The pain caused by the calcaneal spur and the decreased quality of life are the hallmark features of this condition. Radiotherapy has been the subject of increasing evolution in recent decades for pain relief in both benign and malignant pathologies. The aim is to evaluate the efficacy in pain relief and the toxicity associated with the treatment. A retrospective review of a group of patients with painful complaints due to calcaneal spur who underwent Radiotherapy. Between 2012 and 2023, twelve patients, seven men, and five women, with a median age of 61 years (40-82) underwent palliative radiotherapy for calcaneal spur. Five patients had calcaneal spur on the right, five on the left, and two with bilateral spurs. All had complaints of pain in the calcaneus. One patient had undergone previous surgery and one radiofrequency and corticosteroid infiltration without resolution of the painful condition. The treatment regimens varied, with the majority (n=7) receiving 15Gy in 3 fractions of 5Gy on alternate days. 100% of the patients reported complete pain relief after treatment. One patient required re-irradiation after 4 months, with a complete response in pain control. No patient experienced toxicity related to radiotherapy. Radiotherapy plays an important role in pain control for this pathological condition, as demonstrated in this analysis. Classical studies have shown that a minimum total dose of 5Gy would be necessary for better pain control. There is a need to raise awareness among healthcare professionals about the important role of radiotherapy in pain management in this pathology.

Keywords: radiotherapy, calcaneal spur, pain

Calcaneal spur was first described in the early 10th century by the German surgeon Plettner. Calcaneal spur is an abnormal bone growth (exostosis at the level of the plantar fascia insertion) that in most cases occurs on the underside of the calcaneus in the cartilaginous ligament, specifically in the plantar fascia ligament. It affects about 8 to 10% of the population, generally in the age group over 40 years old. Risk factors for the development of the spur are associated with obesity, foot deformities such as flat feet, microtrauma, age and sports such as running, jumping and ballet.

Pain and the associated decrease in quality of life are the hallmark features of this pathology, although up to 20% of cases on average may be asymptomatic.

The pathophysiology, although still not fully understood, is based on the hypothesis of longitudinal traction with inflammation and reactive ossification as a consequence of excessive traction between the initial part of the plantar fascia and the calcaneal tuberosity. That is, the main hypothesis is the occurrence of repetitive microtraumas in the insertion of the plantar aponeurosis, causing loss of elasticity of the insertion cartilage and a consequent invasion of it by mesenchymal cells favoring the appearance of scar tissue that slowly ossifies and originates the spur.

Traditionally, the treatment of the spur was based on the combination of orthopedic measures such as the use of insoles, infiltration with corticosteroids and local anesthetics, the use of nonsteroidal anti-inflammatory drugs, as well as different surgical techniques. However, in parallel with the innovation of pharmacological, surgical and systemic strategies, radiotherapy has been the target of increasing evolution in recent decades, allowing more and more to acquire effectiveness in pain relief both in benign and malignant pathologies. In fact, radiotherapy offers adequate control of pain caused by the calcaneal spur.

Retrospective review and descriptive analysis of a group of patients with complaints of pain due to calcaneal spur undergoing External Radiotherapy treatment.

To evaluate the effectiveness of pain relief and associated toxicity of the treatment.

Between 2012 and January 2023, 12 patients, 7 male and 5 female, with a median age of 61 years (40-82), underwent pain-relieving radiotherapy for calcaneal spur in a radiotherapy service in Portugal. 5 patients with calcaneal spur on the right, 5 on the left and 2 with bilateral spur. 100% of the patients with initial complaint of pain at the level of the calcaneus and 4 of them with associated plantar fasciitis. 1 patient had undergone previous surgical treatment and 1 had been treated with radiofrequency and corticosteroid infiltration without resolution of the pain.

Most patients (n=6) underwent the fractionation scheme of 3 fractions of 5 Gy per fraction on alternate days, for a total dose of 15 Gy. 2 underwent the scheme of 10 fractions of 2 Gy each, 5 fractions per week (total dose of 20 Gy). 1 patient received 5 fractions of 3 Gy/fraction on alternate days (total dose of 15 Gy). 1 patient received 6 fractions of 1 Gy/fraction, daily (total dose 6Gy). 1 patient received 4 fractions of 2 Gy/fraction (total dose of 12 Gy) on alternate days and, finally, 1 patient received 5 fractions of 2 Gy/fraction (total dose of 10 Gy) on alternate days. Only one patient received IMRT (Intensity Modulated Radiotherapy) treatment, while the others received 3D conformal radiotherapy.

100% of the patients reported complete pain relief after RT treatment. One patient required re-irradiation after 4 months, having initially undergone the fractionation scheme of 6 fractions of 1 Gy/fraction, daily (total dose 6Gy) and then underwent the scheme of 4 fractions of 2 Gy/fraction (total dose of 12 Gy) on alternate days with complete response in terms of pain control.

No patient reported radiotherapy-related toxicity. Only one patient reported increased pain in the calcaneus after the fourth fraction of treatment, with spontaneous resolution.^1-7

Radiotherapy plays an important role in pain control for this pathological entity, as demonstrated in this analysis.

The study by Canylmaz et al randomized 124 patients with plantar fasciitis to a radiotherapy arm (6Gy in daily fractions of 1 Gy per fraction) and another group to local infiltrations of corticosteroids and anesthetics. With a median follow-up of 12.5 months, pain relief was significantly superior in patients who underwent RT, 68% compared to 28% with local infiltrations, p < 0.001.⁸

More classic studies have shown that a minimum total dose of 5Gy would be necessary for better pain control.

When the fractionation scheme of 10 fractions of 0.3 Gy was compared with 10 × 0.5 Gy, the second was superior and comparable to the classic scheme of 6 x 1 Gy (3x per week) in two sessions with an interval of 6 weeks and a total dose of 12 Gy. In this study, the pain control rate ranged from 67% to 71%. More recently, a multicenter study analyzed 127 patients and compared the classic fractionation (6x1Gy) two fractions per week with (12x0.5Gy) three fractions per week. In those patients who did not show improvement in pain after 12 weeks, the same classic cycle (6x1Gy) was repeated. There was no difference between the treated groups and no treatment-related toxicity was found.

There are numerous studies on the effectiveness of Radiotherapy in relieving pain caused by calcaneal spur, however, there is a growing need to raise awareness among health professionals about the important role of RT in pain control in this pathology.^9-14

None.

No conflicts of interest to declare.

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