Sydney Heel Pain Clinic
Heel spurs can develop underneath the heel or around the back of the calcaneus. Despite their appearance on X-ray, the spur itself is not usually the primary source of pain.
In most patients, symptoms arise from irritation or pathology within the soft tissues attached to, or positioned around, the heel bone. The clinical priority is therefore to identify the symptomatic tissue rather than assume that the bony spur is responsible.
Does This Sound Familiar?
Symptoms differ according to whether the affected region is underneath the heel or around the posterior calcaneus.
The Important Distinction
A heel spur can appear substantial on medical imaging without being the structure responsible for the patient's symptoms.
A plantar calcaneal spur can appear sharp and prominent on an X-ray. It is therefore understandable that patients frequently assume that the spur itself must be producing the pain.
In most cases, however, the symptomatic structure is the plantar fascia rather than the spur.
Plantar fasciitis develops around the attachment of the plantar fascia to the calcaneus, often in the same anatomical region in which the spur is visible.
Once the plantar fascia has recovered, symptoms can resolve completely even though the heel spur remains visible on X-ray.
Posterior calcaneal spurs develop close to the insertion of the Achilles tendon. Their presence does not automatically establish that the bone itself is responsible for the pain.
Symptoms in this region are frequently associated with insertional Achilles pathology, bursal irritation or compression of the surrounding soft tissues.
Clinical examination therefore needs to establish whether the symptoms originate from the Achilles insertion, a bursa, adjacent soft tissues or, less commonly, direct mechanical pressure from a substantial bony prominence.
Associated Soft-Tissue Pathology
Heel spurs frequently coexist with pathology within structures attached to, or positioned around, the calcaneus.
The most common source of pain associated with a plantar heel spur is pathology within the plantar fascia at its attachment beneath the calcaneus.
Plantar fasciitis →Pathological change within the Achilles tendon close to its calcaneal insertion can produce focal pain, stiffness, thickening and compression sensitivity.
Insertional Achilles tendinopathy →Irritation of the bursa positioned between the Achilles tendon and calcaneus can produce deep posterior heel pain, particularly where local compression is increased.
Retrocalcaneal bursitis →Sydney Heel Pain Clinic
Heel pain cannot be diagnosed from the presence of a spur alone. Examination must identify the symptomatic tissue and establish the mechanical factors maintaining stress and irritation through that structure.
Sydney Heel Pain Clinic combines investigative clinical assessment, biomechanical investigation, gait assessment, footwear analysis and medical imaging where clinically indicated.
A heel spur is one clinical finding. Assessment determines whether symptoms arise from the plantar fascia, Achilles insertion, bursal structures, surrounding soft tissues or direct mechanical compression from the calcaneus.
Medical Imaging
Medical imaging can be useful when symptoms persist, the diagnosis remains uncertain or the relationship between bony anatomy and the surrounding soft tissues requires further investigation.
X-ray imaging demonstrates calcaneal bone formation and allows the position, orientation and size of plantar and posterior heel spurs to be assessed.
Ultrasound or MRI can confirm plantar fascia pathology consistent with plantar fasciitis and assess tissue thickening, degeneration, inflammation or structural change where further investigation is clinically indicated.
Treatment
In most patients, the heel spur itself does not require treatment. Management is directed towards the symptomatic soft tissue and the mechanical forces maintaining stress through it.
The first priority is to identify the mechanical drivers maintaining persistent stress and irritation through the plantar fascia, Achilles tendon or surrounding soft tissues.
Treatment then focuses on reducing tissue irritation and inflammation, managing load and assessing tissue tolerance while removing or modifying the mechanical forces that are preventing recovery.
Depending on the clinical findings, this may involve modification of activity or loading, footwear recommendations, shockwave therapy to stimulate healing in selected chronic presentations, or custom orthoses where foot mechanics are contributing to persistent biomechanical stress.
In most cases, symptoms resolve once the painful soft tissue has recovered, even though the heel spur itself remains.
The clinical priority is to establish whether the spur is an incidental finding or whether symptoms arise from pathology within the surrounding soft tissues or direct mechanical compression from a substantial bony prominence.
Surgical Intervention
Surgical intervention is considerably more relevant to selected posterior calcaneal abnormalities than to routine plantar heel spurs. Plantar heel spurs themselves rarely require surgical removal.
At the back of the heel, however, a substantial bony prominence can become clinically significant when its size and position create persistent compression against footwear or interfere mechanically with the Achilles tendon insertion.
A prominent posterosuperior calcaneus, including a Haglund-type deformity, can create significant mechanical compression between the posterior heel, Achilles region and footwear.
Substantial spur formation extending into or around the Achilles insertion can also alter the contour and available space around the tendon, affecting normal tendon movement and flexibility.
Where there is persistent insertional Achilles pathology, substantial bony prominence and symptoms that remain despite appropriate conservative management, surgical assessment may be required.
Surgery is therefore considered after the symptomatic soft tissues, relevant mechanical drivers and conservative treatment options have been appropriately investigated and addressed.
Frequently Asked Questions
Usually not. Underneath the heel, symptoms are commonly caused by plantar fasciitis affecting the plantar fascia around its attachment to the calcaneus.
At the back of the heel, symptoms frequently arise from the Achilles insertion, a bursa or adjacent soft tissues. Patients can become completely pain-free following treatment even though the heel spur remains.
Heel spurs are clearly demonstrated on X-ray. However, the presence of a spur does not establish that it is responsible for the symptoms. Clinical examination is required to identify the painful structure and determine whether the spur has any clinical relevance.
No. Once established, the bony spur generally remains. Successful treatment does not depend on removing the spur. Treatment is directed towards resolving the pathology and mechanical irritation affecting the symptomatic soft tissue.
Yes, although surgical removal of a routine plantar heel spur is uncommon. Surgery is more relevant to selected posterior heel abnormalities where substantial bone formation produces persistent mechanical compression, significant Achilles insertional involvement or symptoms that remain despite appropriate conservative treatment.
No. A heel spur is bone formation arising from the calcaneus. Plantar fasciitis involves pathology of the plantar fascia at its attachment beneath the heel. The two can coexist but they are not the same condition.
Clinical assessment identifies the symptomatic tissue, investigates the mechanical factors maintaining irritation and determines whether the heel spur itself has any clinical significance.
