By Dr. Kayla Wright, DPM
If an X-ray shows a heel spur, it is easy to assume the spur is what hurts. Often, it is not. Plantar fasciitis and heel spurs commonly occur together, but they are different findings: plantar fasciitis is a clinical condition involving pain and irritation where the plantar fascia attaches near the heel, while a heel spur is extra bone that develops over time. Many people have heel spurs without any heel pain at all.
That distinction matters because treatment should target the pain generator, not simply the most visible thing on an X-ray.
Plantar fasciitis vs. heel spur at a glance
| Feature | Plantar fasciitis | Heel spur |
|---|---|---|
| What it is | Painful disorder involving the plantar fascia near its heel attachment | Bony projection from the calcaneus (heel bone) |
| How it is diagnosed | History and physical examination; imaging is often unnecessary | Usually identified on X-ray |
| Typical pain pattern | Pain under or toward the inner heel, often worst with the first steps after rest | Frequently causes no symptoms by itself |
| Common relationship | Can occur with or without a spur | Can be present with or without plantar fasciitis |
| Main treatment target | Load, mobility, strength, footwear and the plantar fascia | Usually the underlying painful condition, not the spur itself |
Why heel spurs get blamed
Heel spurs are easy to see. Pain is not.
If a patient has heel pain and an X-ray also shows a bony projection, the visible finding can become an appealing explanation. But clinical studies and specialty guidance have long shown that heel spurs are common in people without symptoms. The American Academy of Orthopaedic Surgeons notes that most people with heel spurs do not have heel pain and that plantar fasciitis can be treated without removing the spur.
A useful way to think about it is this:
The X-ray tells you a spur exists. It does not, by itself, prove the spur is causing the pain.
The symptom pattern and examination determine whether the plantar fascia, a nerve, the heel fat pad, the Achilles insertion, bone, or another structure is more likely responsible.
What plantar fasciitis usually feels like
Plantar fasciitis has a recognizable pattern. Common features include:
- pain on the bottom or slightly inner side of the heel
- sharp or intense pain with the first few steps after getting out of bed
- “start-up” pain after sitting for a while
- tenderness near the plantar fascia's attachment to the heel
- symptoms that may loosen after a few minutes of movement, then worsen again after prolonged standing or activity
If your heel hurts most when you first stand up in the morning, our guide to morning heel pain explains why that pattern is clinically useful.
What does a heel spur feel like?
This is where the comparison becomes less straightforward: there is no unique symptom that reliably tells you a heel spur is the culprit.
A plantar heel spur can be completely asymptomatic. When heel pain and a spur coexist, the symptoms may feel indistinguishable from plantar fasciitis because the painful soft tissue around the heel—not necessarily the extra bone—is often the important issue.
This is also why the size of a spur does not neatly predict how much pain someone will have.
Why heel spurs form
A plantar heel spur develops gradually where tissues attach to the heel bone. Chronic mechanical stress and traction at that region are associated with spur formation.
That does not mean the spur “caused” plantar fasciitis. It is more accurate to view the two as findings that can share mechanical and anatomical relationships over time.
This also explains why simply removing a spur without understanding the surrounding problem is rarely the starting point for heel-pain care.
If the X-ray shows a spur, do you need surgery?
Usually not.
For a typical plantar-fasciitis presentation, treatment generally begins without surgery and without attempting to remove a spur. Evidence-based care may include:
- plantar-fascia-specific stretching
- calf stretching and mobility work
- progressive foot and ankle strengthening
- taping in selected patients
- activity and load modification
- supportive footwear
- prefabricated or custom orthotics when appropriate as part of a broader plan
- night splints when first-step morning pain remains prominent
- additional nonoperative options for persistent cases
The 2023 clinical practice guideline for plantar heel pain specifically supports stretching and therapeutic exercise, while recommending that orthoses be used with other treatments rather than as a stand-alone solution.
For persistent cases, treatment decisions should be based on the diagnosis and prior response—not simply the presence of a spur.
When an X-ray is actually useful
Plantar fasciitis is usually diagnosed clinically, so an X-ray is not mandatory for every person with first-step heel pain.
Imaging becomes more useful when:
- there was a significant injury
- pain is highly localized to bone
- symptoms do not fit the usual plantar-fasciitis pattern
- there is concern for fracture, arthritis, or another bony condition
- symptoms remain persistent despite appropriate treatment
An X-ray can show a heel spur, but its more important role may be helping evaluate other explanations for heel pain.
What else can mimic plantar fasciitis?
Not every pain under the heel is plantar fasciitis, with or without a spur. Other possibilities include:
- calcaneal stress injury
- heel fat-pad irritation or atrophy
- nerve entrapment
- referred neurologic pain
- inflammatory arthritis
- posterior heel conditions when pain is actually farther back
This is why “the X-ray showed a spur” should not end the diagnostic process when the clinical story does not fit.
The most useful question to ask about your X-ray
Instead of asking only:
“Do I have a heel spur?”
ask:
“Does this finding actually explain where and when my heel hurts?”
That question shifts the focus from an image to the diagnosis.
Frequently asked questions
Can you have a heel spur without plantar fasciitis?
Yes. Heel spurs can be present in people without plantar fasciitis symptoms. They are an anatomical finding, not proof of an active painful condition.
Can you have plantar fasciitis without a heel spur?
Yes. A heel spur is not required for plantar fasciitis. Diagnosis is based primarily on the clinical pattern and examination.
Will a heel spur go away if plantar fasciitis gets better?
The bony spur itself generally remains. The important point is that symptoms can improve even when the spur remains visible on X-ray. Successful treatment does not require making the spur disappear.
Does a bigger heel spur mean worse pain?
Not necessarily. Imaging findings and symptom severity do not match perfectly. The location and behavior of your pain, examination findings, and other possible diagnoses matter more than spur size alone.
Should a heel spur be removed?
Removal is rarely the first-line treatment for plantar heel pain. Surgery is generally reserved for carefully selected patients with persistent symptoms after extensive nonsurgical treatment, and the procedure is directed at the actual pathology rather than an incidental X-ray finding alone.
Heel pain evaluation in Tempe, Arizona
If you were told you have a heel spur but are still unsure what is actually causing the pain, the next step is to match the imaging finding to the clinical pattern. Metro Foot & Ankle evaluates plantar fasciitis and other causes of heel pain in Tempe and throughout the East Valley.
If heel pain is persistent, worsening, or interfering with work, walking, running, or sport, request an evaluation.
This article is for general educational purposes and does not replace individualized medical advice, diagnosis, or treatment.
Sources
- Koc TA Jr, Bise CG, Neville C, et al. Heel Pain – Plantar Fasciitis: Revision 2023. Journal of Orthopaedic & Sports Physical Therapy. 2023;53(12):CPG1–CPG39. https://www.orthopt.org/content/s/heel-pain-plantar-fasciitis-revision-2023 (opens in a new tab)
- American Academy of Orthopaedic Surgeons. Plantar Fasciitis and Bone Spurs. OrthoInfo. https://orthoinfo.aaos.org/en/diseases--conditions/plantar-fasciitis-and-bone-spurs (opens in a new tab)
- Cleveland Clinic. Heel Spurs. https://my.clevelandclinic.org/health/diseases/21965-heel-spurs (opens in a new tab)
- Kirkpatrick J, Yassaie O, Mirjalili SA. The Plantar Calcaneal Spur: A Review of Anatomy, Histology, Etiology and Key Associations. Journal of Anatomy. 2017;230(6):743-751. https://pmc.ncbi.nlm.nih.gov/articles/PMC5442149/ (opens in a new tab)