Understanding Plantar Calcaneal Spurs: A Detailed Review
Plantar Calcaneal Spurs (PCS) are bony outgrowths that develop on the underside of the heel bone (calcaneus), where the plantar fascia attaches to the calcaneus. Although these spurs are typically small, they can cause significant heel pain, also known as talalgia. PCS is a common cause of heel pain and is often associated with conditions like plantar fasciitis. Repetitive stress, poor foot mechanics, or certain health conditions can contribute to the formation of these spurs.
How Common It Is and Who Gets It? (Epidemiology)
Plantar calcaneal spurs are commonly seen in adults, particularly those over 40. The condition is more prevalent in individuals who are overweight, have flat feet, or have high arches. It is also seen more frequently in athletes or individuals who engage in high-impact activities that put repeated stress on the feet. While many people with PCS may experience no symptoms, those who do typically report pain in the heel, particularly during the first steps in the morning.
Why It Happens – Causes (Etiology and Pathophysiology)
The exact cause of PCS is not fully understood, but several factors contribute to its development:
- Traction Theory: Chronic pulling or traction of the plantar fascia at its attachment to the calcaneus is thought to lead to inflammation and ossification (bone formation).
- Vertical Compression Theory: Repetitive vertical forces, such as those experienced during walking or standing, may cause microfractures in the heel bone, prompting the body to form a calcaneal spur as a protective response.
- Heel Pad and Fascia Thickening: With age and weight gain, the heel pad may thicken, reducing the flexibility of the plantar fascia, leading to increased tension and the formation of spurs.
How the Body Part Normally Works? (Relevant Anatomy)
The calcaneus is the largest of the tarsal bones in the foot and is responsible for bearing weight during walking, running, and standing. The plantar fascia, a dense band of connective tissue, runs from the heel to the toes and helps support the arch of the foot. When the plantar fascia is subjected to repetitive stress, the tension at the point where it attaches to the calcaneus can lead to the development of a bony spur. This spur can irritate the surrounding tissues and cause pain.
What You Might Feel – Symptoms (Clinical Presentation)
Common symptoms of PCS include:
- Heel pain that is often described as sharp or stabbing, especially with the first steps in the morning.
- Swelling and tenderness in the heel.
- Pain that worsens with prolonged standing or walking.
- Pain during activities like running or climbing stairs.
- In some cases, PCS can cause swelling and irritation in the surrounding tissues.
How Doctors Find the Problem? (Diagnosis and Imaging)
- Physical Exam: The doctor will check for tenderness on the bottom of the heel, particularly at the site where the plantar fascia attaches to the calcaneus.
- X-rays: X-rays are typically used to confirm the presence of a calcaneal spur. The spur is visible as a bony outgrowth on the calcaneus.
- MRI: MRI can be used to assess soft tissue inflammation and to check for concurrent conditions like plantar fasciitis or bursitis.
- Ultrasound: This imaging technique can be used to assess the plantar fascia and the calcaneus for any abnormal growth or inflammation.
Classification
Plantar calcaneal spurs are typically classified based on their size and the degree of symptoms:
- Mild: Small spurs with minimal symptoms.
- Moderate: Larger spurs causing discomfort with prolonged standing or walking.
- Severe: Spurs that cause chronic pain, inflammation, and significant disability.
Other Problems That Can Feel Similar (Differential Diagnosis)
Conditions that can mimic the symptoms of PCS include:
- Plantar fasciitis: Inflammation of the plantar fascia often presents with heel pain, particularly with the first steps in the morning.
- Tarsal tunnel syndrome: Compression of the tibial nerve can cause pain in the heel, similar to PCS.
- Heel bursitis: Inflammation of the bursa near the heel can cause pain, especially when standing or walking.
- Achilles tendonitis: Pain at the back of the heel, which may sometimes radiate to the bottom of the foot, can mimic PCS.
Treatment Options
Non-Surgical Care
Most cases of PCS can be treated conservatively:
- Rest and activity modification to reduce strain on the heel.
- Ice and compression to reduce swelling and pain.
- NSAIDs: Nonsteroidal anti-inflammatory drugs can help reduce inflammation and discomfort.
