Heel Spur

It isn't really either-or. Plantar fasciitis is a soft-tissue problem, and a heel spur is something an X-ray shows. You can have one, the other, both or neither.

• Only imaging shows a spur. Pressing on the sore spot can't tell a spur from a thickened plantar fascia ².
• The numbers don't line up neatly. An estimated 50% of people with heel pain have a spur, and so do around 20% of people with no symptoms at all ⁵.
• Pain under the heel that's worst on your first steps in the morning is the classic plantar fasciitis pattern ¹. Our plantar fasciitis page covers it in detail.

Several other conditions can be mistaken for a spur, and they need ruling out before treatment is planned ⁴:

• Haglund's deformity, a bony prominence at the back of the heel ⁴
• Sever's disease, overload irritation of the heel bone's growth area ⁴
• A heel stress fracture from repetitive load ⁴
• Nerve problems, including Baxter nerve entrapment and tarsal tunnel syndrome ^3,4
• Heel fat pad syndrome, thinning or irritation of the heel's shock-absorbing pad ⁹
• Peroneal tendinopathy, irritation of the peroneal tendons ⁹

The reassuring part: working out why your heel hurts often doesn't need a scan ¹. The physiotherapy guideline keeps imaging for when simple treatment has failed ⁷. A clinician asks about your symptoms, your work and how active you are, then examines your feet and calves for tightness and weakness ¹. They'll find where the heel is most tender and check how far your ankle bends upwards ⁶. Pain on pressing where the plantar fascia attaches, and a positive windlass test, are among the guideline's signs ⁷.

An X-ray or ultrasound is mainly there to rule out other causes, such as a fracture or arthritis ^{1 6}. A spur may turn up on that X-ray, but most people with one have no heel pain ⁶. It's a finding to note. An MRI is rarely ordered ⁶.

An honest caveat. Much of this guidance was written for heel pain in general. It treats plantar fasciitis and heel spur syndrome as the same problem ⁴.

Heel pain with a spur on the X-ray follows The Well Motion Recovery Path™. You move up a phase when the heel copes with more, not when a date arrives.

• Reset: the first weeks. Stretching, padding, strapping and insoles come first ⁴, with taping before activity and a break from whatever provokes the heel ¹. Expect your first steps each morning to be the last thing to ease. We move you on once you can walk without limping.
• Rebuild: the longest phase. We add load gradually ¹, with manual therapy for a stiff calf or ankle and a night splint if mornings stay painful ⁷. Shockwave therapy is a later option, because its results are mixed ⁶. We move you on when the heel handles your normal day without complaining the next morning.
• Return: back to whatever you cut down: long shifts on your feet, walking, running. Running comes back gradually, with rest between sessions ¹. You leave with a stretching and footwear plan for flare-ups.

How long it usually takes. One review reports that more than 90% of people with plantar fasciitis, the pain a spur usually travels with, get relief within 3 to 6 months of conservative treatment ¹¹. That figure is expert opinion, not a trial result. If pain persists past 6 months, a specialist may consider other treatment ¹¹. This describes the pain settling, not the bone changing.

These steps are aimed at plantar heel pain, the soft-tissue problem a spur usually travels with ¹, because that's where the risk factors have been studied ⁷:

• Your calves and ankles. An ankle that doesn't bend up far enough is a risk factor in the physiotherapy guideline ⁷, and tight calves are flagged too ^{1 6}. Warm up before any activity ¹.
• What's under your feet. Long hours on your feet at work count, more so on surfaces with poor shock absorption ⁷. Replace athletic shoes before they stop supporting you ⁶. Insoles are less certain. In a trial of 306 navy recruits, contoured insoles cut four overuse injuries, plantar heel pain among them, from 26% to 18% over 11 weeks, a difference that wasn't statistically significant ⁸.
• How fast you add running. Running is on the guideline's list ⁷. Bring it in gradually and rest between activities ¹.
• Body weight. A high body mass index is a risk factor in people who aren't athletes ⁷.