Eur J Orthop Surg Traumatol DOI 10.1007/s00590-014-1482-4

ORIGINAL ARTICLE

Role of radiotherapy in the management of heel spur Bora Uysal • Murat Beyzadeoglu • Omer Sager • Selcuk Demıral • Hakan Gamsız • Ferrat Dıncoglan Mustafa Akın • Bahar Dırıcan



Received: 23 December 2013 / Accepted: 6 May 2014 Ó Springer-Verlag France 2014

Abstract Aims and background The purpose of this study is to investigate the use of low-dose radiotherapy (RT) in benign painful heel spur management. Methods Between the years of 2009 and 2012, in Gulhane Military Medical Academy Radiation Oncology Department, patients with heel spur undergoing radiotherapy for pain relief were analyzed retrospectively. In the evaluation of treatment response, Verbal Numeric Scale (VNS) scoring method was used to compare the pain status before and after radiotherapy. Age, gender, laterality, VNS score before RT, VNS score after RT, RT doses of the patients and patients undergoing second course of radiotherapy were recorded. All patients received 8 Gy RT in two fractions with Co-60 teletherapy machine. Statistical Package for Social Sciences, version 16.0 was used for data analysis with the level of significance set at p \ 0.05. Results The total number of patients receiving RT for heel spur pain was 450. Median age was 52 years (range 40–85 years). Two hundred and ninety-two (65 %) of the patients were women and 158 (35 %) were men. Radiologically calcaneal spurs were bilateral in 432 (96 %) patients, whereas unilateral left in 8 (1.8 %) patients and unilateral right heel location in 10 (2.2 %) patients. Ten (2.2 %) of the patient group received second course of RT due to refractory pain. Comparative evaluation of VNS scores before and after RT revealed statistically significant pain relief by radiotherapy (p \ 0.05).

B. Uysal (&)  M. Beyzadeoglu  O. Sager  S. Demıral  H. Gamsız  F. Dıncoglan  M. Akın  B. Dırıcan Department of Radiation Oncology, Gulhane Military Medical Academy, Gn. Tevfik Saglam Cad., 06018 Etlik, Kecioren, Ankara, Turkiye e-mail: [email protected]

Conclusion Low-dose radiotherapy is an effective and reliable painkilling treatment method that can be used in the treatment of epin calcanei refractory to medical and surgical treatment. Keywords Treatment

Epin calcanei  Heel spur  Radiotherapy 

Introduction Heel spur, described initially by Piettner in 1900, is the most frequent reason of the calcaneal pain. Painful heel spur with typical radiological appearance is a prevalent entity worldwide despite the fact that some cases are asymptomatic. There is not a distinct relation between the intensity of pain symptoms and the size of the calcaneal spur [1]. Although the etiological mechanism of heel spur is not that clearly known, it can be explained by microtrauma and conglomeration of ossification consistent with the pressure exerted on nervus suralis and nervus tibialis posterior [2]. Calcaneal spur has tendency to occur in persons with high body mass index, Reiter’s syndrome, rheumatoid or chronic arthritis and in women over the age of 40 years [3]. Particularly, the pain is characterized by becoming manifest as a result of walking and standing as matutinal pain. Surgery, physiotherapy, steroid injection and RT are used in the treatment of epin calcanei. The surgical methods that have been used for patients who are refractory to conservative medical treatment include excision of the heel spur or surgical operations to release excessive tightness of the plantar fascia [4]. Physiotherapy modalities involve in sock, heel cup and orthopedic shoe usage. Medically, nonsteroidal anti-inflammatory drugs and local steroid injections may be used. Laser, microwave and ultrasound therapies are also

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Eur J Orthop Surg Traumatol Table 1 Patient characteristics Number of patients

450

Gender

65 % (female) 35 % (male)

Median age

52 (range 40–85)

Laterality

96 % (bilateral) 1.8 % (left) 2.2 % (right)

Reirradiation

2.2 %

Median VNS score

8 (range 4–10) (before RT) 1 (range 0–3) (after RT) p \ 0.05

the alternative physiotherapy modalities [5]. Electrophoresis with acetic acid, laseropuncture and massage are the experimental treatment methods [6]. Low-dose radiotherapy may be a therapeutic option for the management of painful epin calcanei when surgical and conservative treatments have failed [7]. In this study, we evaluated the use of radiotherapy in the management of 450 patients with refractory painful heel spurs who were referred to Gulhane Military Medical Academy (GMMA) Radiation Oncology Department between 2009 and 2012.

undergoing reirradiation. Primary endpoint was pain relief. VNS scores before RT and after RT were compared with student’s t test.

