Morphometric Analysis of Calcaneal (Heel) Spurs in Ancient and Modern Anatolian Populations

Abstract

Heel spurs are the bony protrusion seen especially on the dorsal and plantar face of the calcaneus bone at the attachment site of the muscles. It was aimed herein to obtain data about the life styles, daily lives, and especially the socioeconomic structures of modern and ancient Anatolian populations by evaluating the prevalence, location, age, and gender differences of heel spurs on the calcaneus and comparing these findings between the populations. Herein, the 251 calcaneus bones of 137 skeletons, which had been previously analyzed paleodemographically and dated to the Middle Ages, and 68 calcaneus bones belonging to a modern population, whose gender was unknown but lived in Anatolia, were examined in terms of heel spurs. In the current study, the presence of dorsal, plantar, or both dorsal/plantar heel spurs on these in 251 calcaneus bones was 43.9 %, 11.1 %, and 10.3 %, respectively. The presence of dorsal, plantar, or both dorsal/plantar heel spurs was determined as 22 %, 3 %, and 1.5 %, respectively, among the 68 calcaneus bones belonging to the modern population. When a comparison was made of the current study with studies in the literature on modern and prehistoric populations, a higher prevalence of heel spurs was found in prehistoric samples than in modern populations. It is our belief that this situation may have derived from the heavy labor force, environmental, or sociocultural differences in ancient Anatolian populations, insufficiency of vital materials due to inadequate industrial conditions, and the solution of anatomical disruption. In addition, the findings determined herein will guide the development of future and industrial studies on the foot and foot structure.

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Int. J. Morphol.,
38(6):1729-1734, 2020.
Morphometric Analysis of Calcaneal (Heel) Spurs
in Ancient and Modern Anatolian Populations
Análisis Morfométrico de los Espolones Calcáneos
en Poblaciones de Anatolia Antiguas y Modernas
Ahmet Kürsad Açıkgöz1; Raciha Sinem Balci2; Ahmet Cem Erkman2; Pınar Göker1; & M. Gülhal Bozkir1
AÇıKGÖZ, A. K.; BALCI, R. S.; ERKMAN, A. C.; GÖKER, P.; & BOZKIR, M. G. Morphometric analysis of calcaneal (heel)
spurs in ancient and modern anatolian populations. Int. J. Morphol., 38(6):1729-1734, 2020.
SUMMARY: Heel spurs are the bony protrusion seen especially on the dorsal and plantar face of the calcaneus bone at the
attachment site of the muscles. It was aimed herein to obtain data about the life styles, daily lives, and especially the socioeconomic
structures of modern and ancient Anatolian populations by evaluating the prevalence, location, age, and gender differences of heel spurs
on the calcaneus and comparing these findings between the populations. Herein, the 251 calcaneus bones of 137 skeletons, which had
been previously analyzed paleodemographically and dated to the Middle Ages, and 68 calcaneus bones belonging to a modern population,
whose gender was unknown but lived in Anatolia, were examined in terms of heel spurs. In the current study, the presence of dorsal,
plantar, or both dorsal/plantar heel spurs on these in 251 calcaneus bones was 43.9 %, 11.1 %, and 10.3 %, respectively. The presence of
dorsal, plantar, or both dorsal/plantar heel spurs was determined as 22 %, 3 %, and 1.5 %, respectively, among the 68 calcaneus bones
belonging to the modern population. When a comparison was made of the current study with studies in the literature on modern and
prehistoric populations, a higher prevalence of heel spurs was found in prehistoric samples than in modern populations. It is our belief
that this situation may have derived from the heavy labor force, environmental, or sociocultural differences in ancient Anatolian populations,
insufficiency of vital materials due to inadequate industrial conditions, and the solution of anatomical disruption. In addition, the findings
determined herein will guide the development of future and industrial studies on the foot and foot structure.
KEY WORDS: Heel spur; Calcaneus; Dorsal spur; Plantar spur.
INTRODUCTION
Anatolia has hosted many societies during the
historical process and many different cultures have coexisted
in this context. Paleoanthropological materials provide us with
very important insight toward understanding the stresses, li-
ving conditions, socioeconomic structures, and health
conditions that past societies were exposed to. In particular,
the calcaneus bone, one of the best indicators of physiological
stress, provides important information about life in the past.
