Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Heel Spur (Calcaneal)


Related Terms

  • Achilles Tendon Spur
  • Calcaneal Spur
  • Calcaneal Step Deformity
  • Exostosis of the Heel
  • Haglund's Deformity
  • Jogger's Heel
  • Pump Bump

Differential Diagnosis

  • Bone cyst or tumor
  • Bursitis of heel
  • Compression of posterior tibial nerve (tarsal tunnel syndrome)
  • Contusion of heel
  • Fat pad atrophy of heel
  • Fracture of heel bone (calcaneus)
  • Lumbar radiculopathy
  • Plantar fasciitis
  • Reactive arthritis (previously called Reiter's syndrome)
  • Sciatica
  • Tendonitis (Achilles)

Specialists

  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist
  • Sports Medicine Physician

Factors Influencing Duration

Factors influencing length of disability include the severity of pain associated with the calcaneal (heel) spur, the individual's response to treatment and adherence to recommendations, and the individual's job requirements and leisure activities. Individuals who require surgery to remove a bone spur associated with chronic, refractory soft tissue irritation are subject to surgical complications including poor wound closure, infection, and adverse reactions to anesthesia.

Medical Codes

ICD-9-CM:
726.73 - Heel Spur; Calcaneal Spur

Overview

The calcaneus is the weight-bearing bone that forms the heel of the foot. A bony growth on the undersurface (plantar surface or inferior surface) of this bone is called a heel spur (calcaneal exostosis).

Heel spurs may also occur at the back (posterior) of the heel, where the edge of the shoe may rub; this is also known as a "pump bump," or a posterior heel spur. A posterior heel spur may also form where the Achilles tendon inserts into the calcaneus (retrocalcaneal exostosis, or calcaneal step deformity).

The spur can be seen on x-ray and is often discovered incidentally in x-rays done for another reason. Pain in this region is typically not the result of the spur, but from inflammation of the tissue in the area. Many people have heel spur(s) and do not have pain in the area.

Common causes of pain in the heel include a bruise (contusion) of the fat pad in the heel, plantar fasciitis, Achilles tendonitis, and inflammatory diseases, including Reiter's syndrome.

Plantar calcaneal (heel) spurs are thought to be caused in part by tension (longitudinal traction) of soft tissues, such as the plantar fascia pulling against the bone, but recent research indicates plantar calcaneal spurs may be more likely formed as an adaptive response to vertical (axial) compression on the heel bone (Menz 7). Posterior heel spurs resulting in a calcaneal step deformity can form in response to an abnormally tight Achilles tendon that causes chronic tendon inflammation and reactive bone formation at its insertion.

Incidence and Prevalence: Calcaneal bone spurs on the bottom of the heel (plantar calcaneal spurs) are present in 15% to 25% of the general population (Singh 172). In one study, 52.4% of plantar calcaneal spurs were found to be embedded within the plantar fascia, and 47.6% were determined to be external to the plantar fascia (Barrett 51).

Fifty-five percent of individuals aged 62 to 94 exhibit at least one plantar calcaneal spur, and 48% have a posterior calcaneal spur (Menz 7).

Plantar calcaneal spurs are found on x-ray in approximately 50% of individuals with heel pain from plantar fasciitis (“Plantar Heel Pain”).

Source: Medical Disability Advisor



Causation and Known Risk Factors

The risk of calcaneal (heel) spurs on the bottom of the foot (plantar surface) or back of the heel (posterior surface) increases with obesity, osteoarthritis, and advancing age (Kaplan 139).

Men and women are equally at risk for developing heel spurs. Posterior heel spurs are slightly more common in young women, in whom the abnormal bony growth is often related to long-term bursitis caused by the pressure of wearing pump-style shoes, and also in athletes who participate in running sports (DeLee).

Source: Medical Disability Advisor



Diagnosis

History: Calcaneal (heel) spurs, although visible on x-ray, are generally asymptomatic. The correct term for “heel spur pain syndrome” is plantar fasciitis, since the spur is not the cause of pain. In individuals with a posterior heel spur, the pain is generally caused by inflammation of adjacent soft tissues (e.g., Achilles tendon, bursa).

Individuals with heel pain may report symptoms with weight-bearing activities (standing, walking) and when wearing non-supportive or inadequately padded footwear.

Physical exam: Most spurs are asymptomatic on examination. However, when the physician touches (palpates) the affected area, the individual with a heel bone spur may experience pain or discomfort. In individuals with a posterior calcaneal spur, the heel may be tender to palpation where the Achilles tendon inserts into the heel bone; here, the physician may observe a thickening of the soft tissues and pain during ankle range of motion.

Tests: The majority of calcaneal (heel) spurs are typically found incidentally on an x-ray being performed for another reason. Most individuals with a bone spur on their x-ray never develop symptoms. If painful heel symptoms suggest nerve or muscle dysfunction, other tests, such as magnetic resonance imaging (MRI), computed tomography (CT), or electromyography (EMG), may be used.

Source: Medical Disability Advisor



Treatment

Treatment is directed at the cause of the patient's pain and varies depending on the structures involved. Calcaneal (heel) spurs are not usually a cause of pain.

Nonsteroidal anti-inflammatory drugs (NSAIDs) may be helpful to reduce pain and inflammation of irritated tissues adjacent to a calcaneal (heel) spur. Heel pain may be reduced by using soft insoles, heel pads, or shock-absorbing footwear. Pain at the back of the heel may improve by stretching tight calf muscles and wearing heel lifts to decrease tension on the Achilles tendon. Patients are encouraged to choose footwear with adequate heel space to prevent friction of the posterior calcaneus against the back of the shoe.

