Plantar Fasciitis vs. Heel Spurs: What's Actually Hurting

If you've had an X-ray of a painful heel, there is a good chance someone pointed at a little hook of bone on the image and said "there's your problem." They were probably wrong.

The relationship between calcaneal heel spurs and heel pain is one of the most misunderstood in musculoskeletal medicine. Spurs are common. Painful heels are common. The overlap between the two has been studied carefully — and the conclusion is awkward: in most people, the spur is not the thing causing the pain.

This piece lays out the anatomy, what the imaging literature actually says, and how clinicians work out which one (or both) is in play. It is not an attempt to get you to ignore a diagnosis. It is an attempt to give you accurate mental furniture.

The anatomy, quickly

The plantar fascia is the thick band of connective tissue running along the bottom of your foot from the heel to the toes. Plantar fasciitis is degeneration and micro-tearing where the fascia attaches to the heel bone.

A heel spur (calcaneal spur, plantar exostosis) is a small, hook-shaped outgrowth of bone that forms on the underside of the heel, usually where the plantar fascia attaches. Bone grows where it gets pulled on — the same mechanism that gives weightlifters thicker femurs. Years of repetitive traction at the fascia insertion can deposit a small beak of calcium, visible on X-ray.

So the two are related — the spur is often a consequence of long-term fascia traction — but "spur present" does not mean "spur causing pain."

Why the spur is usually innocent

This is where the literature is unambiguous. Large imaging studies consistently find:

• Roughly 10–27% of asymptomatic adults have a visible heel spur on X-ray [1]. Plenty of people walk around happily with a spur and never know.
• In people with plantar heel pain, the prevalence of spurs is higher — around 50–75% [2]. That raises the question: which is the chicken and which is the egg?
• When you remove the spur surgically but leave the fasciosis untreated, pain relief is mediocre. When you treat the fasciosis and leave the spur alone, most people improve.

The modern clinical consensus: heel spurs are usually incidental findings. The pain is almost always coming from the soft-tissue fasciosis, even when the spur is visible on imaging.

How clinicians actually tell them apart

We rarely need imaging to diagnose plantar fasciitis. The history and a 60-second exam covers most cases. Here is the hierarchy:

1. History first. Classic first-step pain, eased by walking, worse with prolonged standing, tender on the inside of the heel — that pattern is plantar fasciitis in 9 out of 10 people.
2. Physical exam. Palpation reproduces the pain at the fascia insertion; dorsiflexion of the big toe stretches the fascia and often reproduces the pain (positive windlass test).
3. Imaging only if needed. Ultrasound shows fascia thickening >4mm in true fasciitis. X-ray shows spurs but is largely irrelevant to the diagnosis. MRI is reserved for atypical cases where we worry about a stress fracture, a tear, or a nerve entrapment.

If you are unsure what the pain pattern actually is, run through our 90-second at-home foot self-assessment first. It will tell you whether the presentation is typical or whether you should book a clinical review.

Why treatment overlaps so much anyway

This is the practical takeaway: even if you do have a spur, the first-line treatment is the same as for plantar fasciitis without a spur. Offload the tissue, restore calf and big-toe mobility, build fascia tolerance progressively, and change the footwear that loaded you in the first place.

Surgery to remove the spur is rarely indicated. A 2015 systematic review concluded that spur removal in isolation had inconsistent outcomes, and that the majority of patients respond to the same conservative care used for fasciitis alone [3].

What this means for you

If an X-ray was the basis of your diagnosis, do not panic about the spur. Focus on the exercise programme, footwear, and load management instead. If after eight weeks of consistent conservative care things aren't shifting, that's the signal to see a podiatrist for a proper work-up.

The plantar fascia responds to the same inputs whether or not there's a bump of bone on the imaging. Treat the tissue. The spur, in almost every case, gets to stay where it is.