Surgery for Bone Spur on the Back of the Heel and Treatment for Top of Foot Pain in Singapore

The bone spur located on the back of the heel is a bony growth that is also known as a calcaneal heel spur. This condition can be a cause of pain at the back of the heel. This can occur with or without a plantar fasciitis. The location of the pain is usually the result of damage to the skin directly over the spur. This condition is commonly associated with an inflammation of the Achilles tendon. This is due to the tendency to walk with more weight on the ball of the foot because of the pain in the heel. This will result in the irritation of the plantar muscles on the bottom of the foot and the increase in tension of the Achilles tendon. A heel spur is caused by the displacement of calcium on the bone. This is a result of the continuous pulling of the plantar fascia, causing repeated minimal trauma. It is also common among athletes who run and jump. Osteoarthritis and decreased flexibility can also lead to the development of a calcaneal heel spur. Who is affected: An estimated 10% of the population will develop this condition, but only a small percentage have heel pain. This is an extremely painful and disabling condition.

Overview of bone spur on the back of the heel

A bone spur is a bony outgrowth that can occur on the edges of a bone. It is also called an osteophyte. The bone spur is usually a result of joint damage associated with osteoarthritis. The occurrence of a bone spur in the foot often provokes pain and inflammation due to pressure from footwear. As our feet are the foundation to our entire bodies, our feet must be able to handle the pressure of our body weight; therefore, extra bone will form as a reaction to the pressure. A bone spur can cause corns or calluses when tissue builds up to provide extra padding over the bone spur. Unfortunately, other bone spurs may exist without creating any symptoms. Often these spurs are found through an x-ray. The main reason a bone spur develops on the back of the heel is a result of the plantar fasciitis. The term plantar fasciitis means inflammation of the plantar fascia which is a thick band of connective tissue that runs along the underneath of the foot from the heel to the toes. The plantar fascia supports the foot arch and it has an important role in movement. If tension on this band of tissue becomes too great, damage to the plantar fascia may occur. A stress reaction from this damage may cause the formation of the bone spur. A bone spur at this location may also be accompanied with an Achilles tendon tightness. Often the repetitive pulling of the plantar fascia on the heel bone will cause inflammation to the surrounding tissue and a sensation of pain on the bottom of the foot.

Causes and symptoms of bone spur on the back of the heel

There is a lack of scientific data regarding disorder of the back of the heel. The cause of bone spurs has been attributed to an increase in walk or energy consuming activities by some, but the true cause is a result of friction and stress at the insertion of the Achilles tendon. Those who are afflicted with the problem of insertional Achilles tendinopathy have pain at the back of the heel which can be inflamed as bone spurs develop. The condition insertional Achilles tendinopathy is mainly a degenerative disorder with chronic activity-related pain, swelling and thickening of the Achilles tendon occurring at the insertion on the back of the heel. It can be difficult to differentiate between insertional Achilles tendinopathy and mucoid degeneration with a cyclops lesion as the pain and swelling mimics that of an inflamed Achilles tendon. Insertional Achilles tendinopathy is not associated with posterior ankle pain and walk or energy consumption increase, so those with this pattern of pain may be suffering from general inflammation around the Achilles tendon and are still in the early onset of insertional Achilles tendinopathy. Insertional Achilles tendinopathy with bone spur is more common in the age group 40-60 and those with diabetes are more prone to the development of bone spur due to impaired bone and joint health.

Treatment options for bone spur on the back of the heel

A way to test if it is the plantar fasciitis and not the spur that is causing the pain, we can use a local anesthetic and inject it into the area where the arch meets the heel. If symptoms are lessened, it is likely the pain is from the insertional plantar fasciitis. A recent foot pressure study done by surgeons in Evansville, Indiana shows that it is actually pain near the arch and not at the bottom of the heel which hurts most. A bad heel pain in the bottom of the heel at the spur site can lead to an alteration in gait and weight displacement as to alleviate pressure. This, in turn, may cause pain and discomfort on the sole near the arch at a later time. Heel spur syndrome patients rarely report any result in pain at the back of the heel.

When a patient does not improve with these treatments, an operative procedure may be needed to surgery to remove bone spur on back of heel. However, because a significant amount of the time with bone spurs at the heel, it is not the spur itself that is causing the pain. Knowing that bone spurs at the heel give an enclosure of the plantar fascia where it inserts under the foot. The symptoms are usually a sharp pain on the first step in the morning or after sitting for a prolonged period and usually decrease to a dull discomfort.