Rarely, a large posterior calcaneal spur that rubs against the Achilles tendon may require surgical removal (excision).

Source: Medical Disability Advisor



ACOEM

ACOEM's Practice Guidelines, the gold standard in effective medical treatment of occupational injuries and illnesses, are provided in this section to complement the disability duration guidelines.*
 
Ankle and Foot Disorders
 
* The relationship between the MDGuidelines (MDA) content and ACOEM's guidelines is approximate and does not always link identical diagnoses. The user should consult the diagnostic codes in both guidelines, as well as the clinical descriptions, before assuming an equivalence.

Source: ACOEM Practice Guidelines



Prognosis

The predicted outcome for calcaneal (heel) spurs is good in that the symptoms associated with most bone spurs can be resolved with conservative treatment more than 90% of the time, even if plantar fasciitis coexists ("Plantar Heel Pain"); however, the spur persists and may gradually enlarge over time.

Surgical removal of the heel spur is usually not indicated since bone spur removal does not address the core concern; therefore, surgical results are not predictable. In cases of posterior calcaneal spurs adjacent to the Achilles tendon that require surgical removal, bone spur excision is successful, and the individual experiences a complete recovery with return to normal function.

Source: Medical Disability Advisor



Rehabilitation

Rehabilitation for calcaneal (heel) spurs depends on the location of the bone spur as well the extent of the condition. Individuals with symptomatic heel spurs may require outpatient physical therapy to address pain and swelling in associated soft tissues.

The primary focus of rehabilitation is to reduce the pain associated with the spur. This can be achieved by reducing pressure on the surrounding tissue and using modalities involving heat, cold, and ultrasound as appropriate. With plantar calcaneal bone spurs, the therapist will reduce the pressure on the spur through instruction in activity modification and/or use of orthopedic padding, such as heel cushions or soft insoles. With posterior calcaneal bone spurs, the therapist will instruct the individual to perform calf-stretching exercises to reduce tension on the Achilles tendon, and to modify sports activities, such as running, to decrease weekly mileage, hill work, and sprinting. The therapist may also suggest adding a 1/4- to 1/2-inch heel lift inside the shoe of the affected heel to reduce tension on the Achilles tendon (DeLee).

Source: Medical Disability Advisor



Complications

As calcaneal (heel) spurs enlarge, they can cause pain when then individual puts weight on that part of the foot. Posterior calcaneal spurs may rub against the Achilles tendon, causing chronic tendonitis.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

The treatment and the condition itself may limit the individual’s ability to return to previous work activities temporarily. Use of an assistive device, such as a cane or walker, may be necessary to limit weight bearing and pressure on the affected area. If the condition requires surgical intervention, temporary restrictions to limit prolonged standing and walking may be necessary. Use of prescribed medications for management of pain and inflammation may require review of drug policies. Safety issues may need to be evaluated.

Source: Medical Disability Advisor



Regarding diagnosis

Regarding diagnosis:
  • Where are the bone spurs located?
  • Is pain present? Does individual report sharp pain when putting weight on the feet?
  • On physical exam, was the area tender to palpation? With range of motion?
  • Were other conditions with similar symptoms (e.g., plantar fasciitis, Achilles tendonitis) ruled out?
  • Was an x-ray performed?

Regarding treatment:

  • Are anti-inflammatory medications being used for pain relief?
  • Does individual wear appropriate footwear?
  • Was physical therapy necessary?
  • Was surgery necessary?
  • Does individual have a recurrent heel spur? Is spur becoming larger?

Regarding prognosis:

  • Is individual active in rehabilitation?
  • Is individual compliant with recommendations for orthopedic foot support devices? Leisure activity modification?
  • Does individual have any conditions that may affect ability to recover?
  • Has individual developed tendinitis? Bursitis? Plantar fasciitis?

Source: Medical Disability Advisor



References

Cited

Barrett, S. L. , T. T. Pignetti, and B. R. Egly. "Endoscopic Heel Anatomy: Analysis of 200 Fresh Frozen Specimens." Journal of Foot and Ankle Surgery 34 1 (1995): 51-56.

Menz, H. B. , K. B. Landorf, and S. E. Munteanu. "Plantar Calcaneal Spurs in Older People: Longitudinal Traction or Vertical Compression?" Journal of Foot and Ankle Research 11 1 (2008): 7-7.

Panchbhavi, V. K. "Plantar Heel Pain: Diagnosis and Workup." eMedicine. 17 Jun. 2009. Medscape. 24 Jun. 2009 <http://emedicine.medscape.com/article/1233178-diagnosis>.

Singh, D. , G. Bentley, and S. G. Trevino. "Fortnightly Review: Plantar Fasciitis." BMJ 315 (1997): 172-175.

General

Kaplan, Robert J. "Regional Musculoskeletal Pain Syndromes: Ankle and Foot." Physical Medicine and Rehabilitation Review. 2nd ed. McGraw-Hill, 2006. 138-139.

Wapner, Keith L., and R. Luke Bordelon. "Heel Pain, in Chapter 30, Foot and Ankle." DeLee and Drez's Orthopaedic Sports Medicine. Eds. Jesse DeLee and David Drez. 2nd ed. 2 vols. Saunders, 2003. MD Consult. Elsevier, Inc. 25 Jun. 2009 <http://www.mdconsult.com/das/book/body/145937721-3/856205125/1103/1155.html#4-u1.0-B0-7216-8845-4..50032-6--cesec364_4718>.

Source: Medical Disability Advisor






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