Heel Spurs: Symptoms, Types, Causes and Treatment

Heel spurs are a common yet often misunderstood condition associated with heel pain. Whether you’re an athlete, a busy worker, or someone who enjoys long walks, understanding heel spurs can make a significant difference in your foot health. In this article, we’ll explore the key symptoms, types, causes, and treatment options for heel spurs—drawing on up-to-date scientific research to provide a clear and comprehensive guide.

Symptoms of Heel Spurs

Heel spurs often conjure up images of sharp, stabbing pain, but not everyone experiences symptoms the same way. Some people may have prominent heel spurs visible on X-rays yet feel no discomfort at all, while others may endure significant pain even with a small spur. Recognizing the symptoms is crucial for timely diagnosis and effective management.

Symptom	Description	Frequency/Severity	Source(s)
Heel Pain	Pain on plantar surface of heel	Ranges from mild to severe	1, 2, 3
Pain on Weight-Bearing	Discomfort when standing or walking	Often worse in the morning	2, 3, 4
Disabling Pain	Severe, limiting daily activities	Less common, but possible	2, 1
Asymptomatic	No noticeable symptoms	Frequently observed	2, 9

Table 1: Key Symptoms

Understanding Heel Spur Symptoms

Heel spurs most commonly present with pain localized to the underside of the heel, particularly where the plantar fascia attaches to the calcaneus (heel bone) 1. The pain is often sharp and most intense during the first steps in the morning or after long periods of rest 2. While some people may find the pain disabling, preventing them from walking or engaging in daily activities, others may remain entirely symptom-free despite having a large spur 2.

Symptom Variability and Progression

• Pain on Weight-Bearing: For many, pain worsens with prolonged standing, walking, or running, especially on hard surfaces 2.
• Disabling Pain: In rare cases, heel spurs can cause pain so severe that it becomes disabling, often related to changes in foot mechanics or underlying conditions like plantar fasciitis 2 3.
• Asymptomatic Cases: Interestingly, heel spurs are often discovered incidentally during X-rays for unrelated foot problems, indicating that not all spurs cause pain or functional problems 2 9.

Differentiating from Plantar Fasciitis

Although heel spurs are closely associated with plantar fasciitis, they are not always the direct cause of heel pain. Recent research suggests the presence of a heel spur may be an indicator of other underlying conditions or changes in foot anatomy rather than the primary source of pain 9.

Types of Heel Spurs

While the classic image of a heel spur is a single bony outgrowth, research has shown that heel spurs come in various types, classified by their location, shape, and relationship to surrounding tissues. Understanding these types is crucial for diagnosis and treatment planning.

Type	Location/Shape	Clinical Significance	Source(s)
Type A	Superior to plantar fascia	Less severe plantar fasciitis	3
Type B	Within plantar fascia	More severe plantar fasciitis	3
Horizontal	Extends horizontally	Responds well to treatment	4
Vertical	Projects vertically	Less common	4
Hooked	Curved, hook-like appearance	Greatest improvement post-treatment	4
Dorsal/Plantar	Dorsal or plantar calcaneus	Dorsal linked to activity, plantar to weight	5

Table 2: Types of Heel Spurs

Location-Based Classification

• Type A and Type B Spurs: Type A spurs are located above the plantar fascia insertion, while Type B spurs are embedded within the fascia itself. Type B spurs are associated with more severe plantar fasciitis and inflammatory changes 3.
• Dorsal vs. Plantar Spurs: Dorsal spurs occur on the upper side of the heel bone, often linked to repetitive activity, while plantar spurs, found on the underside, are more common in modern populations due to prolonged standing and excess weight 5.

Shape-Based Classification

• Horizontal, Vertical, and Hooked Spurs: Radiographic studies classify plantar heel spurs by shape. Horizontal spurs are most common and respond well to treatment, while vertical and hooked spurs are less frequent but may show pronounced improvement with therapy 4.
  • Horizontal: Most frequently observed, often responds best to conservative management 4.
  • Vertical: Less common, clinical implications still being studied 4.
  • Hooked: These curved spurs show the greatest improvement in pain and function after treatment 4.

Size and Severity

Heel spurs can also be described by size:

• Less than 5 mm (most common)
• 5–10 mm
• Greater than 10 mm

Interestingly, before treatment, neither shape nor size significantly correlates with pain; however, larger horizontal or hooked spurs show the most noticeable improvement after therapy 4.

Causes of Heel Spurs

Heel spurs develop due to a complex interplay of mechanical, degenerative, and biological factors. While they are often associated with plantar fasciitis and repetitive foot strain, other underlying causes and risk factors contribute to their formation.

Cause	Description	Risk Factors/Associations	Source(s)
Repetitive Trauma	Microtears/strain at plantar fascia enthesis	Athletes, runners, heavy use	6, 7, 8
Degenerative Changes	Breakdown at fascia-bone interface	Age, osteoarthritis	5, 7, 6
Weight-Bearing Stress	Excess load on heel bone	Obesity, prolonged standing	5, 8, 9
Inflammatory Process	Chronic inflammation at enthesis	Plantar fasciitis, arthritis	6, 7, 9
Genetics and Anatomy	Predisposing foot structures	Foot position, biomechanics	6, 5
Systemic Conditions	Metabolic or systemic disease	Diabetes, arthritis	9

Table 3: Causes and Risk Factors

Mechanical and Degenerative Origins

Heel spurs often form in response to repeated microtrauma at the insertion (enthesis) of the plantar fascia on the calcaneus. Over time, the body reacts with new bone formation at this site, especially as degenerative changes set in with age or overuse 6 7. The process involves both intramembranous and endochondral ossification, resulting in a bony outgrowth 7 8.