There are both non-operative and operative treatment options for heel spurs. Most patients with heel pain can be successfully treated without surgery by stretching the calf muscles and plantar fascia, icing the area, using an orthotic device or shoe insert. In more severe cases of spurs and prolonged symptoms, we sometimes use a corticosteroid injection to reduce inflammation and pain.

Top of foot pain: Causes and treatment

There are several causes of top of foot pain. The most common are acute or stress fracture of the 2nd, 3rd or 4th metatarsal bones, a sprained Lisfranc joint, or a condition known as metatarsalgia. Less common conditions causing pain at the top of the foot are a ganglionic cyst arising from a joint capsule or a neoplasm (tumor). Fractures are usually caused by a direct impact of the foot with another object, or by a sudden increase in load (e.g. starting running, or increase in training load). A stress fracture is usually caused by a relative insufficiency of bone strength to bone load i.e. doing a bit too much on a bit too little bone. A typical example might be a middle-aged female trying to return to netball or squash and getting foot pain. Lisfranc injuries are typically caused by an axial load to a dorsiflexed foot (e.g. missing a step and falling forwards). Metatarsalgia is a chronic overuse injury of the area of the foot just before the toes. It is common in many impact sports and involves inflammation of the soft tissues and sometimes swelling around the joints between the metatarsal bones and the bones of the toes. This can cause some deformity of the foot and can be associated with a painful callus on the sole. A ganglionic cyst is a quite specific diagnosis often found after a long duration of symptoms and possibly associated with a previous injury to a joint. A neoplasm causing top of foot pain is a very rare thing and is more an area of academic interest rather than a practical clinical problem.

Common causes of top of foot pain

Musculoskeletal injuries. Any injury to the bones, muscles or tendons in the foot can cause top of foot pain. The most common cause of a muscle-related injury is overuse, particularly in sports that require the athlete to push off of one’s toes. This may cause a muscle strain in some cases. A sudden injury such as getting stepped on can cause a foot contusion. A direct blow can cause a fracture of one of the metatarsal bones; this will cause pain at the site of the break and sometimes swelling that may migrate to the top of the foot. Fractures are diagnosed using an X-ray and treatment may involve surgery or immobilization of the foot in a rigid surgical shoe or a below the knee walking cast. An avulsion fracture may also occur, this is where the tendon pulls off a fragment of the bone. This occurs due to sudden trauma or powerful muscle contractions. This requires a similar treatment approach to a regular fracture. High ankle sprains have also been shown to cause top of foot pain. Arthritis. Arthritis is a condition where changes occur in the joints of the body. This can cause chronic pain, stiffness and swelling. There are many types of arthritis, the most common form is osteoarthritis. Osteoarthritis causes joint pain and stiffness due to the breakdown of joint cartilage. The cause of osteoarthritis is unknown although it may occur following a fracture, or other joint injury. It has also been shown to occur from ligament injuries in the foot. Arthritis injuries in the foot are best diagnosed using a combination of a physical examination from a doctor and an X-ray. Treatment may involve anti-inflammatory medication or in more severe cases corticosteroid injections. Weight loss can also help to lower the stress one puts on their joints.

Diagnosing top of foot pain

X-rays are a useful tool in diagnosing many conditions that cause pain on the top of the foot. There are many articulations and small joints in the midfoot which can be a hidden source of pain. Stress fractures of the metatarsal bones and the cuneiform bones are common. Arthritic changes in the big toe joint can also cause pain at times when the joint is stressed in specific shoes or activities. In many instances though the x-rays may be normal.

Clinical examination will be done to determine the location of the pain and the causative structure. Sometimes the exact cause of pain can be elusive, and diagnostic injections are helpful to determine exactly which region is causing the pain.

Various diagnostic techniques can be used to determine the cause of pain on the top of the foot. Your doctor will begin by taking a detailed history of when and how the pain began. Details such as the type of footwear worn, occupation, and specific types of physical activities and sports are important. It will also be helpful if the patient can remember if the pain began after a specific injury or incident.

Non-surgical treatment options for top of foot pain

Change in footwear: Footwear with a flexible sole or a large amount of lacing can cause the foot to bend more on each step. This increases the likelihood of the foot becoming strained, so it may be beneficial to wear supportive athletic footwear. Lace the footwear to provide a snug fit, reducing movement of the foot within the shoe. If the pain is located at the toe joints, it may be beneficial to wear footwear with a rocker sole to reduce bending of the toe joints.

