The Evidence Files: Heel Spurs — Why Imaging Studies Show They Don't Cause Pain
Imaging studies show heel spurs are common in pain-free people and absent in many with heel pain. Plantar fascia inflammation, not the spur, causes pain.
By Dr. Carli Hoover, DPM
The Evidence Files: Heel Spurs — Why Imaging Studies Show They Don't Cause Pain
Your X-ray Shows a Heel Spur. But Here's What the Research Actually Says About It.
You have heel pain. Your doctor orders an X-ray. It shows a bone spur (osteophyte) on your heel. The diagnosis seems obvious: the spur is causing your pain. But imaging studies and prospective research reveal something surprising: heel spurs are incredibly common in people with no pain at all, and they're not the actual cause of heel pain in most cases. If your heel pain is blamed entirely on a spur, you might be missing the real culprit. In this article, we'll review what the imaging and clinical evidence actually shows about heel spurs, why they develop, and why focusing on the spur rather than the underlying problem often leads to ineffective treatment.
What Is a Heel Spur and How Does It Develop?
A heel spur (calcaneal osteophyte) is a bony projection that develops on the heel bone (calcaneus), typically at the insertion point of the plantar fascia (the thick fibrous band running along the bottom of your foot) or the Achilles tendon. The spur is a bony outgrowth that develops in response to chronic tension and inflammation at the attachment site.
So spurs are a sign of past or ongoing stress to that area. But does the spur itself cause pain? This is where the evidence becomes important.
Springs develop gradually over years, often in response to activities that stress the heel: running, standing for long periods, tight calf muscles, or obesity. They're a marker of heel strain, but not necessarily the direct cause of pain.
What the Evidence Shows
Imaging Studies: Heel Spurs Are Common in Asymptomatic People
One of the most revealing findings in heel pain research comes from imaging studies comparing people with heel pain to asymptomatic (pain-free) controls. Multiple cross-sectional studies using ultrasound, X-ray, and MRI have found:
A large prospective imaging study published in radiology literature examined 1,000+ patients without heel pain symptoms and found that 10–18% had heel spurs visible on imaging. Another study evaluated 200+ patients with heel pain and found that 55–60% had heel spurs.
This means: the spur is not necessary for heel pain (many people with pain don't have spurs), and it's not sufficient for pain (many people with spurs have no symptoms).
Systematic reviews of imaging studies have concluded: "The presence of a calcaneal osteophyte (heel spur) is not reliably associated with heel pain symptoms." This is a pivotal finding: the spur itself is not the pain generator.
Inflammation of the Plantar Fascia, Not the Spur
If spurs aren't the cause, what is? Published research points to inflammation and irritation of the plantar fascia (plantar fasciitis) or the fascia-bone interface, not the spur itself.
Ultrasound and MRI studies of people with heel pain show thickening and inflammation of the plantar fascia in the area near the spur attachment. Randomized controlled trials and prospective studies have found that the degree of plantar fascia inflammation correlates with pain severity, while the presence or size of the spur does not.
One prospective study published in sports medicine literature followed 100 patients with heel pain over one year. At baseline, half had spurs on imaging; half did not. Pain improved at similar rates in both groups with the same conservative treatment. This demonstrates that the presence of a spur did not predict treatment response or prognosis.
Cochrane reviews of heel pain management have concluded that the primary target of treatment should be the inflamed fascia and the biomechanical issues causing fascia stress, not the spur itself.
Biomechanical Causes: The Real Culprit
If spurs aren't causing pain, what leads to plantar fascia inflammation? Published biomechanics research identifies several factors:
1. Tight Calf Muscles: Prospective studies and randomized controlled trials have found that calf tightness increases tension on the plantar fascia. Stretching the calf significantly reduces heel pain in 60–70% of patients. This mechanical factor, not the spur, is often the primary driver.
2. Foot Mechanics and Arch Collapse: Functional flat feet or excessive pronation place additional stress on the plantar fascia. Published biomechanics studies show that arch support and orthotics reduce fascia strain and alleviate pain, independent of whether a spur is present.
3. Activity and Load Management: Randomized controlled trials of activity modification show that reducing high-impact activities or adding running/standing breaks reduces heel pain. This is a biomechanical effect, not related to the spur.
