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heel pain, plantar fasciitis and bone spurs
Author: Dr. Marc MitnickReviewed by: Medical Review Board
Plantar Fasciitis and Other Causes of Heel Pain
When heel pain persists or worsens with movement, several conditions beyond standard inflammation may be responsible. Identifying the specific cause is essential for effective treatment.
- Plantar Fasciitis: Sharp, stabbing pain typically felt with the first steps in the morning or after long periods of rest.
- Heel Bursitis: Inflammation of the fluid-filled sacs in the heel, often causing swelling, redness, and pain when the area is squeezed.
- Heel Neuroma: A pinched or entrapped nerve within the area of inflammation that causes localized nerve pain.
- Tarsal Tunnel Syndrome: Compression of the posterior tibial nerve, similar to carpal tunnel but located in the ankle and foot.
- Fat Pad Atrophy: A loss of the natural fat cushioning in the heel, leading to a bruised sensation as the bone loses its protection.
- Plantar Fascial Tear: A physical rupture or tear of the ligament rather than simple inflammation.
- Heel Fracture: A stress fracture or break in the calcaneus (heel bone) that worsens significantly the more you walk.
WHAT CAUSES PLANTAR FASCIITIS
Heel pain including plantar fasciitis and bone spurs are one of the most common complaints seen in the foot. Plantar fasciitis is an inflammation of the large ligament on the bottom of the foot. Although most cases of plantar fasciitis occur near the heel, often described as sharp pain, this condition can be evident anywhere from the heel all the way to the ball of the foot.
In order to feel the plantar fascial ligament, with one hand bend the big toe upwards, run your finger from your other hand along the bottom of the foot, you will feel a large cord like structure that runs from the ball of your foot to your heel. The purpose of this structure is to act like a bowstring in order to support the structure of your arch.
In the picture below, the yellow band represents the plantar fascial ligament. Notices how it attaches from the heel to the ball of the foot.
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Factors that can cause plantar fasciitis
- foot structure- in general, high arched feet and feet that flatten out too much are more prone to this condition.
- excessive body weight
- wearing flimsy shoes like flip-flops or ballerina shoes, or even going barefoot.
- occupations that require a lot of standing especially on concrete floors and a lot of walking.
- physical activity such as participating in athletic activities.
Many authors consider the plantar fascial ligament to actually be a direct extension of the Achilles tendon. Once again refer to the diagram above.
People who exhibit an equinus or lack of dorsiflexion in the foot (the inability to bend the foot upwards beyond a 90 degree angle to the leg with their knee in a locked position) will be more inclined to suffer from plantar fasciitis. People who have a tight Achilles tendon are generally inclined to pronate more, to compensate for the Achilles tightness and this puts an added strain on the plantar fascial ligament.
Many women who suffer from plantar fasciitis will tell me that their heel feels better when they are in high heels. Why, because wearing a high heel reduces the tension on the Achilles tendon and thus reduces the tension on the plantar fascial ligament. If an equinus does exist, it must be addressed in the overall treatment plan because no matter what type of therapy your doctor may recommend, the tendency to overstretch the plantar fascial ligament will continue and so will the pain.
The problem with most foot symptoms unlike a hand injury for example, is that it is very hard to “rest” a foot in order to allow it to get better. So every time you take a step you are re-injuring an injured area and for that reason foot injuries can take a long time to heal, especially heel pain because every time you take a step you are putting pressure on the heel.
The table below compares other conditions which may also cause heel pain.
| Condition | Primary Symptom | Pain Location | Best Initial Treatment |
|---|---|---|---|
| Plantar Fasciitis | Sharp pain with the first steps in the morning. | Bottom of the heel, near the arch. | Stretching, orthotics, and icing. |
| Heel Spur | Chronic, dull ache that worsens with activity. | Directly under the heel bone. | Cushioned shoe inserts and rest. |
| Achilles Tendonitis | Pain and stiffness at the back of the heel. | Back of the heel/Lower calf. | Eccentric loading exercises and heel lifts. |
| Bursitis | Swelling and redness; pain when squeezing the heel. | Back or bottom of the heel. | Anti-inflammatories and footwear changes. |
PLANTAR FASCIITIS SYMPTOMS
Most people relate a similar story:
- Pain in the heel when they first stand up after getting up in the morning or after being seated for a long period of time.
- As they walk around the pain will subside in varying degrees, but in almost all situations the pain will not completely disappear.
- As they begin to do a lot of walking, the pain will increase.
plantar fasciitis and heel spur
When there is excessive inflammation particularly at the insertion of the ligament into the heel bone, calcification can occur and you end up with what is routinely known as a heel spur which is the classic bone spur in the foot. One could argue that this is simply an exacerbation of the plantar fasciitis. In fact, in this day and age, seeing a heel spur on x-ray, does not change my treatment plan for any given patient.
Below is a picture of a true heel spur; a calcification of the plantar fascial ligament.