- Physical Therapy: Stretching exercises for the plantar fascia and strengthening exercises for the foot can help relieve pain.
- Orthotics: Custom shoe inserts can help redistribute pressure on the heel and reduce the tension on the plantar fascia.
- Extracorporeal Shock Wave Therapy (ESWT): Uses high-energy sound waves to stimulate healing and reduce pain.
- Cryo-Ultrasound Therapy: Combines cold therapy and ultrasound to reduce inflammation and alleviate pain.
Surgical Care
Surgery is generally reserved for cases that do not respond to conservative treatments after several months. Surgical options include:
- Plantar Fasciotomy: Involves releasing the tension in the plantar fascia to reduce stress on the heel.
- Spur Resection: Removal of the calcaneal spur to alleviate pain and improve function.
Recovery and What to Expect After Treatment
- Non-surgical recovery: Many patients experience relief within 4–6 weeks with rest, physical therapy, and orthotics. Recovery time may vary based on the severity of the symptoms.
- Surgical recovery: After surgery, recovery can take several months. Patients are typically advised to avoid weight-bearing for the first few weeks, followed by gradual rehabilitation.
Possible Risks or Side Effects (Complications)
- Recurrence of pain: If the underlying cause is not addressed or if the spur reoccurs.
- Infection: A risk associated with surgical treatment.
- Nerve damage: In rare cases, surgery may damage nerves in the surrounding area.
- Joint stiffness: Following surgery, some patients may experience reduced range of motion.
Long-Term Outlook (Prognosis)
The prognosis for PCS is generally favorable with conservative treatment, and many individuals can return to normal activities after a period of rehabilitation. Surgical outcomes are typically positive, with most patients experiencing significant pain relief. However, some individuals may continue to experience mild discomfort, especially if there are underlying conditions like plantar fasciitis or arthritis.
Out-of-Pocket Costs
Medicare
CPT Code 28119 – Ostectomy, Calcaneus (Resection of Calcaneal Spur): $120.00
CPT Code 28250 – Fasciotomy, Plantar (for Plantar Fascia Release): $136.05
Medicare Part B typically covers 80% of the approved cost for these procedures once your annual deductible has been met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield typically cover the remaining 20%, reducing or eliminating out-of-pocket expenses for Medicare-approved surgeries. These plans work in coordination with Medicare to fill the coverage gap.
If you have Secondary Insurance such as TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it acts as a secondary payer. These plans usually cover any remaining balance, including coinsurance or small deductibles, which typically range from $100 to $300 depending on your plan and provider network.
Workers’ Compensation
If your calcaneal spur treatment is related to a work injury, Workers’ Compensation will cover all treatment costs, including surgery and rehabilitation. You will not have any out-of-pocket expenses, as the employer’s insurance carrier covers all costs directly.
No-Fault Insurance
If your calcaneal spur or plantar fascia condition is related to an automobile accident, No-Fault Insurance will typically cover the full cost of treatment, including surgery and postoperative care. The only potential out-of-pocket expense may be a small deductible or co-payment based on your policy.
Example
John Peterson required calcaneal ostectomy (CPT 28119) to remove a painful spur on his heel. His estimated Medicare out-of-pocket cost was $120.00. Since John had supplemental insurance through Blue Cross Blue Shield, his remaining balance was fully covered, leaving him with no out-of-pocket expenses for the procedure.
Frequently Asked Questions (FAQ)
Q. What is a calcaneal spur?
A. A calcaneal spur is a bony outgrowth from the heel bone that forms where the plantar fascia connects to the heel.
Q. What causes a calcaneal spur?
A. Calcaneal spurs are caused by chronic inflammation of the plantar fascia leading to bone growth at the heel.
Q. What are the symptoms of a calcaneal spur?
A. Symptoms can include sharp pain in the heel, especially when standing up after rest, and pain during walking or running.
Q. How is a calcaneal spur diagnosed?
A. Diagnosis is typically made based on a clinical examination and confirmed with an X-ray showing the bony growth.
Q. Who is at risk of developing a calcaneal spur?
A. People who are obese, have flat feet or high arches, wear poorly fitting shoes, or engage in repetitive activities like running are at higher risk.
