Heel spurs: causes and risk factors

A heel spur is a bony enthesophyte on the underside of the heel bone. It often occurs in people without any complaints and is often painless. The primary cause of this "first morning" heel pain is most often a degenerative lesion of the plantar fascia, which is now more accurately called "plantar fasciopathy." Therefore, the doctor's goal is to treat not the "spur," but the underlying clinical syndrome of heel pain. [1]

Radiographic spur is found in approximately 15-20% of the population, and in fasciopathy, in approximately one in two cases. The presence of an enthesophyte increases the likelihood of pain, but does not prove its cause: in a significant proportion of patients, pain is entirely explained by overuse, microdamage, and thickening of the fascia. This is important to consider to avoid unnecessary interventions aimed at filing down the spur. [2]

Plantar fasciopathy is one of the most common foot conditions in adults aged 40 to 60. Up to 10% of people experience it during their lifetime, with runners and those who stand for long periods at work having a higher risk. With early, appropriate treatment, most patients improve within 6 to 12 months without surgery. [3]

Repeated subfascial corticosteroid injections provide only short-term relief and carry the risk of fascial rupture and thinning of the heel fat pad. Conservative methods with high evidence—specific stretching, strengthening exercises for the foot and lower leg, night orthoses, taping, a correct balance between rest and activity, as well as low-level laser and extracorporeal shock wave therapy—are indicated as first-line treatments. [4]

Table 1. Myths and facts about heel spurs

Statement	What does science say?
The spur is always the cause of pain.	Often no: enthesophyte occurs in healthy people, but the fascia hurts. [5]
The larger the spur, the more severe the pain.	Size does not necessarily correlate with symptoms.[6]
The diagnosis is made by x-ray.	The diagnosis is clinical; imaging is needed selectively. [7]
The best treatment is a steroid injection.	Short-term benefits and risks; priority is given to non-drug measures. [8]

Anatomy and what is a "spur"

The plantar fascia is a thick, fibrous band extending from the medial tuberosity of the calcaneus to the bases of the toes. During walking, and especially during push-off, it stretches, supporting the arch of the foot through a "windlass mechanism": dorsiflexion of the big toe "winds" the fascia and elevates the arch. Overload, decreased tissue elasticity, and limited dorsiflexion of the ankle joint increase tension at the attachment site of the fascia to the heel. [9]

A bone spur forms as an enthesophyte at the attachment site of the tendon-ligament apparatus or as a reaction to chronic tension in the short flexor muscles of the toes. This is an adaptive remodeling process, not a "salt deposit" in the common sense. Its presence reflects the long-term mechanical history of the heel, but does not equal pain. [10]

The modern view of fasciopathy is "degeneration plus an inflammatory component," rather than pure inflammation. Microtears, mucoid remodeling, thickening, and hypovascularity contribute to pain, especially during the first steps in the morning, when the fascia is still shortened. These tissue changes are readily detectable by ultrasound. [11]

The heel fat pad is a distinct anatomical structure. Its thinning or injury causes a different type of pain, which is important to distinguish from fasciopathy. Incorrectly targeting the "spur" in cases of fat pad syndrome is ineffective. [12]

Table 2. What is in the "problem heel" area?

Structure	Role	What hurts with fasciopathy?	What hurts when you have a spur?
Plantar fascia	Arch support, load transfer	Enthesis at the medial tubercle of the calcaneum	It may drag on, but it doesn't have to be the cause.
Fat pad	Shock absorption	Usually no	In case of atrophy or injury - yes
Heel bone	Bears the load	No	The spur itself is rarely the source of pain.
[13]

How common is this?

Up to 10% of people experience symptoms of fasciopathy during their lifetime. The peak incidence occurs between ages 40 and 60, with no significant difference between men and women. Among all foot pathologies, plantar fasciopathy accounts for approximately 15%. It is more common in occupational groups that spend long periods standing and among runners. [14]

The "spur" itself, as a radiographic finding, is detected in a significant minority of painless patients and in many with pain. According to reviews, the enthesophyte is present in approximately 50% of patients with fasciopathy and in 15% or more of painless individuals. This fact emphasizes the need to treat the person and the symptoms, not the image. [15]

Medical care is highly sought: in the US alone, millions of visits are recorded annually for heel pain, a significant portion due to fasciopathy. However, instrumental diagnostics are not always required at the outset if the clinical picture is typical. This explains the focus of modern guidelines on clinical management. [16]