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plantar fasciitis and other causes of heel pain
Additionally, when the pain in the heel seems to worsen the more you ambulate other problems may be present. In addition to the plantar fasciitis you may also be suffering from:
Heel bursitis
A heel neuroma, which is simply a pinched nerve that gets entrapped in the area of inflammation.
Tarsal tunnel syndrome
Lack of fat in the heel. The fat is supposed to act as a cushion, but some people either do not have enough fat, or as we age we lose some of the fat, and now the heel bone becomes bruised because there is not enough fat to protect it.
Plantar fascial tear- instead of being inflamed, the ligament may actually be torn.
heel fracture- a fracture of the calcaneus bone will cause heel pain that will worsen the more you ambulate.
It is essential that a well-trained foot specialist be consulted to rule out the cause of the heel pain. (These are the most common but not an all inclusive list of causes of heel pain).
Making the right diagnosis and eliminating the factors aggravating the heel pain are essential in alleviating the problem. If my patient happens to be very much overweight or wears very flimsy shoes, the chances of success in alleviating the problem are greatly diminished unless those issues are addressed.
Frequently Asked Questions: Heel Pain & Plantar Fasciitis
What is the most common cause of heel pain?
The most common cause is plantar fasciitis, an inflammation of the large ligament on the bottom of the foot that acts like a bowstring to support your arch.
How do I know if I have plantar fasciitis?
A classic symptom is sharp, stabbing pain during your first steps in the morning or after sitting for a long period. The pain often subsides as you move but can return with prolonged standing.
What is the difference between plantar fasciitis and a heel spur?
Plantar fasciitis is the inflammation of the ligament, while a heel spur is a calcium deposit on the bone resulting from that inflammation. Usually, the presence of a spur does not change the primary treatment plan.
Why does my heel feel better when I wear high heels?
Wearing a heel lift or high-heeled shoe reduces the tension on the Achilles tendon, which in turn reduces the "pull" and strain on the plantar fascial ligament.
Could my pain be something other than plantar fasciitis?
Yes. If pain worsens the more you walk, it could be Heel Bursitis, Fat Pad Atrophy (loss of natural cushioning), Tarsal Tunnel Syndrome (nerve compression), or even a Stress Fracture.
What is the best initial treatment for heel pain?
For standard cases, the most effective starting treatments include consistent stretching, the use of orthotics (shoe inserts), and icing the area to reduce inflammation.
Expert advice provided by Dr. Marc Mitnick, DPM.
REFERENCES
American Podiatric Medical Association
continue to plantar fasciitis treatments
Questions I Have Answered From Visitors
Chronic plantar fasciitis — is surgery the only option?
Visitor's question
Heel pain when walking, arch pain with frequent muscle spasms. Pain present while exercising but tolerable. (Group exercise instructor with 14 classes per week.) Can’t walk in the morning or evening.
I have done PT for several months, ice 3× daily, 4 cortisone injections, PRP injection (not effective), wore a boot for 2 months. The boot allowed me to walk but caused my arch to collapse due to no support. (I have a high arch.)
My doctor is recommending surgery. Is this the only other option?
Doctor's answer
Hi Candy,
Well, it does sound like you are running out of options. I am wondering if all these treatments have been on the recommendation of only one doctor, or if you have been to multiple doctors who have each tried something different to no avail.
The reason I ask is because even though it sounds like you have plantar fasciitis, there is always the possibility that you have more than just plantar fasciitis. Plantar fasciitis pain is typically worst when you first get up on the foot — the ligament tightens overnight and initial standing stretches it, causing pain that usually subsides somewhat as you walk.
However, if you have pain the *more* you are on your foot, that may or may not be plantar fasciitis. The more you are on your foot, the more pounding there is on the heel, and pain could be from another source such as heel bursitis or a heel neuroma — both of which can mimic plantar fasciitis.
Along those lines, has any doctor ruled out tarsal tunnel syndrome?
I would also assume at this point you have had at least an MRI. An MRI would show potential heel pain problems such as a partially torn plantar fascial ligament, a stress fracture of the calcaneus, or even the very remote possibility of an abnormal growth in the heel bone.
As you can see, there is the possibility that you could have surgery, have the plantar fascial ligament released, and still have pain afterwards because there are other issues going on in your foot.
The reason I asked if you have seen more than one doctor is because sometimes physicians have “tunnel vision” — they see heel pain and assume plantar fasciitis, whereas if you have been to multiple doctors, particularly foot specialists, I would assume someone would have ruled out more than just plantar fasciitis.
As a side note, walking in a boot with no support for your high‑arched foot could actually make the problem worse or at the very least have been a waste of two months. This also begs the question of whether or not you were given orthotics as a treatment option. For plantar fasciitis, orthotics are the central point of my treatment regimen. Without supporting the plantar fascial ligament while you walk and exercise, the ligament continually overstretches and never has a chance to heal.