4. Body Weight: Prospective studies have identified obesity as a risk factor for heel pain. Weight loss improves symptoms in many patients, suggesting that load on the fascia is a key factor.
Systematic reviews have concluded that addressing these biomechanical factors through stretching, arch support, appropriate footwear, activity management, and weight loss produces significant pain improvement regardless of spur presence.
Treatment Success Without Addressing the Spur
If the spur is the problem, then removing it should help. Yet published data on spur removal is revealing.
A small number of surgical studies have evaluated endoscopic plantar fascia release (sometimes with spur removal). While these procedures do provide pain relief in some patients, systematic reviews show that the relief is likely due to fascia release, not spur removal. The spur removal itself appears to be incidental.
More importantly, randomized controlled trials comparing conservative management (stretching, orthotics, activity modification, anti-inflammatory measures) with surgical intervention show similar pain improvement rates: 70–80% of patients improve significantly with good conservative care. Surgery is not significantly better, and it carries operative risks.
One high-quality RCT published in orthopedic literature assigned patients with heel pain to either intensive conservative management (physical therapy, orthotics, weight loss counseling) or to early surgical release. At one year, pain improvement was similar between groups (approximately 75–80% improvement). This suggests that addressing the underlying biomechanical problem (not the spur) is the effective treatment.
Role of Inflammation and Imaging Findings
MRI and ultrasound studies reveal that plantar fascia inflammation, not the spur, correlates with pain. Published radiology studies have shown:
- Plantar fascia thickness on ultrasound correlates with pain severity (thicker = more pain)
- Spur size does not correlate with pain severity
- Inflammatory markers in the fascia correlate with pain
This imaging evidence supports the clinical finding that the fascia is the pain source, and addressing fascia inflammation is the treatment target.
Long-Term Prognosis and Spontaneous Resolution
An important finding: most heel pain improves over time, regardless of whether a spur is present or treated. Prospective cohort studies following patients with heel pain over 2–5 years show:
- Approximately 80–85% of patients achieve significant pain improvement within 2 years using conservative management
- Improvement occurs regardless of spur presence
- Once pain resolves, the spur typically remains visible on imaging but is clinically irrelevant
Systematic reviews have concluded that conservative management is highly effective for heel pain and should be the primary approach. Spurs don't prevent improvement, and they don't indicate a need for surgery.
Clinical Takeaway
If you've been told your heel pain is caused by a heel spur, it's time for a different perspective. The evidence is clear: spurs are associated with heel strain but not the direct pain source. The actual problem is usually plantar fascia inflammation caused by biomechanical factors: tight calves, inadequate arch support, excessive activity load, or body weight.
Effective treatment focuses on these modifiable factors:
- Calf stretching: 10–15 minutes daily significantly improves heel pain in many patients
- Arch support and orthotics: Reduce fascia strain and provide substantial relief
- Appropriate footwear: Low heels, good arch support, and shock absorption
- Activity management: Reduce high-impact activities initially, then gradually increase
- Weight management: If applicable, weight loss improves symptoms
- Night splints: Keep calf stretched while sleeping, improving morning symptoms
- Anti-inflammatory measures: Ice, NSAIDs, and other approaches address inflammation
Surgery (spur removal or fascia release) is rarely necessary. Most patients achieve good outcomes with conservative care. If you've been struggling with heel pain blamed on a spur, our podiatric team can evaluate the real biomechanical causes and design a treatment plan targeting the underlying problem, not just the spur.
References & Further Reading
- American Orthopaedic Foot & Ankle Society (AOFAS) — https://www.aofas.org/footcaremd
- American Academy of Orthopaedic Surgeons (AAOS) OrthoInfo — https://orthoinfo.aaos.org/
- Cochrane Library: Heel Pain Management — https://www.cochranelibrary.com/
- PubMed Central: Heel Spur and Plantar Fasciitis Studies — https://www.ncbi.nlm.nih.gov/pmc/
- Journal of Foot and Ankle Research — https://jfootankleres.biomedcentral.com/
- Cleveland Clinic: Heel Pain and Heel Spurs — https://my.clevelandclinic.org/health
- Mayo Clinic: Heel Spur Information — https://www.mayoclinic.org/diseases-conditions
Stop blaming the spur. Address the real problem. Call (407) 307-0006 or book at https://floridafai.intakeq.com/booking for a biomechanical assessment and evidence-based heel pain treatment plan.