Q. How is a calcaneal spur treated initially?
A. Initial treatment includes rest, ice application, stretching exercises, orthotics, anti-inflammatory medications, and proper footwear.
Q. When is surgery considered for a calcaneal spur?
A. Surgery is considered when conservative treatments fail to relieve symptoms after an extended period.
Q. What does surgery for a calcaneal spur involve?
A. Surgery may involve removing the spur and releasing part of the plantar fascia to reduce tension.
Q. What is the recovery like after surgery for a calcaneal spur?
A. Recovery typically involves rest, gradual weight-bearing, physical therapy, and a slow return to activities.
Q. Can calcaneal spurs come back after treatment?
A. Yes, there is a possibility that a calcaneal spur can recur, especially if the underlying causes are not addressed.
Q. What non-surgical treatments help manage calcaneal spur pain?
A. Non-surgical treatments include stretching exercises, orthotic devices, physical therapy, proper footwear, and anti-inflammatory medications.
Q. How can calcaneal spurs be prevented?
A. Prevention involves maintaining a healthy weight, wearing supportive shoes, avoiding repetitive stress on the heel, and performing regular stretching exercises.
Q. Is a calcaneal spur the same as plantar fasciitis?
A. No, but they are closely related; plantar fasciitis refers to inflammation of the plantar fascia, while a calcaneal spur is a bony growth that may develop due to chronic inflammation.
Q. Why does the pain from a calcaneal spur feel worse in the morning?
A. Pain often feels worse in the morning because the plantar fascia tightens overnight, and stretching it during the first steps puts tension on the spur.
Summary and Takeaway
Plantar calcaneal spurs are a common cause of heel pain, particularly in older adults and individuals who are overweight or have abnormal foot mechanics. While the exact cause of PCS remains debated, several theories suggest that factors like repetitive stress, increased weight, and aging contribute to their formation. Fortunately, most cases of PCS can be managed effectively with conservative treatments like stretching exercises, orthotics, and shockwave therapy. In rare cases, surgical intervention may be required.
Clinical Insight & Recent Findings
A 2025 clinical study by Zeynep Karakuzu Güngör compared two advanced, non-invasive treatments for calcaneal spur–related heel pain: Extracorporeal Shock Wave Therapy (ESWT) and High-Intensity Laser Therapy (HILT).
Both therapies significantly reduced pain and improved function in patients over a three-month follow-up period. ESWT works by stimulating tissue repair through focused mechanical waves, while HILT uses laser energy to reduce inflammation and promote healing.
Although both treatments were safe and effective, ESWT provided slightly greater improvements in functional recovery. The findings support ESWT and HILT as strong alternatives to surgery for patients who do not respond to standard conservative treatments. (“Study comparing shockwave and laser therapy for heel spurs – see PubMed.“)
Who Performs This Treatment? (Specialists and Team Involved)
Treatment for PCS is typically managed by orthopedic foot and ankle surgeons, podiatrists, and physical therapists.
When to See a Specialist?
Consult a specialist if you experience heel pain, especially if it is persistent and not alleviated by rest or conservative treatments.
When to Go to the Emergency Room?
Go to the emergency room if you experience severe pain, swelling, or a visible deformity, or if you suspect an infection or other complications.
What Recovery Really Looks Like?
Recovery from PCS typically involves rest, physical therapy, and rehabilitation. Surgical recovery may take several months, with full recovery possible after successful surgery.
What Happens If You Ignore It?
If left untreated, PCS can lead to chronic pain, joint damage, or long-term disability, including arthritis and permanent joint damage.
How to Prevent It?
Wear shoes with proper arch support, maintain a healthy weight, and avoid excessive strain on the heels. Regular stretching exercises can also help prevent PCS.
Nutrition and Bone or Joint Health
A diet rich in calcium, vitamin D, and omega-3 fatty acids supports joint health and reduces inflammation.
Activity and Lifestyle Modifications
After healing, return to low-impact activities such as swimming or cycling while strengthening the ankle under medical supervision. Avoid high-impact activities until the condition is fully resolved.
Dr. Mo Athar
