Heel Spur Treatment

What Are Heel Spurs and Plantar Fasciitis? The Real Source of the Pain

• Heel Spur (Calcaneal Spur): A small, pointed bony outgrowth that forms on the underside of the heel bone (calcaneus), usually where the plantar fascia attaches. It can be seen on X-ray films.
• Plantar Fasciitis (Plantar Fasciitis / Fasciosis): The thick, strong band of connective tissue on the sole of the foot that starts at the heel bone and fans out toward the toes, supporting the arch of the foot, is called the plantar fascia. Plantar Fasciitis is a condition in which this fascia becomes excessively strained where it attaches to the heel bone, developing repeated micro-tears and, as a result, either inflammation (the tendinitis stage) or, more commonly, chronic degeneration (structural breakdown – the fasciosis stage).

Important Point: Although a heel spur is often seen on X-rays of patients with heel pain, the true source of the pain is usually not the heel spur itself. The pain largely stems from inflammation or degeneration of the overstretched and worn plantar fascia. The heel spur, on the other hand, is a bony outgrowth that develops over time as the body’s response to the plantar fascia’s constant pulling on the heel bone, and it can be found in many people who have no pain at all. For this reason, treatment primarily focuses on healing the plantar fascia, the actual source of the pain; surgical removal of the heel spur is usually not necessary.

Why Does Plantar Fasciitis Occur? Risk Factors

The main factors that lead to excessive strain and wear on the plantar fascia are:

• Overuse / Repetitive Strain: Standing, walking, or running for long periods, especially on hard surfaces. Suddenly increasing training intensity or duration.
• Foot Mechanics Problems:
  
  • Flat Feet (Pes Planus): Because the foot arch is low, the fascia is excessively stretched.
  • High Arch (Pes Cavus): Because the foot arch is higher than normal, the fascia cannot stretch enough and remains tight.
  • Gait abnormalities.
• Tightness in the Calf Muscles and Achilles Tendon: Shortness or tightness of the calf muscles (gastrocnemius, soleus) and the Achilles tendon restricts the upward movement of the ankle (dorsiflexion) and increases the load placed on the plantar fascia during walking. This is a very important cause.
• Improper Footwear: Worn-out shoes or shoes offering inadequate arch support or cushioning. High-heeled shoes or, conversely, very flat shoes (such as ballet flats).
• Excess Weight / Obesity: An increase in body weight directly increases the load placed on the plantar fascia.
• Age: More commonly seen in middle-aged individuals, typically between 40 and 60 years old.
• Occupation: Occupations that require standing for long periods, such as teachers, factory workers, and waiters.

Symptoms: Pain That Intensifies With the First Step in the Morning

The most typical symptom of plantar fasciitis is as follows:

• Heel Pain: The pain is usually felt on the inner-underside of the heel, where the fascia attaches to the bone. It can be sharp, stabbing, or knife-like.
• First-Step Pain (Classic Symptom): The pain is most severe during the first few steps taken when getting out of bed in the morning, or when standing up after sitting for a long time. Because the fascia shortens overnight, its sudden stretching with the first step causes severe pain. After a few steps, as the fascia stretches somewhat, the pain eases.
• Relationship With Activity: The pain may decrease as you walk during the day but increases again after standing or walking for long periods. The pain is usually more noticeable after exercise rather than during it.
• Tenderness: Tenderness when pressure is applied to the underside of the heel or when the area is pressed with a finger.
• Limping: Limping may occur in the morning or at the end of the day due to pain.

How Is It Diagnosed?

The diagnosis of plantar fasciitis is usually made based on the patient’s typical history and a careful physical examination.

• Patient History: When the pain started, exactly where it is located, whether first-step morning pain is present, factors that worsen or relieve the pain, activity level, and the shoes used are all questioned.
• Physical Examination: The doctor checks for tenderness by pressing a finger on the plantar fascia’s attachment point under the heel. Ankle range of motion (especially Achilles tendon tightness) and foot structure (flat feet/high arch) are assessed. Gait is examined.
• Imaging Methods:
  
  • X-ray: Usually requested. It does not directly show plantar fasciitis but is taken to rule out other causes of the pain (such as stress fracture, bone tumor, or arthritis). A heel spur (calcaneal spur) may or may not be seen on this X-ray. It should be reiterated that the presence or absence of a heel spur does not change the diagnosis or treatment of plantar fasciitis.
  • Ultrasound (US) or Magnetic Resonance Imaging (MRI): Usually not necessary for diagnosis. However, if the diagnosis is uncertain, symptoms are atypical, or the patient is not responding to treatment, these may be requested to evaluate thickening of the plantar fascia, edema, partial tears, or other issues such as nerve entrapment.

Treatment Options: Patience and Conservative Methods Come First!

In the treatment of plantar fasciitis, more than 90% of patients recover with non-surgical (conservative) methods. However, the healing process can be slow and requires patience (it usually takes 6-12 months). The main goal of treatment is to reduce the load on the plantar fascia, increase its flexibility, and resolve the inflammation/degeneration.

