Heel Pain: Plantar Fasciitis or Heel Spur? Diagnosis and Treatments
Published on 2026-05-21
Heel Pain: Plantar Fasciitis or Calcaneal Spur?
Heel pain is one of the most common reasons for consultation in musculoskeletal medicine. Two diagnoses often come up: plantar fasciitis and calcaneal spur (or Lenoir's spur). These two conditions are often confused, yet they are distinct and require different therapeutic approaches.
Plantar Fasciitis: The Most Common Cause
Plantar fasciitis is an inflammation or degeneration of the plantar fascia, the band of fibrous tissue that extends from the heel to the toes. It is characterized by:
- Pain under the heel, especially on the first step in the morning ("first step pain")
- Pain that subsides after a few minutes of walking
- Tenderness to palpation of the medial border of the heel
- Fascial thickening > 4 mm visible on ultrasound
Calcaneal Spur: A Bony Growth
A calcaneal spur is a bony growth (osteophyte) that forms on the calcaneus at the insertion of the plantar fascia. Contrary to popular belief, it is not the direct cause of pain:
- 30% of people without heel pain have a calcaneal spur visible on X-ray
- The spur is a consequence of chronic traction of the plantar fascia on the bone
- The pain comes from inflammation of the fascia, not the spur itself
How to Differentiate Them?
Diagnosis is based on clinical examination and imaging:
- X-ray: visualizes the calcaneal spur (bony growth) but does not show the plantar fascia
- Musculoskeletal ultrasound: directly visualizes the plantar fascia, measures its thickness, detects fluid collections or tears, and assesses the presence of neovascularization — all essential for diagnosis and guiding treatment
Treatment
Treatment depends on the primary diagnosis and its severity:
- Conservative measures: stretching, orthotic insoles, ice, activity modification, and NSAIDs
- Extracorporeal Shock Wave Therapy (ESWT): highly effective for chronic plantar fasciitis, especially calcified spurs
- PRP injection: ultrasound-guided injection to stimulate healing of the fascia
- Corticosteroid injection: for acute inflammatory flares, under ultrasound guidance for optimal precision
- Surgery: reserved for severe cases refractory to all other treatments after 12 to 18 months
Frequently Asked Questions
Is the calcaneal spur the cause of my heel pain?
Not necessarily. A calcaneal spur is present in 30% of asymptomatic people. The pain usually comes from inflammation of the plantar fascia (fasciitis) rather than the spur itself. Ultrasound can differentiate between the two.
Does the calcaneal spur need to be surgically removed?
Spur excision surgery is very rare and reserved for cases where all conservative and interventional treatments have failed for more than 12 to 18 months. Shockwave therapy and PRP offer highly effective alternatives that avoid surgery in the vast majority of cases.
What is the difference between radial and focused shockwave therapy for the heel?
Radial shockwaves are less powerful and cover a larger surface area, suitable for superficial tissues. Focused shockwaves are more precise and penetrating, ideal for targeting the plantar fascia insertion and fragmenting calcaneal spurs. The choice depends on the pathology and response to treatment.
Are orthotic insoles really useful?
Yes, custom-made orthotics with good arch support and a cushioned heel pad reduce tension on the plantar fascia and heel pain. They are particularly useful in people with flat feet or hyperpronation.
Why is my heel pain worse in the morning?
This is the classic sign of plantar fasciitis. During the night, the plantar fascia shortens and contracts. On the first morning step, the sudden stretching of this inflamed fibrous tissue causes intense pain. After a few minutes of walking, the fascia loosens and the pain decreases.