Heel Spur and Plantar Fasciitis
The most common cause of heel pain is plantar fasciitis: wear and pain where the strong band running the length of the sole (the plantar fascia) attaches to the heel bone. The bony projection commonly called a “heel spur” is usually not the cause of the pain but a consequence.
Spur or Fascia?
The heel spur seen on X-ray forms over time as the bone responds to traction from the band on the sole. What matters is this: a heel spur is found in a significant proportion of people with no pain at all; conversely, many people with severe heel pain have no spur.
Treatment is therefore aimed not at “getting rid of the spur” but at reducing the load on the plantar fascia and increasing the tissue’s load-bearing capacity.
The Typical Symptom: First-Step Pain
The most recognisable feature of plantar fasciitis is sharp pain in the heel on the first steps after getting out of bed in the morning. The pain eases after walking for a few minutes and increases again after standing for long periods during the day.
- Point tenderness on the sole of the heel, towards the inner side
- Pain increased on the first steps in the morning and when getting up after sitting for a long time
- Symptoms worse at the end of the day after prolonged standing and walking
- Pain becoming marked when walking barefoot on hard floors
- Tightness in the calf and Achilles region
Risk Factors
- Tightness of the calf and Achilles — the most common modifiable factor
- Weight gain
- Standing for long periods at work, standing on hard floors
- A sudden increase in training load (rapidly increasing running distance or speed)
- Unsupportive, worn-out footwear
- Foot structure: a very flat or a very high arch
Diagnosis
The diagnosis is largely made from the history and examination: point tenderness on the inner side of the sole of the heel together with first-step pain in the morning is typical. The examination also assesses calf tightness and foot alignment.
X-ray is not essential; it is requested where there is a history of injury, atypical findings or prolonged resistant symptoms. Ultrasound can show the thickness of the fascia. If the picture is atypical, a stress fracture of the heel bone, nerve compression, Achilles problems and rheumatological conditions are considered in the differential diagnosis.
Treatment
Plantar fasciitis is managed with non-surgical methods in the great majority of patients. The programme requires patience; results come over weeks, not days.
The core steps
- Stretching: calf and plantar fascia stretching — stretching in bed before the first step in the morning can be particularly helpful
- Footwear: shoes that support the heel and cushion adequately; avoiding walking barefoot on hard floors at home
- Insoles: a heel cushion or an arch-supporting insole
- Load management: temporarily reducing running and long walks, maintaining fitness with alternatives such as cycling and swimming
- Weight control
- Pain management; a night splint may reduce morning pain in selected patients
Resistant cases
If symptoms persist despite a regularly applied programme, additional options are considered. Corticosteroid injection into the fascia is approached with care: it may reduce pain in the short term, but repeated applications have been associated with a risk of fascial rupture and thinning of the heel fat pad.
Surgery is considered as a last resort in resistant cases that persist and restrict daily life. The great majority of patients reach an adequate level with the non-surgical programme without coming to this stage.
Daily Life Suggestions
- Before getting out of bed in the morning, stretch the ankle and toes a few times
- Wear supportive shoes rather than slippers at home
- Increase training load in small weekly increments
- Replace your shoes when the soles are worn
- Continue the stretching programme for a while after the pain has settled
When Should You Seek Assessment?
- If your first-step pain in the morning has lasted weeks
- If heel pain is shortening your walking distance
- If pain continues at rest and at night
- If numbness or tingling accompanies it
- If symptoms are increasing despite stretching and footwear changes
When to Seek Medical Help Without Delay
- Redness, warmth, swelling and fever at the heel
- Heel pain after a fall or jump from a height with inability to bear weight (suspected fracture)
- Sudden pain in the sole beginning with a sense of “snapping”, with inability to bear weight
- In people with diabetes, an open wound or colour change on the heel
These findings require urgent assessment. Outside office hours, go to the nearest emergency department.
Frequently Asked Questions
Do I need to have the heel spur removed?
Generally no. The spur is usually not the cause of the pain and can be found in people with no symptoms at all. Treatment is aimed at reducing the load on the plantar fascia, not at removing the spur.
Why is it worse in the morning?
During sleep the ankle rests pointing downwards and the fascia heals in a shortened position. The sudden stretch of the first step causes sharp pain. This is why stretching before getting out of bed is recommended.
Should I walk or rest?
Complete rest is not recommended. Long walks on hard surfaces that markedly increase pain are temporarily reduced, while movement is maintained with alternatives such as cycling and swimming. Load is then increased gradually.
Should I have a steroid injection?
It may reduce pain in the short term; however, repeated applications have been associated with a risk of fascial rupture and thinning of the heel fat pad. The decision is therefore made carefully by your physician according to the clinical picture.
Do I need an insole?
It is not essential; however, a heel cushion or arch-supporting insole reduces symptoms in many patients. The need for a custom insole is assessed according to foot structure and examination findings.
How long does it take to settle?
The timeframe varies from person to person and is related to how long symptoms have been present. For that reason no fixed period is given; maintaining stretching and load management regularly is the most important factor affecting the outcome.
Academic Work
Assoc. Prof. Bertan Cengiz, MD has scientific work published in national and international peer-reviewed journals in the field of foot and ankle surgery and related areas. The publication list and verifiable academic sources are available on the Publications page.
Related Pages
The information on this page is for general guidance and does not replace an in-person medical examination. Diagnosis and treatment require a physician’s clinical assessment. Outcomes of any treatment or surgical intervention may vary from person to person; no guarantee of a specific result or timeframe is given on this page.