The general consensus is that surgery would be the next option since you have tried everything (except an orthotic) and assuming the other potential heel problems have been ruled out. This is an elective procedure and as such there are inherent risks involved (hopefully your doctor will explain them to you). But the risk‑reward ratio is in your favor because you have tried most conservative treatments and they have proved futile.
In closing, do not be afraid to ask your doctor about the possible conditions I have mentioned, and if you have any doubts, go get yourself a second opinion.
Marc Mitnick DPM
Continued pain and nerve issues after surgery for plantar fasciitis
Visitor's question
Last year I started walking for exercise, about 4–5 hours a week. I had heel pain but powered through it. I finally went to the doctor 6 months later as it continued to get worse. He gave me orthotics, took an X-ray which showed a heel spur, and told me to always wear my shoes. I also received several cortisone injections.
The pain lessened temporarily but eventually hurt 24/7. It became hard to drive and I was often crawling by nighttime. Four months ago, I had surgery for plantar fasciitis and heel spur removal, along with a Topaz debridement.
After surgery, my pinky toe could no longer move outward. The incision became infected about a month later but was treated with a cream. Two and a half months after surgery, my foot was hurting more. I was given anti-inflammatories. The area where the Topaz was done became very swollen — after a bath, that area was touching the ground because of the swelling.
Another doctor in the office said I have tarsal tunnel syndrome. I was given a steroid shot in my hip and a steroid pack. My original doctor then did deep tissue laser therapy three times in one week, which made my foot more uncomfortable. I later told him I was losing feeling in part of my foot. He gave me another cortisone shot which was extremely painful — he said he was going through adhesions. More laser therapy followed.
I am scheduled for another cortisone shot but plan to cancel and get a second opinion. My foot is in pain or feels strange 24/7. I have shooting pains, burning, tingling, aching, spasms, numbness, and pain from the heel through the arch and up to the inside of the ankle. Tapping near the incision gives me tingling. I am unsure if something else was going on before surgery or if this is a complication. I am a 43-year-old mother of 4 and am very concerned about my future.
Doctor's answer
Hi,
The best piece of advice I could give you would be to get a second opinion immediately. Based on your narrative, it sounds like the doctors in this group are just “guessing” at this point.
You do not mention it, but I am wondering if you had an MRI prior to surgery. There are too many conditions that cause heel pain, and when it gets to the point of considering surgery, an MRI is mandatory in my opinion. It helps rule out things like a plantar fascial tear, heel fracture, or even a tumor in the heel bone (a remote possibility).
Additionally, tarsal tunnel syndrome can cause heel pain, as can a heel neuroma — neither of which would have been resolved with the type of surgery you had. I am assuming you had the Topaz coblation on the bottom of the heel, and the small scar on the inside of your heel suggests you had an endoscopic plantar fasciotomy.
The fact that you cannot move your pinky toe outward, along with the lack of feeling in part of the foot, burning, tingling, and shooting pains — these are all nerve-type symptoms. It could be a worsening of tarsal tunnel syndrome (if that is what you actually have), or it could be nerve damage from the surgery.
Since tapping on the incision gives you a tingling sensation, that is very suggestive of a heel neuroma.
Complicating all of this is the fact that you had surgery on the heel. Four months post-op, I would not expect you to be doing cartwheels, but I would expect you to be improving week by week — clearly, you are not.
You need someone to isolate exactly what your problem is, possibly through nerve conduction studies and an MRI. Once the true cause is identified, it will be easier to proceed in a way that improves your situation. You cannot continue to have people guessing what is going on.
Marc Mitnick DPM
If you happen to live in the New York - New Jersey area and would like to visit our office
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DISCLAIMER: The purpose of this site is purely informational in nature. It is not intended to diagnose, treat or cure any medical condition. This information is not a substitute for advice from a medical professional. Please consult your healthcare provider for accurate diagnosis and treatment. The information presented here may be subject to errors and omissions.
SITE LAST UPDATED: MAY 2026
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anonymous
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Whichita, KS
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Colorado
Wonderful advice
by: Anonymous
This is the best site for foot problem info.
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by: Max
location unknown
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Canada
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North Carolina
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KG
location unknown
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Florida
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Lynne T.
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New Jersey
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a mom
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Lenoir, NC
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Bellevue, WA
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Jodi
location unknown
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Because of supply chain shortages as well as staffing shortages particularly during the pandemic, many institutions extended the time between dressing changes for chronic wounds. Is this really the be… -
Food choices that raise your risk of type 2 diabetes
Jan 08, 23 10:07 AM
A good review of how blood sugars can become elevated and the harm that can do. Certain food groups have a tendency to raise your blood sugars and should be avoided. -
Outcome stats from Scarf bunionectomy
Jan 03, 23 03:04 PM
The Journal of Foot and Ankle Surgery recently reported a meta analysis of outcomes in 1583 Scarf bunionectomies that met their inclusion criteria. Adverse events did not seem to be any better or wors…