One of the most common misconceptions surrounding chronic heel pain is that the heel spur is the problem. Many patients are told they have a "large heel spur" after having an X-ray and naturally assume that the bony projection is digging into the soft tissues every time they stand or walk. Fortunately, this is rarely the case.
Research over many decades has demonstrated that heel spurs are extremely common in people who have absolutely no heel pain. Likewise, many patients with severe chronic heel pain have little or no heel spur visible on X-ray. This simple observation tells us that the presence of a heel spur alone does not explain why someone develops symptoms.
A heel spur develops gradually over many years where the plantar fascia attaches to the heel bone. Rather than being the cause of plantar fasciosis, it is generally considered to be a sign that longstanding traction forces have been present at the attachment of the plantar fascia. In many respects, the spur is better thought of as a marker of chronic loading rather than the source of pain itself.
The pain experienced in plantar fasciosis usually arises from degeneration within the plantar fascia, microscopic tissue injury, abnormal collagen repair and, in some patients, irritation of nearby nerves. These pathological changes occur within the soft tissues rather than within the bony spur itself. Consequently, removing the spur without addressing the underlying pathology is unlikely to resolve the patient's symptoms.
This is one of the reasons why modern heel pain surgery has evolved considerably over the past several decades. Earlier surgical techniques often included routine removal of the heel spur. As our understanding of plantar fasciosis improved, it became clear that most patients recovered without the spur being removed. Today, many surgeons no longer routinely excise heel spurs during plantar fascia surgery because doing so adds surgical trauma without consistently improving outcomes.
There are, however, occasional exceptions. In rare circumstances, a particularly prominent spur may mechanically irritate surrounding soft tissues, contribute to local impingement or interfere with adjacent structures. Occasionally, imaging demonstrates an unusual anatomical relationship where the spur forms part of the overall pathology. These situations are uncommon and require careful clinical correlation rather than relying on the X-ray appearance alone.
The decision to remove a heel spur should therefore never be based solely on its size. Some patients have very large spurs without any symptoms whatsoever, while others experience severe heel pain despite having little or no visible spur. The patient's history, physical examination and advanced imaging findings remain far more important than the appearance of the X-ray.
High-resolution musculoskeletal ultrasound and MRI frequently provide much more clinically useful information than a plain X-ray. These investigations allow assessment of the plantar fascia itself, surrounding nerves, tendons, bone marrow and adjacent soft tissues. They help determine whether the patient's symptoms are due to plantar fasciosis, Baxter's nerve entrapment, stress injury, bone marrow oedema or another condition entirely. Treating the correct pathology is far more important than treating the radiographic appearance.
If surgery is required for chronic plantar fasciosis, the operation is usually directed at the diseased plantar fascia rather than the heel spur. Depending on the individual pathology, surgery may involve a partial plantar fascia release, debridement of degenerative tissue or another procedure specifically designed to address the underlying diagnosis. Removing the heel spur generally provides little additional benefit unless there is a separate indication for doing so.
Patients are often reassured to learn that living with a heel spur is perfectly normal. The spur itself does not continue to grow rapidly, and leaving it in place does not usually cause ongoing damage. Once the underlying soft tissue condition has been successfully treated, the heel spur frequently becomes an incidental finding that no longer causes concern.
Published research consistently supports this modern approach. Numerous studies have found poor correlation between heel spur size and pain severity. Clinical outcomes following plantar fascia surgery are primarily related to correcting the underlying soft tissue pathology rather than excising the spur itself. This shift in understanding has helped reduce unnecessary surgery while improving long-term patient outcomes.
Ultimately, heel spurs should be viewed as part of the overall clinical picture rather than the diagnosis itself. Treating the patient instead of treating the X-ray leads to more accurate diagnoses, better treatment decisions and improved long-term results.