Without targeted treatment, symptoms often last longer than 12 months. However, with proper exercise programs and loads, most patients achieve significant relief within 6-12 months. Those who systematically apply proven methods have a lower risk of chronicity. [17]

Table 3. Heel pain figures

Indicator	Grade
Lifetime prevalence of fasciopathy	up to 10% of the population [18]
Share among foot pathologies	about 15% [19]
The presence of a spur in fasciopathy	≈ 50% of cases [20]
Asymptomatic spur	≥ 15% of the population [21]

Why it happens: Mechanics and factors

The key mechanics are repetitive overload of the enthesis fascia at the medial tuberosity of the calcaneus. This is facilitated by decreased ankle dorsiflexion, tight calf muscles, and sudden changes in load. The worse the dorsiflexion, the higher the risk of fasciopathy—it is one of the most powerful modifiable factors. [22]

Excess body weight increases heel impact forces and increases fascial tension. Prolonged standing on hard surfaces, running on hard surfaces, and minimalist or worn-out shoes without cushioning increase the risk. Biomechanical foot variations, such as overpronation or high arches, can also alter force distribution. [23]

The spur itself often reflects chronic tension and adaptive remodeling rather than being a direct cause of pain. Even in the presence of an enthesophyte, the primary goal is to reduce the abnormal tension of the fascia with exercises, tapes, and orthoses, rather than "remove the spur." This explains why conservative treatment is effective in most patients. [24]

In a small percentage of people, metabolic factors and comorbid conditions act as triggers: diabetes mellitus, hyperglycemia, associated tendinopathies, and activity limitations following injuries. But even in these cases, the core of care remains biomechanical and behavioral. [25]

Table 4. Factors that increase the risk of heel pain

Factor	Comment
Decreased ankle dorsiflexion	One of the strongest predictors of risk.[26]
Overweight	Increases impact load. [27]
Long periods of standing and running on hard surfaces	Total enthesis overload. [28]
Foot biomechanics (pronation, high arch)	Changes the vector and magnitude of fascia tension. [29]

How it manifests itself: typical symptoms

The most characteristic symptom is a sharp, initial pain in the medial heel when first taking steps in the morning or after rest. The pain often subsides after warming up, but returns by the end of the day or after prolonged exercise. Palpation tenderness is greatest at the medial tubercle of the calcaneus. [30]

A provocative "windlass test" with passive dorsiflexion of the first toe can reproduce familiar pain. It is highly specific and low-sensitivity: a positive test confirms the diagnosis, while a negative one does not rule it out. Therefore, the physician relies on a combination of symptoms. [31]

Pain associated with fat pad syndrome is typically more central, stabbing, and worsens on hard surfaces and with prolonged standing; the morning "starting" component is less pronounced. These nuances help differentiate the conditions and choose the right treatment. [32]

With a "pure" heel spur without fasciopathy, there may be no pronounced morning symptoms at all, and pain is often associated with concomitant soft tissue inflammation. This is a rare scenario and requires selective confirmation. [33]

Table 5. Heel pain: how the main conditions differ

Sign	Plantar fasciopathy	Fat pad syndrome	"Clean" spur
Time of maximum pain	First steps in the morning	After standing/walking for a long time	Variable
Pain point	Medial tubercle of the calcaneum	Center of the heel	Variable
Windlass test	Often positive	Usually negative	Uninformative
Ultrasound signs	Fascia thickness > 4 mm, hypoechogenicity	Thinning/separation of the septa of the fat pad	No specifics
[34]

How is the diagnosis made?

The first step is clinical. The doctor determines the onset, nature, and rhythm of the pain, as well as the load, footwear, and changes in weight and activity. The examination includes palpation of the medial tubercle, assessment of ankle dorsiflexion, a dorsiflexion test of the big toe, and an assessment of footwear and gait. This is often the first step to making a probable diagnosis. [35]

The second step is selective imaging. Ultrasound reveals fascial thickening greater than 4 mm, hypoechoic areas, and increased blood flow; this is the most readily available method for confirming fasciopathy. Magnetic resonance imaging is necessary in cases of atypical presentation, suspected calcaneal stress fracture, compression neuropathy, or tumor. [36]

Radiography can reveal a "spur" but rarely changes management if the clinical picture is typical. It is used to rule out a fracture, assess posterior enthesis of the Achilles tendon, or evaluate severe sclerosis. In cases of typical fasciopathy, radiography is not mandatory. [37]