The first ossified calcaneus bone is the largest,
strongest, longest bone of the tarsal bones and forms the shape
of the heel protrusion, supports body weight, and acts as a
lever arm of the calf muscle (Snell, 1993; Kullar et al., 2014).
The bony protrusion on the plantar side of the foot was first
described by Plettner, a German physician, in 1900, and was
named Kalkaneussporn (Micke et al., 2004; Kullar et al.).
Moreover, the bone spurs, which are located on the insertions
of the muscles, were named enthesophytes (Weiss, 2012).
These structures are a bone growth that extends from the
skeleton to the soft tissue, and appears like a spinal protrusion
that splits off from the bone and adheres to the surface (Rogers
et al., 1997; Benjamin, 2006). The most common bone spurs
are observed as the dorsal spurs of the tendo calcaneus and
bone spurs of the plantar fascia (Weiss) (Fig. 1). Heel spurs
are a bony outgrowth that is greater than 2 mm in size that
originated from the medial tubercule of the calcaneus, which
is located on the plantar fascia at the level of the junction of
calcaneus. The pain and sensitivity of the medial tubercule of
the calcaneus on the anterior side is a characteristic symptom
of heel spur syndrome (Kose et al., 2004).
Although the existence, shape, location, and
differences between genders, and right-left sides of heel spurs
have been investigated in the literature previously,
1 Department of Anatomy, Faculty of Medicine, Çukurova University, Adana, Turkey.
2 Department of Anthropology, Faculty of Science and Literature, Ahi Evran University, Kırsehir, Turkey.

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insufficient studies exist that have examined, evaluated,
and compared heel spurs in modern and ancient populations
in detail. Therefore, it was aimed herein to obtain data about
the life styles, daily lives, and especially the socioeconomic
structures of modern and ancient Anatolian populations
by evaluating the prevalence, location, age, and gender
differences of heel spurs on the calcaneus and comparing
these findings between the populations.
MATERIAL AND METHOD
In this study, 137 skeleton samples (80 males, 57
females) that dated to the Middle Ages, which were
obtained from the excavation sites of Höyüktepe, Attepe,
Dereköy, Tokul (Aegean region), and Van Castle Mound
(eastern Anatolian region), and their 251 calcaneus bones,
in addition to 68 calcaneus bones belonging to a modern
population, whose gender was unknown, were examined
for the presence of heel spurs at the Anatomy Laboratory
of Çukurova University Faculty of Medicine. Calcaneus
bones that were deformed or exhibited pathological
changes were excluded from the study.
The skeleton samples from the Middle Ages consisted
of 114 bilateral and 23 unilateral calcaneus bones. The
skeletons were analyzed paleodemographically by Kırsehir
Ahi Evran University and are currently preserved in the
Anthropology Department of Ahi Evran University. In the
age determination of the adult individuals, tooth wear, auri-
cular surface morphology with symphysis pubis in coxae,
body cross-section of the clavicle, degree of closure of the
sutures in the skull, changes in the sternal ends of the costae,
proximal sections of the femur and humerus bones, and
complex aging methods were taken into consideration and
had previously been described in the literature (Çırak et al.,
2015). The skeletons were evaluated in three categories
according to age, as 18–29.9, 30–44.9, and >45.
T
here were no fractures or deterioration in the
calcaneus that would have prevented them from being
studied with regards to heel spurs. SPSS 22.0 software
was (IBM Corp., Armonk, NY, USA) was used for the
statistical analyses. The prevalence of heel spurs according
to age and sex distribution in the populations was obtained
using descriptive statistical methods.
RESULTS
The distribution of the presence of heel spurs
according to location in the 251 calcaneus bones from the
Middle Ages is shown in Table I.
When the 251 calcaneus bones of the skeletons in
the current study were examined, it was found that the
presence of only dorsal, only plantar, or both dorsal/plan-
tar heel spores, and the total presence of heel spurs was
found as 37.2 %, 0 %, 10.3 %, and 47.6 % in the males
and 28.3 %, 1.9 %, 10.4 %, and 40.6 % in the females,
respectively. The presence of heel spurs in all of the
skeletons was 33.5 %, 0.8 %, 10.3 %, and 44.6 %,
respectively (Table I).
