Plantar Fasciitis vs. Heel Spur: What's Causing Your Heel Pain
Plantar Fasciitis vs. Heel Spur: What's Actually Causing Your Heel Pain
Quick summary
- Plantar fasciitis is by far the most common cause of heel pain in adults, with a lifetime incidence around 10%, and higher rates in women aged 40–60 and in runners (Trojian & Tucker, 2019).
- A heel spur is a common incidental finding, often present even in people with no heel pain at all, and research shows it has no direct relationship to symptom severity — it isn't considered the actual cause of the pain (Trojian & Tucker, 2019).
- The classic diagnostic sign is sharp pain at the inner heel with the first steps in the morning, which eases with activity but returns by the end of the day.
- A specific clinical test (the windlass test) is highly specific for plantar fasciitis but was found to have low sensitivity in the original validation study — meaning a negative result doesn't reliably rule it out (De Garceau et al., 2003).
Hearing "you have a heel spur" on an X-ray report can be misleading. In most cases of heel pain, the spur itself isn't actually the problem — it's a bystander. The real driver, in the overwhelming majority of cases, is a soft tissue condition called plantar fasciitis.
Plantar Fasciitis Is (By Far) the More Common Culprit
Plantar fasciitis — irritation of the thick band of tissue running along the bottom of the foot from the heel to the toes — is described as the most common cause of heel pain in adults, accounting for roughly one million patient visits a year in the United States alone, with a lifetime incidence of about 10%. It's more common in women aged 40 to 60 and in runners, where rates run higher (around 5–10%). The classic presentation is sharp pain at the inner part of the heel that's worst with the very first steps out of bed, eases somewhat as the foot warms up, and then often returns by the end of the day. On examination, tenderness is typically found at the specific point where the fascia attaches to the heel bone (Trojian & Tucker, 2019).
What About That Heel Spur on the X-ray?
Here's the part that surprises a lot of people: a heel spur showing up on imaging is a very common incidental finding, and it turns up in people who have absolutely no heel pain at all. Research reviewed in a major clinical guideline found that heel spurs show no direct relationship to how severe someone's symptoms are, and a spur often remains visible on imaging even after someone's pain has fully resolved. While people with longstanding, chronic heel pain are somewhat more likely to also have a bone spur, the spur itself isn't considered diagnostic of plantar fasciitis — it's not the thing actually causing the pain (Trojian & Tucker, 2019).
The Windlass Test — Useful, But Not Perfect
One specific physical exam test, the windlass test, is commonly used to help confirm plantar fasciitis: the clinician holds the ankle still and bends the toes upward, which tensions the plantar fascia and should reproduce the characteristic heel pain if the fascia is the problem. The original validation study, comparing people with plantar fasciitis against those with other foot pain and symptom-free controls, found the test was highly specific — nobody in the other two groups had pain with the test, meaning a positive result is a strong sign. However, the same study found sensitivity was quite low: only about 31.8% of confirmed plantar fasciitis patients tested positive in the weight-bearing version, and just 13.6% in the non-weight-bearing version. In other words, a positive windlass test is a meaningful finding, but a negative result does NOT reliably rule plantar fasciitis out (De Garceau et al., 2003).
Practical Takeaways
- Don't fixate on a heel spur finding — it's commonly present in pain-free feet too, and research shows it doesn't track with symptom severity.
- Pay attention to the pattern — sharp first-step-in-the-morning pain that eases then returns later in the day is the hallmark presentation of plantar fasciitis.
- A positive windlass test is meaningful; a negative one isn't the final word — don't assume the diagnosis is ruled out just because one specific test didn't reproduce the pain.
- Note any activities that load the foot repeatedly — running and prolonged standing are common contributing factors worth mentioning to whoever assesses you.
- Persistent heel pain deserves a proper assessment rather than treatment aimed at an incidental imaging finding.
Dealing with heel pain that's worse first thing in the morning?
A hands-on assessment can confirm whether plantar fasciitis is the actual driver and build a practical plan, rather than chasing an incidental finding on a scan.
Frequently Asked Questions
Is a heel spur the same thing as plantar fasciitis?
No. Plantar fasciitis is irritation of the soft tissue band along the bottom of the foot, and it's by far the more common cause of heel pain. A heel spur is a bony growth that's often found incidentally on imaging, including in people with no heel pain at all, and research shows it doesn't correlate with symptom severity.
If I have a heel spur, is that what's causing my pain?
Probably not on its own. Research has found heel spurs show no direct relationship to symptom severity and often remain visible on imaging even after pain has resolved. While chronic heel pain sufferers are somewhat more likely to have a spur, it isn't considered the actual cause.
How common is plantar fasciitis?
It's described as the most common cause of heel pain in adults, with a lifetime incidence of about 10%, higher in women aged 40-60 and in runners (around 5-10%).
How is plantar fasciitis diagnosed?
Diagnosis is primarily clinical, based on the pattern of sharp first-step morning heel pain and tenderness at the fascia's attachment point. A specific test, the windlass test, is highly specific when positive, but research found it has low sensitivity, so a negative result doesn't rule the condition out.
References
- Trojian, T., & Tucker, A.K. (2019). Plantar fasciitis. American Family Physician, 99(12), 744–750.
- De Garceau, D., Dean, D., Requejo, S.M., & Thordarson, D.B. (2003). The association between diagnosis of plantar fasciitis and Windlass Test results. Foot & Ankle International, 24(3), 251–255. https://doi.org/10.1177/107110070302400309