Results All patients were followed-up for a period of at least 1 year. Two hundred and ninety-two (65 %) of the patients were women and 158 patients (35 %) were men. Median age was 52 years (range 40–85 years). Heel spurs were bilateral in 432 patients (96 %), located on the left calcaneus in 8 patients (1.8 %), and in right calcaneus in 10 patients (2.2 %). Ten patients (2.2 %) received a second course of RT at least one year after completion of the first treatment. Four hundred and forty patients (97.8 %) had satisfactory pain relief with a single course of RT. The median VNS score before RT was 8 (range 4–10), whereas median VNS score after RT was 1 (range 0–3). Comparative evaluation of VNS scores before and after RT revealed statistically significant pain relief by RT (p \ 0.05).

Methods Discussion Between 2009 and 2012, a total of 450 patients underwent RT for painful heel spurs at GMMA Radiation Oncology Department. Age, gender, laterality, reirradiation posture, Verbal Numeric Scale (VNS) scores before and after 6 months of the completion of RT were recorded. Informed consents of all patients were taken before treatment. Patient characteristics are shown in Table 1. All patients were radiologically planned by X-ray 2D (dimensional) simulator with both soles in contact. Bilateral calcaneal spurs were included in treatment area. If the heel spur is unilateral, the second calcaneus was not included in treatment planning. At the end of 2D planning, treatment fields were determined and marked on the heels of the patient with permanent pen. After immobilization, all patients received a total dose of 8 Gy delivered in two fractions over two consecutive days using anteroposterior and posteroanterior treatment portals. VNS scores of all patients were recorded in the sixth month before and after RT. VNS is a pain scale in which the patient is asked to score the pain individually and accordingly to state a score number between 0 and 10, with the scale of zero for no pain and 10 for irresistable pain [8]. Statistical Package for Social Sciences, version 16.0 (SPSS, Inc., Chicago, IL) was used for data analysis with the level of significance set at p \ 0.05. Assessed parameters included age, gender, median VNS scores before and after RT and frequency of patients

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Heel spur is a rare calcaneal form of benign exostosis presenting with slight to intractable pain in the plantar region. Despite the use of various therapeutic options, treatment success in terms of pain relief is still debated. RT may be used in the management of this painful condition when surgical and conservative treatments have failed. Micke et al. evaluated the efficiency of RT in painful calcaneal spur treatment in 3,621 patients. The study included patients receiving reirradiation for refractory pain who had complete relief of persisting pain [9]. In another retrospective study by Mucke et al. [10], commencing RT within 6 months of onset of pain symptoms was recommended. In the study by Niewald et al. [11], comparing single 6 Gy RT and single 0.6 Gy RT, patients in the 6 Gy single dose RT arm had no need of reirradiation, whereas patients in the 0.6 Gy RT arm required reirradiation due to refractory pain. In a study with 46 patients receiving calcaneal spur RT, Miszczyk et al. [12] concluded that RT offered an easy, efficient and reliable therapeutic option for epin calcanei management. In the study by Heyd et al. [13], no significant difference was found when total 3 and 6 Gy RT doses were compared. In our study, a total RT dose of 8 Gy was used in the treatment of all patients and the RT fields encompassed unilateral or bilateral epins. Carcinogenic risk after RT was reported to be significantly low in a study by Muecke et al. [14]. No treatment-related adverse affects were noted in the

Eur J Orthop Surg Traumatol

study by Ulutin et al. [15]. In another article by Niewald et al. [16], pain relief achieved at 3 months after RT was the primary endpoint for therapeutic success. Even though the mechanism of action in calcaneal spur RT is debatable [17], it was recommended that RT might be used as the primary treatment particularly in elderly patients in the studies by Schneider and Seegenschmiedt et al. [18, 19]. In conclusion, low-dose radiotherapy is an effective and reliable painkilling treatment method that can be used in the treatment of epin calcanei refractory to medical and surgical treatment. Conflict of interest

There is no conflict of interest.