The distribution of the presence of heel spurs
according to location in the 68 calcaneus bones of the
modern population is shown in Table II.
In the modern population, the calcaneal spurs were
observed as only dorsal, only plantar, or both dorsal/plan-
tar heel spurs in 20.5 %, 1.5 %, and 1.5 % of the calcaneus
bones, respectively. Moreover, the total presence of heel
spurs was determined as 23.5 %.
The distribution of the presence of heel spurs
according to location in the 114 skeletons from the Middle
Ages is shown in Table III.
Fig. 1. (A) Dorsal heel spur, (B) Plantar heel spur, and (C) Both.
AÇıKGÖZ, A. K.; BALCI, R. S.; ERKMAN, A. C.; GÖKER, P.; & BOZKIR, M. G. Morphometric analysis of calcaneal (heel) spurs in ancient and modern anatolian populations.
Int. J. Morphol., 38(6):1729-1734, 2020.

1731
Calcaneal spurs
Type Females Males Total
Only dorsal spurs 30 (28.3 %) 54 (37.2 %) 84 (33.5 %)
Only plantar spurs 2 (1.9 %) 0 (0 %) 2 (0.8 %)
Both dorsal /plantar spurs 11 (10.4 %) 15 (10.3 %) 26 (10.3 %)
Total 43 (40.6 %) 69 (47.6 %) 112 (44.6 %
)
Table I. Incidence of calcaneal spurs according to the calcaneal type in the population from the
Middle Ages. N = 251 (n = 106 females, 145 males)
Type Calcaneal spurs
Only dorsal spurs 14 (20.5 %)
Only plantar spurs 1 (1.5 %)
Both dorsal /plantar spurs 1 (1.5 %)
Total 16 (23.5 %)
Calcaneal spurs
Type Females Males Total
Only dorsal s purs 14 (27.4 %) 23 (36.5 %) 37 (32.4 %)
Only plantar spurs 2 (3.9 %) 0 (0 %) 2 (1.8 %)
Both dorsal/plantar spurs 6 (11.8 %) 8 (12.7 %) 14 (12.3 %)
Total 22 (43.1 %) 31 (49.2 %) 53 (46.5 %)
Table II. Incidence of calcaneal spurs according to the calcaneal
type in the modern population. N = 68
Table III. Incidence of calcaneal spurs according to the calcaneal type in the skeletons
from the Middle Ages. N = 114 (n = 51 females, 63 males).
The distribution of heel spurs according to age, in
the 106 skeletons whose age was known, is shown in Table
IV.
When the presence of heel spurs in the 114 skeletons
from the Middle Ages was examined, the presence of only
dorsal, only plantar, both dorsal/plantar spurs, and the to-
tal presence of heel spurs was 36.5 %, 0 %, 12.7 %, and
4
9.2 % in males and 27.4 %, 3.9 %, 11.8 %, and 43.1 % in
females, respectively. The presence of heel spurs in all of
the skeletons was 32.4 %, 1.8 %, 12.3 %, and 46.5 %,
respectively (Table III). In addition, the presence of heel
spurs in the 106 skeletons with a known age was 5 % in the
18–29.9 year age group, 52.1 % in the 30–44.9 year age
group, and 57.5 % in the >45 year age group (Table IV).
The comparison of the presence of heel spurs in the
calcaneus bones of the modern and medieval populations
is shown in Table V.
When the bones from modern population and that
from the Middle Ages were examined with regards to the
presence of heel spurs, it was observed that the prevalence
was higher in the medieval population.
The comparison of the presence of heel spurs in
studies conducted on modern and prehistoric populations
is shown in Table VI.
Table IV. Distribution of heel spurs according to age.
N = 106
Calcaneal spurs
Type Medieval Modern
Only dorsal spurs 84 (33.5 %) 14 (20.5 %)
Only plantar spurs 2 (0.8 %) 1 (1.5 %)
Both dorsal/plantar spurs 26 (10.3 %) 1 (1.5 %)
Total 112 (44.6 %) 16 (23.5 %)
Table V. Comparison of the presence of heel spurs in the
calcaneus bones of the modern and medieval populations.
