"Is it a heel spur?"

Heel pain is a common complaint, and one of the questions I get asked a lot is whether a heel spur is actually the cause.

A lot of runners get an X-ray, hear the words heel spur, and understandably assume that must be the problem. It sounds structural, permanent, and like something that needs fixing.

But in most cases, that is not how this works.

More often than not, a heel spur is not the main reason your heel hurts.

📊 How common are heel spurs?

Before we even talk about what a heel spur is, it is worth understanding just how common they are.

Heel spurs are common in the general population, with estimates around 15%, and they are seen more often in people with higher body weight, osteoarthritis, and lower limb pain (Moroney 2014; Kirkpatrick 2017).

In people with plantar heel pain, they are even more common.

But here’s the key point 👇

👉 They are also very common in people without pain.

A recent study by Okçu et al. (2023) found:

• Spurs in 85% of painful heels

• Spurs in 71% of painless heels 

Even more interesting:

• Some people had bigger spurs on the pain-free side

• Some people had heel pain with no spur at all 

So straight away, this tells us something important:

👉 The presence of a heel spur alone does not explain pain

🧠 What actually is a heel spur?

A heel spur is a bony outgrowth from the calcaneus, usually at the plantar fascia attachment.

Historically, this was explained as repeated traction from the plantar fascia pulling on the bone.

But that explanation is probably too simplistic.

A more modern view is that heel spurs are an adaptive response to long-term loading, potentially helping redistribute stress at the heel (Kirkpatrick 2017).

So rather than thinking:

👉 “This sharp piece of bone is causing pain”

It is more useful to think:

👉 “This is a footprint of long-term load exposure”

❗ The big myth: “The spur is causing your pain”

This is where a lot of people get misled.

The assumption is:

heel pain = heel spur = problem solved

But the research doesn’t support that.

Moroney et al. (2014) described this as a “conundrum”, and that still holds true. Heel spurs are associated with plantar heel pain, but they do not consistently cause it.

The newer evidence reinforces this.

Okçu et al. (2023) showed:

• Spur presence alone does not determine pain

• Spur type does not determine pain

• Spur size has some association, but does not fully explain symptoms

Even more importantly:

👉 A large number of people have spurs and no symptoms at all 

So while a heel spur may be part of the picture…

👉 It is rarely the main driver

What is more likely causing the pain?

In runners, most heel pain is better understood as:

👉 Plantar heel pain (plantar fasciopathy)

And our understanding of this has shifted significantly.

It is no longer viewed as a purely inflammatory condition.

Instead, it is:

👉 A load-related, degenerative condition of the plantar fascia

This is reinforced in more recent reviews (Tseng 2023), which highlight chronic tissue changes rather than inflammation.

And importantly, this is exactly how the latest clinical guidelines approach it.

The 2023 JOSPT Clinical Practice Guideline recommends:

• Diagnosis based on clinical presentation

• Minimal reliance on imaging

• Treatment focused on load, exercise, and function

Not the presence of a heel spur.

Does size matter?

This is where things get a bit more nuanced.

Cho et al. (2022) showed that:

• Larger spurs and higher BMI are associated with more severe symptoms

And Okçu et al. (2023) found:

• Spur length and base width correlate with pain levels

• Larger spurs (>5 mm) showed greater improvement with treatment 

So yes, size might matter to some degree.

But here’s the key distinction:

👉 Association does not equal causation

The spur may reflect:

• longer symptom duration

• greater cumulative loading

• higher body mass

Rather than being the direct cause of pain itself.

A really important clinical insight (often missed)

One of the most useful findings from the Okçu/Mehmet 2023 paper is this:

👉 Even when spurs change with treatment, that does not necessarily explain pain improvement

Other studies have also shown that:

• Pain improves with treatments like ESWT

• But changes in the spur itself do not consistently correlate with outcomes 

So even when we “treat the spur”…

👉 The improvement is likely coming from changes in the tissue and load tolerance, not the bone itself.

What else is relevant?

There is growing evidence that factors like body weight and metabolic health play a role.

Lee, Metgud and Moore (2023) found that in patients with plantar heel spurs:

• Obesity and larger spur size were associated with symptomatic plantar fasciitis

Again, reinforcing the idea:

👉 The spur is part of the environment, not the whole story.

The takeaway

A heel spur is:

👉 Common

👉 Often incidental

👉 Not a reliable explanation for pain on its own

It is better viewed as:

👉 a marker of long-term loading, not the diagnosis

🔑 Key takeaway:

A heel spur is unlikely to be the primary cause of your heel pain. However, its presence may indicate that the area is under increased load.

For help with your heel pain or to read more, please head here

References

• Ahmad, J., Karim, A. and Daniel, J.N. (2016) Foot & Ankle International, 37(9), pp. 994–1000.

• Cho, B.W. et al. (2022) Clinics in Orthopedic Surgery, 14(3), pp. 458–465.

• Kirkpatrick, J., Yassaie, O. and Mirjalili, S.A. (2017) Journal of Anatomy, 230(6), pp. 743–751.

• Lee, W., Metgud, N. and Moore, M. (2023) Foot & Ankle Orthopaedics, 8(4).

• Moroney, P.J. et al. (2014) Foot & Ankle Specialist, 7(2), pp. 95–101.

• Okçu, M. et al. (2023) Turkish Journal of Medical Sciences, 53(1), pp. 413–419.

• Tseng, W.C. et al. (2023) Journal of Medical Ultrasound, 31(4), pp. 268–274.

• Journal of Orthopaedic & Sports Physical Therapy (2023) Heel Pain—Plantar Fasciitis Clinical Practice Guideline.