Painkillers: If the pain is severe, painkillers such as ibuprofen or paracetamol may be used to reduce the pain. It is recommended to use painkillers with a gastrointestinal protectant, as some painkillers can cause stomach problems after long-term use.

Ice: Apply ice to the affected area for 15-20 minutes at a time, 3-4 times a day. Do not apply the ice directly and instead wrap it in a tea towel. Ice is effective at reducing pain and inflammation and is most effective in the first couple of days following the onset of pain.

Rest: It is important to rest as this will help the healing process. By reducing the amount of walking, running, or standing, the foot will heal faster and the pain will subside sooner.

Several simple non-surgical treatment options can help reduce strains and treat the pain on the top of the foot.

Surgical treatment options for top of foot pain

Bone spurs are thought to occur as a result of repetitive minor trauma that causes the body to deposit extra bone material in an attempt to thicken and protect the bone. Eventually, a bone spur can cause the tissues around it to become inflamed or cause a bursa to form, resulting in pain and reducing the range of motion in the joint. It was noted earlier that a bone spur on the top of foot pain treatment is often a result of a degenerative joint on the midfoot. The most common point of occurrence is at the top and inner side of the foot, near the base of the big toe. Here, a bone spur can cause a bunion to form and lead to bursitis. In severe cases, the damage is great enough to cause adjacent joints to become dislocated. This is a condition that will not improve on its own and will likely require surgical realignment. It is a similar case for a bone spur at the Lisfranc joint.

Surgery to remove bone spur on the back of the heel

The surgery is done with the patient lying on their stomach and a small incision is made on the back of the heel. The Achilles tendon is taken out of the way and the bursa that is on the back of the heel, between the skin and the bone, is removed. The spur is then identified and removed. Sometimes it is necessary to remove a piece of the heel bone. This is usually the case if there has been chronic, long-term inflammation which has resulted in non-reversible, degenerative change in the bone. A special type of X-ray, called a fluoroscopic image, is often used during the surgery to ensure that the bone spur has been completely removed. This is an outpatient procedure but the patient has to keep the foot in a dressing and avoid getting the wounds soaked in water, and hence staying off the foot for a length of time, often using crutches.

Preparing for surgery

This surgery is typically performed as outpatient surgery, so you will not need to stay in the hospital overnight. Make a list of any medications you take (including over-the-counter medications). If the surgeon thinks it is helpful, you may be asked to stop taking some of them prior to surgery. Additionally, you will be asked to fast for about six hours prior to your surgery. Arrange for someone to drive you to and from surgery and to stay with you for at least the first night following surgery. Find out if your surgeon would like a pre-operative medical assessment by an internist or your family physician. Depending on your age and medical history, such assessment may be helpful in preventing potential complications from surgery. Finally, based on your level of activity and strength prior to surgery, your surgeon may suggest specific exercises to strengthen your upper body and maintain your overall level of activity for the duration of the time you will be restricted from walking or bearing weight on your foot (see section on Rehabilitation). A small number of patients are at risk of deep vein thrombosis or a pulmonary embolism after surgery. This risk may be related to a genetic predisposition, age, obesity, smoking, oral contraceptives, hormone replacement therapy, or specific medications. If your surgeon feels that you are at particularly high risk and he or she wishes to take measures to prevent these events, you may need to have a blood test prior to surgery to rule out an undiagnosed clotting disorder.

Procedure for removing bone spur on the back of the heel

Before the surgery is done, there are a few steps that have to be followed by the patient and the doctors in order to achieve a satisfactory result. Firstly, the patient will go through a physical examination and the doctor will ask a few questions about when the symptoms first began and the history of the pain and about prior injuries or surgeries of the heel that is related to the current problem that the patient is facing. Then the doctor will try to take a few x-rays of the affected heel. This is to serve as a confirmation for the location of the bone spur and to rule out other possibilities for the current symptoms. After everything has been checked, the doctor will identify which part of the heel to be operated on and that is why surgeons are beginning to use a minimal incision technique for the operation. This is to prevent larger and more painful cuts on the heel. This technique uses a smaller incision of about 1 inch or less and it causes less pain and has quicker recovery. With a smaller incision, there would be minimal damage to the skin that will lower the risk of infection to the patient and the bones, tendons, and ligaments are not exposed during the surgery. This will allow better visualization of the structures during the procedure. On the day of the surgery, a small incision is made on the affected area and a tube-like instrument known as a burr will be placed in the incision. The burr is operated by electricity and it has a fast-spinning head with a rough surface. This burr is the one that removes the bone spur and it creates heat that turns the small bone fragments created by the burring into the surrounding healthy tissues, therefore bone spur removal is complete with minimal injury to the normal tissues. After the burring is done, the foot will be placed in a cast and the surgery usually takes around half an hour to 45 minutes. This procedure is mostly provided as an outpatient service and patients are allowed to walk with their heel with a special shoe provided by the hospital. Normally, the patients are not allowed to send their heel into prolonged standing or walking and weightbearing should be limited for 1 to 2 weeks.