AÇıKGÖZ, A. K.; BALCI, R. S.; ERKMAN, A. C.; GÖKER, P.; & BOZKIR, M. G. Morphometric analysis of calcaneal (heel) spurs in ancient and modern anatolian populations.
Int. J. Morphol., 38(6):1729-1734, 2020.
Age group Calcaneal spurs
18 to 29.9 years 1 (5 %)
30 to 44.9 years 24 (52.1 %)
> 45 years 23 (57.5 %)

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DISCUSSION
Heel spurs are a common problem and even though
there are several studies about heel spurs in the literature, they
remain poorly understood. The present study focused on
analyzing the presence, location, age, and gender differences
of heel spurs, evaluating data on the lifestyles, daily lives, and
socioeconomic structures of ancient and modern Anatolian
populations, and comparing these data with modern and
ancient populations.
When focus was aimed at previous studies conducted
on ancient populations, it was demonstrated that spur formation
increased with age. In prehistoric hunter-gatherer populations,
the presence of heel spurs was found as 34.2 % in the 117
skeletons in America (Weiss). In a study conducted on the
San and Khoi skeleton collection, examinations were
performed on 54 skeletons and the presence of heel spurs was
found as 13 % (Cermak & Kirchengast, 2015). Furthermore,
a study of enthesopathies in a medieval Spanish population
revealed a dorsal plantar spur prevalence of 15.71 %. In other
study, the presence of plantar and dorsal spurs was observed
as 51 % and 35.7 %, respectively, in a medieval Nubian
population (Marker, 2016). In the skeleton samples examined
herein, the presence of heel spurs in the 114 skeletons of the
ancient population who lived in Anatolia was observed as 46.5
% in the skeletons and 44.6 % in the calcaneus bones. All of
these prevalences were lower than those determined in the
current study. These differences may have derived from ra-
cial factors and the different living periods and conditions of
the populations.
Moreover, many studies have been performed on
modern population samples. In a study of radiographic images
that focused on gross morphological and histological
examinations to find the influencing effects of heel spurs, it
was reported that the development of the heel spurs might be
a response to stress (Li & Muehleman, 2007). A study
conducted regarding related factors of calcaneal spurs
emphasized that there were no differences between genders.
However, it was reported that spurs were more common among
older participants, obesity was related to calcaneal spurs, and
heel spurs were more common in females than in males and
in participants over the age of 40 (Bassiouni, 1965; Kose et
Table VI. Comparison of heel spurs in different studies.
AÇıKGÖZ, A. K.; BALCI, R. S.; ERKMAN, A. C.; GÖKER, P.; & BOZKIR, M. G. Morphometric analysis of calcaneal (heel) spurs in ancient and modern anatolian populations.
Int. J. Morphol., 38(6):1729-1734, 2020.
Calcaneal spurs ( %)
Researchers Region/
population Period Study group N Plantar Dorsal Both Total
Resnick et al. (1977) America 20th century Normal control patients 75 16 11 4 22
Normal s ubjects 400 - - - 15.5
Prichasuk &
Subhadrabandhu (1994) Thailand 20th century Patients with plantar heel
pain 82 - - - 65.9
Galera & Garralda
(1993) Spain Early Middle Ages Skeletal sample 70 - 15.71 - -
Riepert et al. (1995) Caucasian 20th century Normal patients 1 027 11.2 9.3 - 15.7
Kullar et al. (2014) India 21st century Dry human calcaneus 200 6.5 15.5 4.5 26.5
Marker (2016)
Nubian
population/Kul
ubnarti
Medieval Skeletal sample 98 51 35.7 - -
Cermak & Kirchengast
(2015) Africa 19th century Skeletal sample 54 - - - 13
Menz et al. (2008) Australia 21st century Between 62–94 years of age 216 55 48 - -
Rheumatoid arthritis 282 - - - 21.6
Osteoarthrosis 168 - - - 81Bassiouni (1965) Egypt 20th century
Controls 80 - - - 16.2
Weiss (2012) America Dated 2180 to 250
BP Skeletal sample 117 - - - 34.2
With atrophy of the abductor
digiti minimi muscle 100 - - - 48
Chundru et al. (2008) America 21st ce ntury Without atrophy of the
abductor digiti minimi
muscle
100 - - - 7
Perumal & Anand
(2013) India 21st ce ntury Dry human calcaneus 218 - - - 56
Without plantar heel pain 120 - - - 8.3
Kose et al. (2004) Turkey Between 1994–1997 With plantar heel pain 73 - - - 60.2
Skeletal sample 114 1.8 32.4 12.3 46.5
Medieval Dry human calcaneus 251 0.8 33.5 10.3 44.6Present study (2020) Anatolia
20th century Dry human calcaneus 68 1.5 20.5 1.5 23.5

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al.; Menz et al., 2008). As a result of the examinations
conducted in the current study, it was found that heel spurs
were more common among males.