References 1. Savas S (2009) Periarticular foot and ankle disorders. Turk J Phys Med Rehab 55(1):35–40 2. Kuma T, Benjamin M (2002) Heel spur formation and the subcalcaneal enthesis of the plantar fascia. J Rheumatol 29:1957–1964 3. Menz HB, Zammit GV, Landong KB, Muntenau SE (2008) Plantar calcaneal spurs in older people: longitudinal traction or vertical compression? J Foot Ankle Res 1(1):7 4. Karalezli K, Karakoc Y, Karalezli N, Iltar S, Alemdaroglu B, Demir R (2003) Surgical treatment in epin calcanei. J PMR Sci 6(1):25–27 5. Yuzer S, Sever A, Gurcay E, Unlu E, Cakcı A (2006) Comparison of the effectiveness of laser therapy and steroid injection in epin calcanei. Turk J Phys Med Rehab 52(2):68–71 6. Samoilovych VA (2007) Use of the electrophoresis with acetic acid in a complex treatment of heel spurs at a sanatorium. Lif sprava 5–6:97–100 7. Micke O, Seegenschmiedt MH (2008) Radiotherapy for painful heel spurs. MMW Fortschr Med 16:32–34 8. Young DM, Mentes JC, Titler MG (1999) Acute pain management protocol. J Gerontol Nurs 25(6):10–21

9. Micke O, Seegenschmiedt MH (2004) Radiotherapy in painful heel spurs (plantar fasciitis)-results of a national patterns of care study. Int J Radiat Oncol Biol Phys 58(3):828–843 10. Mucke R, Schonekaes K, Micke O, Seegenschmiedt MH, Berning D, Heyder R (2003) Low-dose radiotherapy for painful heel spur. Retrospective study of 117 patients. Strahlenther Onkol 179(11):774–778 11. Niewald M, Seegenschmiedt MH, Micke O, Graeber S, Muecke R, Schaefer V (2012) Randomized, multicenter trial on the effect of radiation therapy on plantar fasciitis (painful heel spur) comparing Standard dose with a very low dose: mature results after 12 months follow-up. Int J Radiat Oncol Biol Phys 84(4):455–462 12. Miszczyk L, Wozniak G, Jochymek B, Trela K, Urban A (2003) Evaluation of the effectiveness of the calcaneal spurs radiotherapy. Chir Narzadow Ruchu Ortop Pol 68(3):191–195 13. Heyd R, Tselis N, Ackermann H, Ro¨ddigger SJ, Zamboglou N (2007) Radiation therapy for painful heel spurs: results of a prospective randomized study. Strahlenther Onkol 183(1):3–9 14. Muecke R, Micke O, Reichl B, Heyder R, Prott FJ, Seegenschmiedt MH (2007) Demographic, clinical and treatment related predictors for event-free probability following low-dose radiotherapy for painful heel spurs-a retrospective multicenter study of 502 patients. Acta Oncol 46(2):239–246 15. Ulutin C, Guden M, Komurcu M, Surenkok S, Oysul K, Pak Y (2000) Radiotherapy results in our heel spur cases. Gulhane Med J 42(4):344–346 16. Niewald M, Seegenschmiedt MH, Micke O, Gra¨ber S (2008) Randomized multicenter trial on the effect of radiotherapy for plantar Fasciitis (painful heel spur) using very low doses-a study protocol. German Cooperative Group on the Radiotherapy for Benign Diseases of the DEGRO German Society for Radiation Oncology. Radiat Oncol 3:27 17. Schafer U, Micke O, Glasho¨rster M, Ru¨be C, Prott FJ, Willich N (1995) The radiotherapy treatment of painful calcaneal spurs. Strahlenther Onkol 171(4):202–206 18. Schneider O, Stucke CA, Bosch E, Gott C, Adamietz IA (2004) Effectiveness and prognostic factors of radiotherapy for painful plantar heel spurs. Strahlenther Onkol 180(8):502–509 19. Seegenschmiedt MH, Keilholz L, Katalinic A, Stecken A, Sauer R (1996) Heel spur: radiation therapy for refractory pain-results with three treatment concepts. Radiology 200(1):271–276

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Role of radiotherapy in the management of heel spur.

The purpose of this study is to investigate the use of low-dose radiotherapy (RT) in benign painful heel spur management...
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