Recovery and rehabilitation after surgery

After the surgery, the patient will be assigned to a walking cast for 2-3 weeks. The walking cast will allow the patient to move around without putting pressure on the healing area. After the walking cast is removed, the patient will wear a shoe with a pad in the heel area for another 2-3 weeks. At the 4-6 week point after surgery, most patients can begin wearing shoes that they were wearing prior to the surgery. It is at this point that patients can increase their levels of activity. The length of rehabilitation will depend on the patient’s pre-surgery activity level, the duration of symptoms prior to surgery, and the type of activities the patient would like to return to. High-impact activities such as running may have to be postponed for 3-4 months, while others can be resumed at a sooner date. Typically return to full activity occurs in 3-4 months after surgery. This is a general guideline and will vary depending on the factors mentioned above. Physical therapy is not required following this type of surgery in most cases. A home exercise program will help regain strength and range of motion at the ankle. One can expect some gentle ankle stiffness and mid-foot soreness after being immobilized for several weeks. This can be effectively treated with time, use of a whirlpool (or simply Epsom salts and water in a pail) to soak the foot and ankle, and therapeutic padding placed in the shoe.

Treatment for top of foot pain in Singapore

The cost of foot pain treatment in Singapore varies depending on the foot pain condition. For example, a bunion surgery in a private hospital in Singapore can cost anywhere from $6000 to $12000, including consultation fees, surgery fees, anesthesia fees, and post-surgery therapy. This is just an estimate, and the actual cost may vary. Electrocautery for an ingrown toenail in the Health and Wellness clinic in Singapore costs approximately $100, not including consultation fees and follow-up medication fees. Health insurance coverage for foot pain treatment also varies. It is best to check with the individual clinics on the range of services offered as well as the cost involved.

There are several specialized clinics and services for foot pain treatment in Singapore. The Singapore General Hospital has a podiatry service, which caters to the prevention, diagnosis, treatment, and rehabilitation of medical and surgical conditions of the feet. The National University Hospital’s Department of Orthopaedic Surgery also provides consultation and treatment for foot and ankle problems.

The healthcare facilities in Singapore are numerous and well-equipped with state-of-the-art technologies. Among the many public hospitals and private healthcare institutions, Singapore is world-renowned for its specialist services and clinics in many medical fields. All public and private clinics are equally capable of treating a wide range of medical conditions, and Singapore boasts some of the world’s best medical specialists.

Overview of healthcare facilities in Singapore

With the opening of the new national specialty centres, patients are now able to access a full range of specialist care for specific types of acute and chronic diseases. This has led to improved cost-effectiveness and better treatment outcomes for patients requiring such care. The combination of services available at the general hospitals and specialty institutions will result in a more clearly-defined separation of acute and chronic disease management.

Tertiary Care Tertiary care is mainly based at our local hospitals and the national specialty centres. Patients can now seek specialty care at the specific institutions for their conditions. This is a change from the past where specialist outpatient clinic services were provided in the general hospitals and patients had to go to particular hospitals to receive specialty care for their condition.

The general hospitals in Singapore are now mainly for treating acute conditions and providing short-term care. Rehabilitation and other long-term care services are readily available in a less costly and more comfortable setting. Northlink Hospital is a good example of a private community hospital that provides high quality, cost-effective services for patients with sub-acute, chronic medical or rehabilitative needs.

Secondary Care In the past, most of the treatment received in our hospitals was acute medical care, with hospital beds being used unnecessarily for long-term treatments and medical investigations. This often resulted in acute cases being turned away as hospitals were near full capacity. The restructuring of our healthcare system has led to the development of more community hospitals with sub-acute and rehabilitation care, allowing hospitals to be less congested. This has resulted in an increase in the availability of hospital beds for acute care treatments.

The major group involved in managing primary care in the public sector is the Singapore polyclinic group. The polyclinics aim to bring healthcare services closer to Singaporeans at an affordable price. With 18 polyclinics located throughout the island, patients can easily access them, especially since the new location-based visit scheme was introduced to reduce waiting times for appointments.

