One of the most common misconceptions about heel pain is that the heel spur is the cause of the symptoms. Many patients are understandably concerned when an X-ray reports a heel spur, believing it must be responsible for the pain. However, current evidence suggests that heel spurs are often an incidental finding and, by themselves, do not necessarily cause pain.
A heel spur is a small bony projection that develops where the plantar fascia attaches to the heel bone. It forms gradually over time in response to long-term mechanical loading rather than appearing suddenly after an injury. Many people with heel spurs experience no heel pain at all, while others with significant heel pain have no visible spur on X-ray.
This means that finding a heel spur does not automatically explain why your heel hurts. The more important question is what is happening within the surrounding soft tissues. Chronic plantar fasciosis, Baxter's nerve entrapment, heel fat pad syndrome, bone marrow oedema and other conditions may all be responsible for symptoms regardless of whether a heel spur is present.
In clinical practice, heel spurs should always be interpreted alongside the patient's history, examination and, where appropriate, diagnostic ultrasound or MRI. Ultrasound can assess the condition of the plantar fascia itself, while MRI provides additional information about deeper bone and soft tissue pathology when indicated. Imaging findings should support the diagnosis rather than dictate it.
I explain to patients that a heel spur is often better thought of as evidence that the area has been under stress for a long time rather than proof that the spur itself is painful. Treating the spur without understanding the underlying pathology is unlikely to provide lasting relief. Instead, treatment should focus on the structures actually generating the symptoms.
Depending on the diagnosis, management may include rehabilitation, footwear modification, orthotic therapy, ultrasound-guided regenerative injections such as prolotherapy or platelet-rich plasma (PRP), ultrasound-guided hydrodissection when nerve irritation is present, or minimally invasive surgery in carefully selected patients after comprehensive conservative care has been exhausted. Removing a heel spur is rarely the primary objective of treatment.
The goal is always to identify the true source of pain. Once the diagnosis is clear, treatment can be directed at the underlying cause rather than an imaging finding that may simply be incidental.