The Heel Spur Myth

Until I performed surgery on the foot and studied advanced radiology I had not appreciated how a common foot complaint could be so easily misrrepresented when dealing with heel pain which made up 15% of my practice.

Defining the Myth about the heel spur

Nothing has been so maligned as the heel spur myth as a cause of heel pain. Many professionals dealing with MSK will no doubt have to consider this. To radiology professionals, it seems pretty straightforward, as indicated in this X-ray.

Typical X-ray showing spur

The view from the side is called the lateral aspect. Any other angle won't show, and hence, there has been a reliance on X-rays. The problem is that most spurs or projections are not pointed but exist as a ledge from one side to the outer side of the heel. The heel bone forms projections both on the sole of the heel and back toward the insertion of the achilles tendon. It rarely requires surgery and only if nothing else works. There are many different treatments available, but the aim is to stop heel pain from becoming chronic.

Heel Pain

We often hear that heel pain is associated with plantar fasciitis, and indeed, this is true. More people suffer from this soft tissue condition than from the less likely spur. The fascia band sits below the so-called spur and does not pull on the calcaneus (Johal et al., 2012). Johal looked at 22 patients with a diagnosis of PF[2] relying on lateral X-rays alone.

The fascial band is illustrated and looks complicated but it is very thin.

The fascial band is skinny and lies over the first layer of muscles, but it is tough. When it thickens beyond 3-4 mm (it is usually much thinner), symptoms can arise. The band is very much overplayed in foot function and there is no doubt if severed surgically, pain relief can be achieved. The band stabilises the soft tissue and braces the heel bone with the forefoot, inserting into the base of toes.

Tears in the band, and soft heel pad pain-causing inflammatory pockets are, therefore, not unusual. The age group tends to be older, mainly +forty after returning to exercise after a period of sedentary occupation.

Large bone projection can undoubtedly add to pain, but this article and clinical experience suggest that most spurs do not cause the pain we once considered in the heel as a right of passage.

Features of Growth

The fascial band shown in powerful MRI 3D scans confirms the fascia's co-association with fibres of the Tendo–Achilles (TA) but not with the bone, causing a spur. This makes sense because, by 12 weeks of intrauterine life, the TA and fascia are as one and then diverge into two different planes. One down the leg, the across the sole of the foot.

The main portion of the fascial band inserts into the medial heel prominence called a tubercle, often associated with the most significant frequency of symptoms.

A separate body of heel bone (calcaneus) arises from 5-6 months but only joins the main heel bone at 12-14 years. The gap is evident in the juvenile, while the MRI shows incomplete bone joining bone (ossification) at this point.

Two images show a teenager's foot, where the smaller section of the (arrows) binds to the main body of the heel bone (Calcaneus). The arrow above the heel bone shows a similar feature in the ankle bone (talus).

The figure illustrates the growing area known as an epiphysis, where the ledge has the potential to form in some but not all people. The achilles tendon (TA) can pull on the upper part of this heel bone, causing pain in the active adolescent child anywhere from 11-14 years, but is usually self-limiting and known as Sever's disease. The lower part seldom causes problems until later in life.

What other people are saying

“The body … attempts to repair itself by growing new bone in this area (a heel spur). Inflammation in the heel can even cause burning or shooting pain from nerve compression.” Michael DeBrulle (USA) posted this in 2009. This certainly was not an uncommon explanation.

“I have a heel spur” – this is something we commonly hear as a podiatrist. When it comes to plantar fasciitis (acute/short term) or plantar fasciopathy (chronic/long term), the evidence shows that pain is due to overuse of the plantar fascia, which is why pain is felt in the arch and heel. It is not always directly at the site of the spur. Heel spurs, also called calcaneal spurs or plantar spurs, develop as a response due to an inability of the plantar fascia to tolerate load. Our body can’t cope with what we are asking from it, and to protect the soft tissue, the bone grows! The overuse causes calcium deposits to form on the heel bone. The research shows that heel spurs are more commonly associated with heel pain. We blame a symptom (spur) rather than the culprit (expecting more from our feet than what their capacity is)! Melissa Zacharia (AU) 2019 

As illustrated in the above samples, internet searches show up on many sites covering heel pain management. Opinions vary, but in most cases, clinicians try to tie up the concept of spur formation exclusively with stretching of the fascial band. While there may be truth in traction, this cannot account for the excess formation of most patients. The myth will always live on where clinicians cannot reach other explanations. 

Surgery

Surgical intervention for spurs is an absolute no-no until all avenues have been explored. Obviously, abnormal bone growth not attributed to spurs will need specialist attention.

Surgery is best performed as a minimal incision procedure and allows rapid mobility with few sutures. Most heel pain will settle with good conservative care.

You can read more about heel from consultingfootpain:

• Plantar Fasciitis and the Art of Stretching

• Heel Pain due to a bruised heel

Conclusion

You can have heel pain with a so-called spur, but it is just happenstance. Johal’s study is compelling, but the size of the cohort perhaps does not have the appropriate sampling. Computerised X-ray scans and CT scanning may be more appropriate to provide a 3D picture. Even looking at Wikipedia, the story is slightly different an the spur becomes the story rather than the cause.

The evidence that spurs cause pain is seen after taking X-rays of both feet. Over a 40-year career, this author found that painful feet frequently had no spur, yet the fascial band’s thickness had increased. Painless feet often present with spurs. Fasciitis is a real foot pain problem, and early management will result in better results than if it is left.

[1] Johal, KS, Milner SA 2012 Plantar Fasciitis and the calcaneal spur: Fact or fiction? Foot and Ankle Surgery 18;39-41[2] PF or plantar fasciopathy is now considered fasciopathy or fasciosis

Thanks for reading ‘The Heel Spur Myth’ by David R. Tollafield.

Consider this introductory book to the adult foot, available from Amazon or from the Institute of Podiatrists.

Since publishing this edition, my book as been very successful as it keeps explanations within the grasp of most readers. Click to purchase.

David is a full-time author and retired podiatric surgeon. He writes for professionals and the public. Consultingfootpain is free and does not promote products except related foot health books.

Published by Busypencilcase Communications Est. 2015 for ConsultingFootPain