One of the most common questions patients ask is whether they need an X-ray to diagnose their heel pain. The answer depends on the suspected cause of the symptoms. Although X-rays remain an important investigation in some situations, they are not the best test for every patient with chronic heel pain because they primarily show bones rather than soft tissues such as the plantar fascia, tendons and nerves.
For patients with longstanding plantar heel pain, an X-ray is often used to assess the overall structure of the foot, identify arthritis, detect fractures, evaluate bone alignment and determine whether a heel spur is present. However, an X-ray cannot directly demonstrate plantar fasciosis, Baxter's nerve entrapment or many of the soft tissue conditions responsible for persistent heel pain.
A common misconception is that finding a heel spur on an X-ray explains the pain. In reality, heel spurs are extremely common and many people with large heel spurs have no symptoms at all. Likewise, some patients with significant heel pain have no heel spur. The presence of a spur should therefore be interpreted alongside the patient's history and examination rather than assumed to be the cause of the pain.
When the clinical concern relates to the plantar fascia or surrounding soft tissues, diagnostic ultrasound often provides more useful information because it allows direct assessment of tissue thickness, degeneration and tearing. If deeper bone pathology such as bone marrow oedema or a stress fracture is suspected, MRI may be the more appropriate investigation. Each imaging modality has strengths, and selecting the right investigation is more important than simply requesting more tests.
The purpose of imaging is to improve diagnosis rather than confirm assumptions. A careful history and physical examination remain the foundation of assessment. Imaging should complement that process by answering specific clinical questions that influence treatment decisions.