The third step is an assessment of the underlying factors: measuring dorsiflexion, short foot muscle strength, body mass index, exercise habits, and shoe selection. This allows for a personalized recovery program and reduces the risk of relapse. [38]

Table 6. Instrumental methods and “what they give”

Method	What helps to confirm	Threshold/sign	When needed
Ultrasound examination	Fasciopathy	Fascia thickness > 4 mm, hypoechogenicity	Often enough
Magnetic resonance imaging	Atypical process, stress fracture, neurogenic pain	Bone edema, ruptures, neuromas	According to the readings
X-ray	Enthesophyte, fracture, posterior enthesis of Achilles	Presence/size of a spur	According to the readings
[39]

Differential Diagnosis: Whom to Watch Out For

Fat pad syndrome is the second most common cause of pain. It causes more central pain, worsens on hard surfaces and when walking barefoot, and is worse in the evening. Ultrasound reveals thinning and disruption of the fat pad septa. [40]

Compression of the lateral plantar branch (Baxter's nerve) mimics fasciopathy but is more often accompanied by numbness and radiating pain. Magnetic resonance imaging and clinical neurological testing are helpful. Treatment strategies vary and include neuromobilization and load modification. [41]

A stress fracture of the calcaneus presents with increasing pain that doesn't subside with "walking" and intensifies with axial loading. This requires urgent visualization and unloading. Incorrectly "pushing" through the pain worsens the condition. [42]

Systemic causes of pain, including spondyloarthritis, gout, and infections, should be considered when red flags are present: night pain, severe morning stiffness for more than 60 minutes, fever, weight loss, multiple joint complaints. In doubtful cases, laboratory and additional tests are required. [43]

Table 7. Red flags for heel pain

Flag	What to do
Night/unexplained pain, fever, weight loss	See a doctor immediately, get an extended diagnosis. [44]
Sharp pain after a crunch or jump	Rule out fascial rupture and stress fracture. [45]
Numbness, burning pain, weakness	Rule out nerve compression. [46]

Treatment: A Basic Program That Works

Current recommendations prioritize non-drug treatments. These include specific stretching of the plantar fascia and calf muscles, plus progressive strength training for the foot and calf muscles. This reduces pain in both the short and long term. [47]

Night braces that maintain the ankle in neutral or slight dorsiflexion are indicated for 1-3 months for severe morning start pain. They reduce the morning "surge" while the fascia regains length and elasticity. This is a high-level recommendation. [48]

Taping the foot with rigid or elastic bands provides a quick but short-term effect lasting 1-6 weeks, especially when combined with exercise. Custom-made or pre-made insoles are best used not as a stand-alone treatment, but rather as a supplement to an exercise program and load control. The difference between custom-made and pre-made insoles in terms of average outcomes is small. [49]

Manual techniques targeting the soft tissues and joints of the foot and lower leg improve function and reduce pain as part of a comprehensive program. A key component is self-management training: regulating step activity, measured walking, short "unloading" breaks, switching to softer surfaces, and properly cushioned shoes. [50]

Table 8. First-line components and their expected effect

Method	Effect	Comment
Stretching the fascia and calf muscles	Pain ↓, function ↑	Base therapy, daily. [51]
Strength training for the feet and calves	Pain ↓, endurance ↑	Progression of pain loads. [52]
Night orthoses	Morning pain ↓	Course 1-3 months. [53]
Taping	Quick short-term effect	In combination with the rest. [54]
Insoles	Support included in the set	Not as monotherapy. [55]

Treatment: medications and physical factors

Nonsteroidal anti-inflammatory drugs (NSAIDs) can reduce pain sensitivity initially, but they do not treat the underlying cause and should not replace exercise. They should be used in short courses after assessing the risks to the stomach, kidneys, and cardiovascular system. Ice and local heat can be used situationally, depending on tolerance. [56]

Low-level laser therapy has gained a stronger position in clinical guidelines for short-term pain reduction in both acute and chronic cases. Electrotherapy and ultrasound have not shown advantages over active methods and can only be considered secondary adjuncts. [57]

Extracorporeal shock wave therapy demonstrates clinically significant improvements in some patients with chronic disease, particularly when carefully selected and integrated into an exercise program. It is a proven second-line option for patients with inadequate response to basic measures. The decision is made on an individual basis. [58]