When previous studies were analyzed with regards
to the prevalence of dorsal/plantar spurs in different
populations, the presence of heel spurs was determined as 26.5
% in an Indian population by Kullar et al. and 22 % by Resnick
et al. (1977). The prevalence was determined as 15.5 % in
400 individuals by Prichasuk & Subhadrabandhu (1994) and
similarly, as 15.7 % by Riepert et al. (1995) in a study of
radiographic images obtained from a Caucasian population.
When focusing specifically on studies of plantar
spurs, the prevalence was determined as 16 % by Resnick et
al. and 11.2 % in a Caucasian population by Riepert et al. In
contrast to these results, Kullar et al. determined the prevalence
of plantar spurs as 6.5 %. On the other hand, Menz et al.
determined the prevalence of plantar spurs as 55 % in an
Australian population. In the current study, the prevalence was
determined as 1.8 % in the skeleton samples and 0.8 % in the
calcaneus bones. The results herein were lower than all of
those reported in the abovementioned studies and resulted from
differences in the age, race, era in which they lived, and living
conditions of the populations. According to the literature
findings, when the prevalence of dorsal spurs was analyzed,
Resnick et al. reported a presence of 11 % and Riepert et al.
reported it as 9.3 %. Similarly, it was reported as 15.5 % in an
Indian population by Kullar et al. Dorsal spur prevalence was
reported as 48 % in a study conducted on an Australian
population by Menz et al. The prevalence was determined as
32.4 % in skeletons and 33.5 % in calcaneus bones. Hence,
Menz et al. obtained highest prevalence results for dorsal and
plantar spurs among all of the abovementioned studies. This
difference mayhave derived from their study population, which
comprised individuals between 64 and 92 years of age. It has
been estimated that this remarkable difference may have been
based on age differences. Some studies in the literature have
focused on the relationship between heel spurs and some
disorders. A study that was conducted on chronic plantar heel
pain patients revealed a spur prevalence of 12.4 % and they
were more common in women and older patients (Moroney et
al., 2014). It was revealed that the incidence of calcaneal spurs
in normal subjects was 8.3 %, while in plantar heel pain
patients, it was 60.2 % (Kose et al.). Moreover, in a study of
patients with rheumatoid arthritis and osteoarthrosis, it was
determined that the prevalence of heel spurs was maximum in
patients with osteoarthrosis (81 %), followed by patients with
rheumatoid arthritis (21.6 %), and the controls (16.2 %)
(Bassiouni). In an investigation focused on a comparison of
calcaneal spurs in patients with and without abductor digiti
minimi muscle atrophy, it was reported that patients with
atrophy had significantly greater prevalence of calcaneal spurs.
In addition, research performed on the radiographs of calcaneal
spurs and plantar fasciitis aimed to improve the calcaneal spur
grading system and compare the prevalence and size of
calcaneal spurs between the plantar fasciitis and the control
groups using an improved system. They reported that the
prevalence of moderate or severe spurs was 60 % in the plan-
tar fasciitis group, while it was 2.5 % among the controls
(Wainwright et al., 1995).
In conclusion, when the results of the current study
was compared with studies performed on modern and
prehistoric populations, the presence of heel spurs was
determined to be very high in the ancient populations. It is
our belief that this situation may have derived from the heavy
labor force, environmental, and sociocultural differences in
ancient Anatolian populations, insufficiency of vital materials
due to inadequate industrial conditions, and the solution of
anatomical disruption.
