Plantar fasciitis or a heel spur: which one do you have?

Two different things that share a location

A heel spur is a calcium deposit that forms where the plantar fascia attaches to the heel bone. It builds slowly, over years, in response to repeated pulling at that attachment. On an X-ray it looks dramatic, like a thorn pointing forward into the foot.

Plantar fasciitis is irritation of the tissue itself. It can exist with or without a spur, and it is what produces the sharp first steps in the morning and the ache after standing.

Why the spur usually is not the problem

Heel spurs are common in people with no heel pain whatsoever. They are often found by accident when a foot is X-rayed for an unrelated reason. At the same time, plenty of people with severe heel pain have no spur at all on imaging.

The spur also does not point into the soft tissue the way the X-ray image suggests. It grows within the layers of tissue, running along the same direction as the fascia rather than stabbing into it.

This matters because it changes the treatment. Removing a spur does not address why the tissue was being pulled in the first place, and the pain often continues afterward.

It also explains why patients are sometimes told a spur is the cause and then find that treatment aimed at the bone does not help. The spur is better understood as evidence that the attachment has been under tension for a long time, rather than as the thing doing the damage.

What an examination looks for

The location of tenderness is the first clue. Plantar fasciitis is tender at a specific point on the inside of the heel where the fascia attaches, and it reproduces when the toes are pulled back. Pain spread across the whole bottom of the heel suggests the fat pad has thinned instead, which is treated differently.

The pattern through the day matters as much as the X-ray. Pain worst on the first steps and after sitting points to the fascia. Pain that builds steadily the longer you are on your feet and is worse at the end of the day suggests something else.

Imaging is used to rule things out, including stress injury, rather than to find a spur and stop looking.

How the pain behaves under load is informative too. Fascia pain typically eases once you are warmed up and returns after rest. A stress injury tends to do the opposite, becoming steadily worse the longer you stay on the foot, and it does not settle with walking.

What this means for your treatment

If the spur is incidental, treatment aims at the tissue and the mechanics loading it: stretching, supportive footwear, and correcting the way the arch behaves under weight. Custom orthotics exist for exactly this, because they change the load rather than the anatomy.

Surgery to remove a spur is a long way down the list, and when heel surgery is appropriate it is usually directed at the fascia rather than the bone. The first question is always what is pulling, not what has grown.