The Most Effective Conservative Treatment Methods:

1. Stretching Exercises (VERY IMPORTANT!):
   
   • Plantar Fascia Stretch: While sitting, cross one leg over the other, pull the toes back toward you until you feel tension in the sole of the foot, and hold for 10-15 seconds. Repeat this movement several times a day.
   • Achilles Tendon and Calf Muscle Stretch: The calf muscles are stretched by leaning against a wall with your hands or by hanging the heel down off the edge of a step. Since tight calf muscles are one of the most important causes of plantar fasciitis, these stretches are of vital importance. They should be done regularly, 2-3 times a day.
   • Morning Stretch: Simple stretches performed before getting out of bed, by pulling your toes and ankle toward you, are very effective at reducing first-step pain.
2. Choosing Supportive Footwear and Orthotics (Insoles):
   
   • Athletic shoes or comfortable shoes with good arch support and heel cushioning should be preferred.
   • Wearing slippers or shoes even indoors, and avoiding walking barefoot on hard surfaces, is important.
   • Off-the-shelf or custom-made orthotics (insoles) are very effective at reducing the load on the fascia by supporting the arch of the foot and providing heel cushioning.
3. Activity Modification: Activities that increase pain (running, jumping, standing for long periods) should be reduced or temporarily stopped. Low-impact activities such as swimming or cycling can be substituted.
4. Ice Application: Applying ice to the painful area for 15-20 minutes several times a day, or rolling a frozen water bottle under the foot, can reduce pain and inflammation.
5. Night Splints: A very effective method. Special splints worn while sleeping keep the ankle in a neutral or slightly upward-flexed position, keeping the plantar fascia and Achilles tendon gently stretched throughout the night. This significantly reduces morning first-step pain.
6. Pain Relievers: NSAIDs (such as ibuprofen or naproxen) can be used to temporarily reduce pain and inflammation, but long-term use should be avoided.
7. Physical Therapy: A program conducted with a physiotherapist may include learning proper stretching techniques, manual therapy, taping (kinesiology or rigid taping), strengthening, and other modalities (ultrasound, laser, etc.).
8. Weight Loss: In overweight patients, losing weight speeds up healing by reducing the load on the fascia.

Other Conservative Options:

• ESWT (Extracorporeal Shockwave Therapy): A non-surgical treatment option proven effective in chronic, resistant cases of plantar fasciitis that have not responded to the above conservative treatments for at least 6 months. It stimulates healing in the area using high-energy sound waves. (You can refer to our ESWT article for more detailed information.)
• Corticosteroid (Cortisone) Injections: Can rapidly and temporarily relieve severe pain. However, due to potential side effects such as weakening the plantar fascia, increasing the risk of rupture, and fat pad atrophy at the heel, they should only be considered very carefully and in limited numbers (usually 1-2 injections), after all other methods have been tried. Not routinely recommended.

Surgical Treatment (Rarely Needed):

In a very small proportion of plantar fasciitis patients (less than 5%), surgical treatment may be considered if severe pain and functional loss persist despite at least 6-12 months of comprehensive conservative treatment.

• Plantar Fascia Release (Fasciotomy): During surgery, part of the plantar fascia (usually the medial band) is cut to release tension. This procedure can be performed via open surgery or an endoscopic (minimally invasive) technique.
• Heel Spur Removal: Usually not necessary. It may be removed only if it is very large and is thought to be causing nerve entrapment.
• Risks: Surgical treatment carries risks such as nerve damage (numbness in the heel), infection, persistent pain, and flattening of the foot arch, and the recovery process takes time. For this reason, surgery should be considered a last resort.

Heel Spur (Plantar Fasciitis) Treatment in Ankara and Prof. Dr. Murat Bozkurt’s Approach

Heel pain and plantar fasciitis are among the most common reasons for visits to orthopedic clinics in Ankara. Prof. Dr. Murat Bozkurt follows these steps in his approach to this common problem:

• Accurate Diagnosis: He listens carefully to the patient’s history and performs a detailed foot and ankle examination. If necessary, he rules out other possible causes with an X-ray. He explains to the patient that the true source of pain is the plantar fascia, and that a heel spur is usually a secondary finding.
• Patient Education: He informs the patient about the nature and causes of the condition and that healing may take time. He emphasizes the importance of patience and active participation in treatment.
• Priority on Conservative Treatment: He states that the foundation of treatment is non-surgical methods. He emphasizes the effectiveness of methods such as regular stretching exercises (Achilles and plantar fascia), proper footwear/orthotic use, and night splints. He refers patients to physical therapy when needed.
• ESWT Option: In resistant cases, he considers ESWT, an effective non-surgical method, as an option.
• Considering Surgery as a Last Resort: He considers surgery only in very rare cases where all conservative methods have failed, and thoroughly informs the patient about the risks/benefits.

Plantar fasciitis, commonly known as a heel spur, is a condition that can be quite uncomfortable but can usually be successfully managed with conservative treatment methods applied with patience. The key to treatment is performing regular stretching exercises, using proper footwear and insoles, and reducing the load on the fascia. In Ankara, you can reach an accurate diagnosis and an effective treatment plan for your heel pain complaint by consulting Prof. Dr. Murat Bozkurt.

For detailed information and appointments, you can contact Prof. Dr. Murat Bozkurt at 0312 502 70 74.