In present day populations, the presence of heel spurs
is low when compared to those in ancient populations,
indicating the importance of the impact of industrial
development on human health. We believe that the incidence
of heel spurs will decrease due to the development of indus-
trial designs. Furthermore, the findings presented herein will
guide both future and industrial studies.
At the present time, the use of inappropriate shoes,
such as high-heeled shoes, is one of the reasons for the increase
in the presence of heel spurs in women. In addition, being
active in business life, for women as well as men, can be
considered as another factor that increases in the presence of
heel spurs.
ACKNOWLEDGEMENTS
This project was supported by the Unit of Scientific
Research Projects of Cukurova University. An early version
of this manuscript was presented at the 1st International
Congress on Sports, Anthropology, Nutrition, Anatomy and
Radiology (SANAR 2018)
AÇıKGÖZ, A. K.; BALCI, R. S.; ERKMAN, A. C.; GÖKER,
P. & BOZKIR, M. G. Análisis morfométrico de los espolones del
calcáneo (espuelas del talón) en poblaciones de anatolia antiguas y
modernas. Int. J. Morphol., 38(6):1729-1734, 2020.
RESUMEN: Los espolones del talón son la protuberancia
ósea que se ve especialmente en la cara dorsal y plantar del hueso
calcáneo en el sitio de inserción de los músculos. El objetivo de
este trabajo consistió en obtener datos sobre los estilos de vida, la
AÇıKGÖZ, A. K.; BALCI, R. S.; ERKMAN, A. C.; GÖKER, P.; & BOZKIR, M. G. Morphometric analysis of calcaneal (heel) spurs in ancient and modern anatolian populations.
Int. J. Morphol., 38(6):1729-1734, 2020.

1734
vida cotidiana y, especialmente, las características socioeconómicas
de las poblaciones anatolias modernas y antiguas mediante la eva-
luación de la prevalencia, la ubicación, la edad y las diferencias de
sexo de los espolones calcáneos y comparar estos hallazgos entre
los poblaciones. La muestra consistió en 251 calcáneos correspon-
dientes a 137 esqueletos, que habían sido previamente analizados
paleodemográficamente y fechados en la Edad Media; tam-
bién se incluyeron 68 calcáneos pertenecientes a una pobla-
ción moderna de Anatolia, sin distinción de sexo. De la
muestra de 251 calcáneos, se encontraron espolones
calcáneos dorsales, plantares y dorsales/plantares, en el 43,9
%, 11,1 % y 10,3 %, respectiva
mente. La presencia de espo-
lones calcáneos dorsales, plantares y dorsales/plantares se
determinó en el 22%, 3% y 1,5%, respectivamente, entre los
68 calcáneos pertenecientes a la población moderna. Cuando
se realizó una comparación del estudio actual con la literatu-
ra sobre poblaciones modernas y prehistóricas, se encontró
una mayor prevalencia de espolones calcáneos en muestras
prehistóricas que en poblaciones modernas. Creemos que esta
situación puede haberse derivado a la gran fuerza de trabajo,
y las diferencias ambientales o socioculturales en las anti-
guas poblaciones de Anatolia, la insuficiencia de materiales
vitales debido a las condiciones industriales inadecuadas pro-
dujo la alteración anatómica. Además, los hallazgos aquí de-
terminados guiarán el desarrollo de estudios futuros e indus-
triales sobre la estructura del pie.
PALABRAS CLAVE: Espolón calcáneo; Espolón
dorsal.
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Corresponding author:
Dr. Ahmet Kürsad Açikgöz, Ph.D.
Faculty of Medicine, Department of Anatomy
Çukurova University, 01330
Adana
TURKEY
Email:akacikgoz@cu.edu.tr
ahmetkursadacikgoz@gmail.com
Received: 06-05-2020
Accepted: 10-08-2020
AÇıKGÖZ, A. K.; BALCI, R. S.; ERKMAN, A. C.; GÖKER, P.; & BOZKIR, M. G. Morphometric analysis of calcaneal (heel) spurs in ancient and modern anatolian populations.
Int. J. Morphol., 38(6):1729-1734, 2020.