Bone spurs

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit

There are three type of bone spurs.

The first are osteophytes that grow near joints affected by osteoarthritis. Osteoarthritis is a disease that affects the cartilage that cushions the ends of bones in the joints. Over time, this cartilage wears down and and roughens. Eventually, if cartilage is worn away enough, underlying bone is exposed.

The body's attempt to repair this problem is what leads to growth of new bone along the side of already existing bone. This new growth is what causes osteophyte formation. They are common features of the osteoarthritic shoulder, elbow, hip, knee and ankle. Removing these osteophytes is an important part of treatment.

A second type of bone spur is the kind that occurs when the attachment of ligaments or tendons to bone become calcified. This can occur at the back of the heel at the attachment of the Achilles tendon, at the bottom of the heel where the plantar fascia attaches, and in the coroacoacromial ligament of the shoulder.

The third type of spur occurs as a result of trauma to a bone or joint. As the body tries to heal this damage, new bone growth can develop causing a bone spur in that location.

Hallux rigidus is the term for arthritis affecting the big toe. The joint at the base of the big toe is called the metatarophalangeal joint, or MTP joint. This joint is especially prone to developing arthritis. In fact, hallux rigidus, or big toe arthritis, is the most common site of arthritis in the foot.

The most common symptom, and the most common reason to seek medical attention for this problem, is pain at the base of the big toe. This pain is worsened with activity, especially running or jumping. Often wearing firm soled shoes that prevent motion at the base of the big toe will help relieve symptoms.

The most common treatments include:

•Wearing stiff-soled shoes that limits motion at the base of the big toe. Other shoe-wear modifications include shoes with a wider toe box, or rocker-bottom heels that allow foot motion without as much bending at the great toe.

•Anti-inflammatory medications decrease pain and swelling. If these are not effective, injection of cortisone may be considered.

•Surgery is sometimes the best treatment for hallux rigidus. The two most common surgical procedures are called a chilectomy or an arthrodesis (fusion). A cheilectomy is removal of bone spurs. This helps if the spurs are causing restriction of joint motion. However, if the joint cartilage is worn, a cheilectomy will not work. An arthrodesis may be needed. It is an excellent procedure for eliminating pain, but it will cause the toe to lose range of motion.

There are many causes for heel pain, but one of the most common causes of heel pain is inflammation of the plantar fascia (plantar fasciitis). This inflammation may lead to the formation of a traction spur. The inflammation is due to repetitive and excessive stretching of the plantar fascia.

Most people develop irritation and inflammation of the plantar fascia because of “overuse”, resulting in excessive pronation (inner turning of feet). The injury may also result in small tears of the plantar fascia.

The pain may either be aching or sharp and can be reproduced by dorsiflexion of the toes. Symptoms tend to worsen after a period of inactivity, then standing and walking. This happens because the fascia is stressed again after a period of rest. As the person walks, the fascia lengthens, reducing the tension and the associated pain.

The repetitive stretch of the fascia irritates the insertion site of the fascia to the heel bone and causes the growth of a hook-shaped spur. A common misconception is that the heel pain is due to the bone spur. The truth is that the pain is due primarily to the inflammation of the fascia and not the bone spur. Significant heel pain can occur in the absence of spurs, and large bone spurs can be detected on x-ray in people with no heel pain.

The treatments recommended for plantar fasciitis include symptomatic treatment for pain, treatment aimed at improving blood flow to the heel, anti-inflammatory medications, and reduction of stress on the plantar fascia.

Physical therapy with ultrasound treatment and electrical stimulation is helpful.

A custom splint worn at night to keep the plantar fascia stretched is sometimes effective. Another modality is taping of the feet with athletic tape. Wearing shoes with higher than ordinary heels, firm heel pads, arch supports, or special orthototics are other things that work. Special exercises that stretch the Achilles tendon and reduce the stress on the plantar fascia also can help. Sometimes a patient needs to replace weight-bearing exercise with non weight-bearing sports such as swimming. Weight loss reduces the load on the affected heel.

