A heel spur is a bony outgrowth (calcaneal exostosis) on the underside of the heel bone, almost always developing where the plantar fascia attaches to the calcaneal tuberosity. Imaging surveys show heel spurs in 10-27% of adults over 40, but only a minority have any heel pain — the spur itself is usually a marker of long-standing tension at the fascia origin rather than the direct cause of pain.
A heel spur, or calcaneal spur (ICD-10: M77.3), is a bony outgrowth that forms on the inferior aspect of the calcaneus (heel bone), almost always at the medial calcaneal tuberosity where the plantar fascia and intrinsic foot muscles insert. Historically considered the cause of plantar heel pain, modern imaging studies and biomechanical research have clarified that the spur is a consequence of repetitive traction at the fascia origin rather than the source of pain. Heel pain in patients with spurs is most often caused by plantar fasciitis (plantar fasciopathy) — degenerative or inflammatory change in the plantar fascia itself — or by fat pad atrophy, calcaneal stress fracture, baxter neuropathy, or systemic inflammatory disease. Up to 50% of patients with plantar fasciitis have a spur, but 10-27% of asymptomatic adults also have one.
The key symptoms of Heel Spur are: Sharp, stabbing pain on the underside of the heel at the medial tuberosity, classically worst during the first steps after waking or after sitting for an extended period (post-static dyskinesia)., Pain that improves after walking around for several minutes but returns or worsens with prolonged standing, walking, or running., Dull aching pain along the arch of the foot extending from the heel forward, particularly after activity., Tenderness on direct palpation of the medial calcaneal tuberosity at the plantar fascia origin., Pain at the back of the heel near the Achilles tendon insertion in posterior calcaneal spur or insertional Achilles tendinopathy., Increased pain when walking barefoot on hard surfaces, climbing stairs, or after intense exercise., Limp or altered gait pattern with avoidance of full heel loading..
Diagnosis is largely clinical. The hallmark history is sharp, stabbing pain on the underside of the heel during the first steps in the morning or after sitting, easing with continued movement but worsening with prolonged standing or activity. Examination begins with inspection of the standing foot for arch height, hindfoot alignment, calluses, and shoe wear pattern. Palpation localizes maximum tenderness to the medial calcaneal tuberosity in plantar fasciitis-related spurs; the windlass test (passive dorsiflexion of the great toe reproduces heel pain) supports the diagnosis. Range of motion of the ankle and subtalar joint, Achilles tendon flexibility (Silfverskiöld test), gait pattern, and neurological examination (tibial nerve, Baxter's nerve) are recorded. Lateral weight-bearing radiograph of the foot identifies the spur (typically 1-5 mm bony outgrowth at the plantar fascia origin), evaluates calcaneal pitch, excludes stress fracture, and screens for arthritis. Ultrasound is sensitive for plantar fascia thickening (>4 mm at the calcaneal insertion supports plantar fasciitis), hypoechoic changes, and fat-pad atrophy; it is increasingly used in clinic. MRI is reserved for atypical presentation, suspected stress fracture, Baxter neuropathy, or pre-operative planning. Blood tests (full blood count, CRP, ESR, HLA-B27, rheumatoid factor, anti-CCP) are obtained in bilateral, persistent, or atypical cases, or when systemic features suggest spondyloarthritis. Differential diagnosis includes plantar fasciitis (often the same condition), calcaneal stress fracture, fat pad atrophy, Baxter neuropathy (entrapment of the first branch of the lateral plantar nerve), tarsal tunnel syndrome, insertional Achilles tendinopathy, retrocalcaneal bursitis, seronegative spondyloarthritis, gout, infection, and bone tumour.
Outlook is generally favourable. Around 80-90% of patients improve substantially with conservative care over 6-12 months. Symptoms typically resolve within 6 months with consistent stretching, supportive footwear, weight management, and time. About 10-20% have chronic symptoms persisting beyond a year and may benefit from advanced therapies (ESWT, PRP) or surgery. Heel spur surgery (plantar fasciotomy) achieves 70-85% symptom improvement in carefully selected patients with prolonged failure of conservative care. Recurrence is common (20-30%) if predisposing factors (obesity, occupational standing, biomechanical abnormalities) are not addressed. Severe long-term disability is rare; major complications of treatment include fascia rupture (2-10% after steroid injection) and persistent post-surgical pain or lateral foot strain after extensive release. Quality of life is significantly affected during symptomatic phases but returns to near-normal in most patients after resolution.
A podiatrist, sports medicine physician, or orthopaedic foot and ankle surgeon assesses biomechanics, excludes alternative causes, prescribes orthotics, performs guided injections, and offers shock wave therapy or surgery in refractory cases. Rheumatology referral is warranted when bilateral or young-onset disease raises suspicion of spondyloarthritis.
Find specialists →Most patients notice improvement with stretching and supportive footwear within 4-8 weeks. Maximum improvement from conservative care typically occurs over 6-12 months. ESWT effects appear over 8-12 weeks. Post-fasciotomy surgery: weight bearing in supportive boot within 1 week, full weight bearing at 4 weeks, return to running at 8-12 weeks, full activity at 4-6 months.
Encourage low-impact aerobic exercise (swimming, cycling, elliptical) during symptomatic phases. Continue stretching daily. Gradually reintroduce walking and running over 4-6 weeks as symptoms allow. Avoid sudden mileage increases; use the 10%-per-week rule. Strengthening of intrinsic foot muscles (towel scrunches, toe pickups) improves arch support.
Choose a clinician with experience in plantar fasciitis and heel pain syndromes, access to ultrasound for diagnosis and guided injection, ESWT or PRP availability, and links to physiotherapy with foot specialism. For surgery, look for a foot and ankle surgeon performing at least 25 fasciotomies a year.
Medically reviewed by AIHealz Medical Editorial Board · May 13, 2026
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