Heel spurs are often misunderstood sources of heel pain. There are several ways heel spurs form and there are several locations they develop in. The spur most commonly assumed to cause pain in actuality causes little to no pain, while another spur that often goes unnoticed can create a great deal of pain. This article will discuss these spurs, and their contribution to foot pain.

There are essentially two places on the heel bone that bone spurs can develop. In most cases, these spurs form as a result of traction and pulling from either tendons or ligaments. It is the foot structure and its effect on the function of the foot during standing and walking that influence this traction, and subsequently the bone spurs that follow. The most common location of a heel spur, and one that is commonly associated with heel pain, is found under the heel bone. However, this spur is rarely ever the true source of heel pain. Attached to the heel bone at this location is a ligament called the plantar fascia. This tissue runs the length of the arch, and is essentially a firm rubbery band that helps support the overlying anatomic structures. In people with flat or flattening feet, gradual tension on this fascia creates inflammation and tissue damage. From this plantar fasciitis develops, which is essentially a chronic inflammatory disease of the tissue. This inflammation and tissue damage is the true source of heel pain on the bottom of the foot. The spur is simply traction-caused calcification of the attaching fascia tissue where it meets the bone, essentially extending the length of the bottom of the heel bone. This spur runs parallel with the ground, and is not felt externally. Many people have heel spurs in this location and have no pain in the heel at all. Even those with very thin heel padding under the skin do not experience discomfort from these spurs.

Like all things, there is an exception to pain in spurs on the bottom of the heel. Certain classes of diseases, particularly immune-response arthritic conditions like rheumatoid arthritis and a group of diseases called seronegative arthropathies, can have heel spurs and pain as part of their symptoms. The spurs found in these conditions differs from the typical spur that stretches outwards parallel with the ground. In these conditions, the heel spurs are fluffy and face downward, into the pad of the heel. The general body inflammation found in these conditions increases the irritation these spurs create, which then leads to pain with weight bearing directly as a result of the spur presence. It should be noted that many people also assume this heel pain is related to 'arthritis', similar to their hip, knee, or hand arthritis. In actuality, these areas of arthritis are simply wear and tear on a solitary joint or group of joints, called osteoarthritis. The arthritic conditions described above that lead to heel spurs are diseases of the immune system that destroy joint tissue, not simply mechanical joint wear. This process differs significantly from the disease most people know as 'arthritis'.

The other location spurs are commonly found is on the back of the heel. These spurs develop around or behind the attachment point of the Achilles tendon, a thick and powerful tendon that allows the foot to bend downward at the ankle. Tightness of this tendon, through either tight tissue or short tissue, creates a great deal of traction on the back of the heel bone. Eventually, this traction results in spur formation behind the tendon, or around where it actually attaches on the heel. Additionally, the tendon itself can become calcified, with bone-like deposits within the tendon tissue at and above the heel attachment. Over time, this excessive bone will create inflammation and irritation to the tight tissue around it, and lead to Achilles tendonitis as well as inflammation of the tissue that covers the bone. The pain from this condition is directly related to the bone spur, and can be quite disabling. The tendon may become weakened, and has the potential to rupture. Fractures of these spurs is also not uncommon, although sometimes the separated tendon calcification is misdiagnosed as a fracture of a spur from the heel bone.

Near this location is another part of the bone that can be implicated in cases of heel pain. The Haglund's deformity, or Pump Bump, is not actually a spur, but simply an enlargement of the top surface of the back of the heel bone. This bone develops thickened growth for a variety of reasons, some of which includes mechanical pressure from shoes that have firm heel material that protrudes into the heel at this spot. This enlarged bone can become inflamed and irritated, and shoe pressure can worsen it. Although a spur in the true sense is not present, the symptoms in this condition may not be distinguishable from an actual spur on the back of the heel.

Treatment of all these conditions requires addressing the underlying cause. For heel pain on the bottom of the foot, direct intervention to the heel spur is not necessary, and simply addressing the inflamed fascia with anti-inflammatory measures and careful arch support usually results in a cure. When the pain is due to the less common spur associated with rheumatic disease, treatment of the underlying disease process can reduce the inflammation component, leading to pain reduction. In rare cases, shaving of the spurs may be necessary to obtain relief. For heel spur pain and Haglund's deformity behind the heel, treatment centers on loosening the Achilles tendon and using anti-inflammatory measures, along with stabilizing the ankle. In many cases however, the spurs themselves need to be removed, the Achilles tendon needs to be removed, repaired, and replaced, or the Haglund's deformity needs to be reduced if present. Surgery is often, but not always, the end result of treatment of spurs behind the heel.

As one can see, the role heel spurs have in heel pain is often misunderstood, as they may or may not be a source of that pain. Prompt identification and treatment of the cause of heel pain is vital for a successful treatment, as the appropriate treatment may be very different from one cause to another.