical order. Radiographs from patients with known rheumatological disease were elimi-
Fig. 1. Radiograph of heel of an adult female black African shOWing both posterior and inferior calcaneal spurs (arrows). TABLE 1 Incidence of Inferior Calcaneal Spurs in Sample Black Population from Parirenyatwa Hospital, 1979-1990 Age (years)
+
No. of inferior spurs
Male
Female
Male
Female
50 60 84 47 22 13 137
0 4 21 14
0 1 10
9
7
14 44
9
Adult
66 114 186 87 46 33 283
37
Totals
815
413
106
73
0-10 11-20 21-30 31-40 41-50 51+
• Department of Anatomy, University of Zimbabwe, Harare, Zimbabwe. t Department of Anatomy, UMDNJ-New Jersey Medical School, Newark, New Jersey. To whom requests for reprints should be addressed at Department of Anatomy, UMDNJ-New Jersey Medical School, 185 South Orange Ave., Newark, New Jersey 07103. Department of Radiology, University of Zimbabwe.
No. of patients
352
Downloaded from fai.sagepub.com by guest on April 16, 2016
9
Foot & AnklejVol. 13, No. 6/July/August 1992
CALCANEAL SPURS
353
50
50
40
% F r
30
e Fig. 2 Percentage of frequency of calcaneal spurs in entire population.
q u
e
n 20
c y 10
0+,----,0-10
11-20
21-30
31-40 Years of Age
41-50
51+
Adutt
70
60
%
50
F r 40
e
q u
e
Fig. 3 Sex frequency distribution of calcaneal spurs.
30
n C
y 20
10
0-10
11 - 20
21 - 30
31 - 40
41 - 50
51+
Adult
Years of Age
records were grouped by 10-year age intervals. Because of the small number of patients in each decade for the older ages, all patients above age 50 were placed in a single group. A separate grouping was used for cases in which the patient's age was given simply as "adult." In the few cases where images of both feet were available, data were only used for the left foot. RESULTS
The results, obtained from 1228 patients and summarized in Table 1 and Figures 2 and 3, show that although three-fourths of the total patient pool was above 20 years of age, 97% of the calcaneal spurs
were found in adult patients. Spur frequency increased with increasing age, peaking after the fifth decade of life (Fig. 2). The vast majority of spurs (N = 179) were of the inferior type, although three instances of posterior spurs were observed, with two of these appearing simultaneously with inferior spurs. Interestingly, two thirds of the patients were males, yet spurs were present more frequently among females of all adult age groups (Fig. 2). This sex difference became more apparent with increasing age. Among the adults of unspecified age, the incidence of calcaneal spurs in females was approximately twice what it was in males. Overall, 13.0% of the males presented with spurs compared with 17.7% of the females. The sex
Downloaded from fai.sagepub.com by guest on April 16, 2016
354
BANADDA ET AL.
Foot & AnklejVol. 13, No. 6/July/August 1992
difference in the occurrence of calcaneal spurs was significant (x 2 ) at the -P < 0.05 level. DISCUSSION
Development of calcaneal spurs, as well as other bony exostoses, seems to be a part of the aging process. This normal tendency is likely to be accentuated by disease and other processes known to increase in frequency with aging. Hence, it is not surprising that, like other investigators, we observed an increase in the percentage of frequency of calcaneal spurs after age 50 (Fig. 2). The incidence of calcaneal spurs (14.6%) in the study population was within the range reported by other investigators (namely, range 11-16% in normal individuals).2,4,8,9 This finding suggests that, in addition to age, the same factors (e.g., excessive weight4,5; abnormal foot biomechanics 1,3,4,6,7,1o; rheumatological diseases 2,5,8) influence the formation of calcaneal spurs in all human populations. However, two observations that may have bearing on this conclusion need to be made. First, calcaneal spurs are said to be associated with excessive weight,4,5 but this condition is not as common among Zimbabweans as it is among Europeans. Second, foot biomechanics may differ among populations and, thus, may play a varying role in influencing spur formation in different groups of humans. It is noteworthy that despite our study population being composed of an excess of males, heel spurs were more likely to be present in females. A similar finding was reported by Shama et al." We offer no explanation for this finding. Finally, the findings that (1) 20% of the patients with heel spurs were less than 31 years old and (2) within
these younger groups there was a greater tendency for males to have heel spurs should not be ignored. We believe this implies that lifestyle (and perhaps cultural practices) may play an unappreciated role in the development of calcaneal spurs. The possibility of such influences should be borne in mind when evaluating the relationship between disease and the presence of heel spurs.
REFERENCES 1. Appenzeller, 0.: Sports Medicine: Fitness, Training, Injuries, 3rd Ed. Baltimore, Urban & Schwarzenberg, 1988, pp. 471-472. 2. Bassiouni, M.: Incidence of calcaneal spurs in osteo-arthrosis and rheumatoid arthritis, and in control patients. Ann Rheum. Dis., 24:490-493,1965. 3. Doxey, G.E.: Calcaneal pain: a review of various disorders. J. Orthop. Sports Phys. Ther., 9:25-32,1987. 4. DuVries, H.L.: Heel spur. Arch Surg., 74:536-542,1957. 5. Furey, G.: Plantar fasciitis: the painful heel syndrome. J. Bone Joint Surg., 57:672-673, 1975. 6. Giannestras, N.J.: Problems of the tarsal portion of the foot in the adolescent and the adult. In Giannestras, N.J. Foot Disorders: Medical and Surgical Management, 2nd Ed. Giannestras, N.J. (ed.), Philadelphia, Lea & Febiger, 1973, pp. 565-591. 7. Gould, E.A.: Three generations of exostoses of the heel inherited from father to son. J. Heredity, 33:228,1942. 8. Kosmahl, E.M., and Kosmahl, H.E.: Painful plantar heel, plantar fasciitis, and calcaneal spur: etiology and treatment. J. Orthop. Sports Phys. Ther., 9:17-24, 1987. 9. McCarthy, D.J., and Gorecki, G.E.: The anatomical basis of inferior calcaneal lesions. J. Am. Podiatr. Assoc., 69:527-536, 1979. 10. Rubin, G., and Witten, M.: Plantar calcaneal spurs. Am. J. Orthop., 5:38-41,53,1963. 11. Shama, 5.5., Kominsky, S.J., and Lemont, H.: Prevalence of non-painful heel spur and its relation to postural foot position. J. Am. Podiatry Assoc., 73:122-123,1983.
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