Local corticosteroid injections are most effective in the short term and do not improve long-term outcomes. Risks include fascial rupture and atrophy of the heel fat pad. If an injection is considered, it is administered selectively and single-shot with ultrasound guidance, followed by strengthening and stretching. [59]

Treatment: Third-line procedures and surgery

Platelet-rich plasma injections are being actively studied, yielding mixed results: in some studies, the effect is comparable or slightly better than shock wave therapy over a period of months, while in others, there is no difference. This should only be considered after a comprehensive first-line program and with realistic expectations. [60]

Radiofrequency microtenotomy and ultrasound-guided percutaneous techniques are minimally invasive options for resistant cases, allowing for mechanical stimulation of remodeling in the enthesis zone. Recent publications describe good short-term results and rapid recovery with proper selection. Further research is ongoing. [61]

Endoscopic partial fasciotomy remains a last-resort procedure for persistent pain after at least 6-12 months of comprehensive conservative treatment. High satisfaction rates are reported, but there are risks of altered fornix biomechanics and neurovascular complications, so the decision should be made by an experienced surgeon and a multidisciplinary team. [62]

Isolated removal of the "spur" without addressing the fascia is rarely justified because it fails to address the underlying cause of pain—pathological tension and degeneration of the fascia. Even after surgery, long-term exercise and proper load modification are essential. [63]

Table 9. What to do if the basic program does not work

Step	Meaning	Who is it suitable for?
Rebuilding the base program	Check technique, progression, shoes	Most chronic
Shock wave therapy	Stimulus for tissue remodeling	If the response is insufficient
Injections (strictly selective)	Short-term analgesia or biostimulation	Point-selected
Minimally invasive techniques/fasciotomy	Resistant cases after 6-12 months	According to the readings
[64]

Lifestyle and relapse prevention

Self-management is the heart of treatment. This includes learning a "stepwise" progression of daily steps, keeping a daily exercise diary, taking short breaks throughout the day, judiciously changing running surfaces, and gradually returning to exercise. A simple guideline: increasing weekly exercise load by no more than 10-15% and avoiding "peaks" after prolonged periods of rest. [65]

Footwear is important: moderate heel and forefoot cushioning, a stable back, sufficient toe box height, and a lack of wear are all beneficial. Soft mats in "work areas" at home are helpful. For some patients, silicone heel cups are helpful as a temporary measure. [66]

Weight management reduces impact loads and decreases the risk of relapse. It's not a cure-all, but it's an important foundation for any therapy. Strength training of the feet, calves, and gluteal muscles improves load-bearing capacity and supports the arch. [67]

The minimum preventative measure for the coming months is a short program 3-4 times a week: 5-10 minutes of fascia and calf stretching, 10-15 minutes of strength training with an elastic band and "heavy slow" calf raises, and 5 minutes of coordination on one leg. This is a real way to maintain the results. [68]

Table 10. Example of a weekly self-care plan (after acute pain has subsided)

Day	What to do
Monday	Stretching the fascia and calf muscles, "herringbone" tape for 1-2 days
Wednesday	Strengthening exercises for the feet and calves, coordination while standing on one leg
Friday	Stretching + walking on a soft surface with a gradual increase in time
Sunday	Power "heavy slow" calf raises + easy walk
[69]

Forecast and answers to frequently asked questions

Most people experience significant pain relief with proper management within 6-12 months. Early education and the inclusion of active methods accelerate recovery and reduce the risk of chronicity. Surgery is rarely required and is considered only after comprehensive conservative therapy. [70]

Question 1. Is it necessary to "file down" the spur to stop the pain? Almost never. More often than not, the pain is caused by the fascia rather than the bony protrusion, so treatment focuses on the tissue and the load. Surgery is only indicated if the pain persists after a comprehensive program. [71]

Question 2: Should a corticosteroid injection be used? It is an option for short-term relief in carefully selected patients, but it is not a "magic bullet." Risks include fascial rupture and fat pad atrophy; when available, active methods and shockwave therapy are better. [72]

Question 3. What tests are required? If the picture is typical, an examination and, if necessary, an ultrasound scan are sufficient. X-rays and magnetic resonance imaging are reserved for cases of atypical progression or suspicion of another pathology. [73]

Question 4. How do I know if I have heel pad syndrome, not fasciopathy? With heel pad syndrome, the pain is most often in the center of the heel, worse on hard surfaces and when walking barefoot, and less intense than in the morning. An ultrasound can confirm this. Treatment strategies vary. [74]