Primary Care Primary care is provided by General Practitioners (GPs) in private practice or within the general polyclinics. Common ailments that do not require the attention of specialists can be managed at this level.

Our healthcare services are now segregated into three levels: primary, secondary, and tertiary care.

In many other countries, patients have a wide choice in health care services ranging from the outpatient sector to the most sophisticated high-technology care in teaching hospitals. This range of services is not often found in a single institution or location. Patients are often confused about what kind of care they need, what kind of care is available, and where it should be sought. Singapore was no different up till the early 90’s. However, with the restructuring of the healthcare system, it is now much easier for patients and General Practitioners to choose the appropriate institutions to seek the most cost-effective and yet quality care available.

Specialized clinics and services for foot pain treatment

In Singapore, you can also find clinics that are specialized in foot pain treatment. The clinic will provide expert diagnosis and comprehensive treatment programs for ankle and foot conditions. This clinic usually has a multidisciplinary team of orthopaedic surgeons, podiatrists, physiotherapists, and orthotists who are trained in the specialist management of foot and ankle problems. With this team, the clinic will provide a holistic approach in managing your foot condition. An example of a specialized clinic in Singapore is The Foot Practice. At this clinic, they specialize in treating lower limb problems which focus on different aspects from arthritic conditions, diabetic foot assessment, sports injuries, chronic pain management to nail surgery. These clinics usually also offer screening and surgery to prevent and manage foot problems for those with diabetes, which is an increasingly significant condition in Singapore. So if you have a serious case of pain on top of your foot, these clinics offer a comprehensive service to eliminate the cause of the problem. This may be a good option, especially for people who are willing to invest for a better diagnosis and comprehensive services to eliminate the pain.

Cost and insurance coverage for foot pain treatment in Singapore

Do seeking patients need to know the costs of various foot pain treatments? Two surveys by Du et al. have shown that patients are willing to pay more than the present costs for improvements in feet and health status, although no specific data collection was used to define foot pain treatments as healthcare services and the surveys were more focused on the affordability of self-care products and footwear due to foot pain. This needs to prompt studies or initiatives to determine the specific Willingness To Pay among patients seeking publicly or privately funded treatment for various foot injuries or degeneration.

It is clear that there needs to be more comprehensive guidelines for the use of these MediSave and insurance plans in order to decrease the out-of-pocket burden that a large percentage of Singaporeans are still facing. Since in 2013, MediSave and MediShield only covered 45% of total bill sizes and this was a decrease from 60% in 2008. The current CareShield Life and Long-Term Care Bill proposed in 2018 needs to be welcomed since it is aimed at helping the elderly and severely disabled with their long-term healthcare costs. The most significant problem regarding the costs of foot pain treatment is the lack of transparency pricing. For public sector patients, knowing the final cost before treatment is possible due to the Fact Sheet on Estimated Bill Size provided by the Ministry of Health. However, this only applies to information from restructured hospitals and is not applicable for other institutions such as specialist centers. Pricing completeness and accuracy for medical procedures in the private sector have been shown to be unsatisfactory in a 2012 article by Tan et al., ultimately making it very difficult for the discernment of total costs to be made by patients, even if it is guaranteed that they can easily enter the private sector using MediSave. An increase in the price transparency requirements for private medical institutions as well as standardization of medical professional fees can only come with further government regulation. Consideration is to be made in future healthcare policies on how to improve the clear forecast of health expenditures, thus allowing Singaporeans to be well-informed and prepared.

It is evident that with such variety in healthcare settings, a similar variation will exist regarding the costs of treatment. Yet, cost is often the deciding factor in the choice of treatment in healthcare. Costs of public healthcare treatment are minimal in comparison to those in private settings, although quality and waiting times can be compromised. For higher income patients, it is often the case that they will bypass public healthcare completely due to the fact that subsidies do not apply to them, while lower income patients will depend largely on the public sector. Private healthcare costs vary and it is increasingly common to find patients using their MediSave accounts and purchasing Integrated Shield Plans with riders to supplement the costs. The introduction of Medical Insurance Moratorium means that pre-existing conditions will not be excluded from insurance plans if the patient has had at least 5 years free of treatment, symptoms, and signs related to that condition. So in order to avoid high initial costs, evidence that a condition has been recurrent or persistent can allow patients to buy insurance at a standard cost and increase their benefits at a later date.

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