Percutaneous needle tenotomy using ultrasound guidance with platelet-rich plasma is usually curative. Ultrasound guided injection of Botox can also releive pain. Shock wave therapy is another effective modality.

Surgery is usually done under local anesthesia and consists of a fascia release procedure in which the fascia is partially cut to release the tendon’s tension.

The ankle may also be affected by spur formation. The ankle consists of two joints. The upper ankle joint is composed of three bones:

• the shinbone (tibia)
• the other bone of the lower leg (fibula)
• the anklebone (talus)

This is called the tibial talar joint and allows the foot to plantar and dorsiflex.

Below the tibial talar joint is another joint (subtalar), where the talus connects to the heel bone (calcaneus). This joint enables the foot to move from side to side.

Most bone spurs in the ankle are caused by osteoarthritis.

Bone spurs can also be caused by an injury to the ankle joint.

Bone spurs in the fingers are caused by osteoarthritis. Nodules affecting the outer row of joints (distal interphalangeal joints) are called Heberdens nodes and the spurs that affect the next row in (proximal interphalageal joints) are called Bouchards nodes. Bone spurs can also be caused by an injury to a finger joint.

Most bone spurs in the elbow are caused by osteoarthritis. Bone spurs can also be caused by an injury to the elbow joint. Removal by tenotomy and ultrasound guided injections of platelet-rich plasma (PRP) can be helpful.

Bone spurs are common in the hip joints. Most bone spurs in the hip are caused by osteoarthritis. They tend to grow outward from the acetabulum (the cup-like part of the pelvis that articulates with the femur).

There are two common locations for bone spurs in the shoulder. Spurs involving the acromioclavicular (where the clavicle meets the scapula) and the glenohumeral (where the humerus meets the scapula) joints are the most common and are caused by osteoarthritis.

Injections of steroid, platelet-rich plasma (PRP), and tenotomy to remove the spurs is often successful.

One of the more common locations for bone spurs is the spine.

The most common cause of cervical and lumbar arthritis is repetitive trauma to the spine from excess strain. Patients may typically develop symptoms of osteoarthritis in their mid 40’s to early 50’s.

Also, enlargement of bony spurs can lead to narrowing of the spinal canal and result in spinal stenosis. This condition can cause nerve and cord compression, leading to pain down the legs that is worse when the patient stands and walks, and is better when sitting.

The symptoms of bone spurs are made worse with activity and often improve with rest. Lumbar arthritis symptoms that cause stenosis, often improve when an individual is bending forward and flexing at the waist, such as leaning over a shopping cart or over a cane.

As the nerves become compressed and irritated, patients with bone spurs complain of several symptoms including:

• Pain in one or both arms or legs
• Numbness or tingling
• Progressive weakness
• If the arthritic processes and stenosis is severe, progressive bowel and bladder dysfunction occurs

Common diagnostic tests include:

The EMG and nerve conduction test (EMG/NCV) tests will help diagnose nerve root compression in the spine and exclude peripheral nerve compression such as carpal tunnel syndrome.

Imaging procedures such as x-ray, computerized tomography (CT scans) with myelography, and/or MRI scans can provide details about spinal architecture and the degree of nerve compression.

Most patients with mild or moderate nerve compression and irritation from bone spurs can be managed with conservative care, such as:

• Medication, such as anti-inflammatory medications and muscle relaxant pain medications, for approximately 4 to 6 weeks.
• Rest is appropriate early on.
• After 1-2 weeks, physical therapy, exercise and manipulation often alleviates the painful joint conditions.
• Glucocorticoid (epidural steroid) injections have potential therapeutic value for some patients with facet joint inflammation by reducing the joint swelling and improving spinal pain and radiating extremity pain syndromes.

Spine specialist consultation is appropriate if these conservative measures to treat bone spurs fail.

Surgery (such as a laminectomy) relieves the pain and neurological symptoms by removing the bone spurs and thickened ligaments causing painful nerve compression. The majority of patients who undergo surgery for bone spurs have good results, often gaining years of relief and improved quality of life.

Spine surgery for bone spurs becomes necessary if nerve or spinal cord compression is either causing unremitting pain or neurologic loss is documented on examination.

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