Weight-Bearing and Lifestyle Factors

• Obesity and Prolonged Standing: Modern lifestyles, characterized by long hours of standing or carrying excess body weight, contribute significantly to the development of plantar heel spurs 5 8 9.
• Occupational Risks: Jobs that require standing or walking for extended periods increase the risk of heel spur formation, especially when combined with poor footwear or hard surfaces 5.

Biological and Systemic Influences

• Age and Osteoarthritis: The risk of developing both dorsal and plantar spurs increases with age and in the presence of osteoarthritis 5.
• Diabetes and Metabolic Disorders: Studies have shown a higher prevalence of heel spurs in patients with diabetes and other systemic conditions, possibly due to changes in soft tissue or bone metabolism 9.
• Genetic and Anatomical Predispositions: Certain foot structures or inherited biomechanical tendencies may make some individuals more susceptible 6.

Theories of Spur Formation

Several theories have been proposed to explain why heel spurs develop:

• Degenerative Theory: Spurs form as a result of degeneration at the fascia-bone interface 6 7.
• Traction Theory: Chronic pulling or traction of the plantar fascia on the calcaneus triggers bone formation (now considered less likely based on newer histological data) 7.
• Compression Theory: Weight-bearing compressive forces, especially in the intrinsic muscles of the foot, are considered a major factor 8.

Treatment of Heel Spurs

Treating heel spurs requires a multifaceted approach, tailored to symptom severity and underlying causes. While many cases respond well to conservative measures, refractory or disabling cases may require advanced therapies or surgery.

Treatment Type	Description/Example	Effectiveness/Notes	Source(s)
Physical Therapy	Stretching, strengthening	First-line, often effective	12, 14
Shock Wave Therapy	Radial shock wave treatments	Highly effective, fewer sessions	11, 14
Ultrasound Therapy	Therapeutic ultrasound	Effective, requires more sessions	11, 14
Radiotherapy	Low-dose RT for refractory pain	Significant pain relief, safe	10, 13
Surgery	Endoscopic or open spur removal	For refractory cases; good results	1, 12
Laser Therapy	High-intensity laser (HILT)	Not superior to standard care	14

Table 4: Treatment Options

Conservative Treatments

• Physical Therapy: Includes stretching and strengthening exercises, especially targeting the plantar fascia and intrinsic foot muscles. Often paired with rest, ice, and proper footwear, it serves as the foundational approach for heel spur management 12 14.
• Shock Wave Therapy: Radial shock wave therapy has shown significant analgesic efficacy, with pain relief achieved in fewer sessions compared to ultrasound 11. This makes it a favorable option for patients seeking non-invasive pain relief.
• Ultrasound Therapy: Provides pain relief, but typically requires a greater number of sessions compared to shock wave therapy 11. Both methods are safe and well-tolerated.

Radiotherapy for Refractory Pain

Low-dose radiotherapy is an effective and reliable option for patients with chronic, refractory heel spur pain who do not respond to conservative treatments. Studies have demonstrated statistically significant pain relief and minimal side effects 10 13. Radiotherapy is particularly useful when other treatments fail.

Surgical Options

• Endoscopic/Minimally Invasive Surgery: For patients with persistent, disabling pain after exhaustive conservative care, endoscopic or open surgical removal of the spur and release of the plantar fascia can provide dramatic relief 1 12. Advances in surgical technique have reduced complication rates and improved outcomes.
• Postoperative Care: Even after surgery, physical therapy may be needed to regain full function, especially for those returning to high-impact activities 12.

Other Modalities

• High-Intensity Laser Therapy (HILT): While safe, HILT has not demonstrated superior effectiveness over established physiotherapy methods in controlled studies 14.
• Patient Education and Lifestyle Modification: Addressing risk factors such as obesity, poor footwear, and prolonged standing is essential for both treatment and prevention.

Conclusion

Heel spurs are a multifaceted condition with a spectrum of symptoms, types, causes, and treatment options. Understanding the latest research can empower patients and healthcare professionals to make informed decisions for optimal foot health.

Key Takeaways:

• Symptoms: Ranging from asymptomatic to disabling heel pain, often worse with weight-bearing 1 2 3 9.
• Types: Classified by location (Type A/B, dorsal/plantar) and shape (horizontal, vertical, hooked), each with unique clinical implications 3 4 5.
• Causes: Develop due to repetitive trauma, degenerative changes, weight-bearing stress, and systemic factors such as age, obesity, and diabetes 5 6 7 8 9.
• Treatment: Most cases respond to conservative therapy (physical therapy, shock wave, ultrasound). Refractory cases may benefit from radiotherapy or surgery. New modalities like HILT are not yet proven superior 10 11 12 13 14.

By recognizing the diverse presentations and causes of heel spurs, individuals can work with clinicians to find the most effective, evidence-based pathway to relief and recovery.