Heel Spurs - Is it the Real Problem?

author : AMSSM

comments : 0

There has been some level of debate suggesting that a heel spur may not cause pain directly, but rather “be an indication of other associated conditions."

Member question

Oh boy...could the news not get any worse?  The X-ray says that I have a heel spur behind my Achilles. This is probably why all the PT I've been doing has been useless.   My Achilles has been rubbing against the spur and causing a "pulling" problem.  My DPM and running doc both referred me to an orthotic specialist.   What is my prognosis for this injury?

Answer from Mark Kasmer, MD and Carly Day, MD
Member AMSSM

A brief review of The Beginner Triathlete forum demonstrates how common “heel spurs” are among athletes. But, is the “heel spur” really the problem? There has been some level of debate, but most scientific literature, including an April 2014 article in Foot & Ankle Specialist,¹ suggest that a heel spur may not cause pain directly, but rather “be an indication of other associated conditions.” Thus, identifying the presence of one of these “associated conditions” and treating it is more important than identifying a heel spur.

The most common “associated conditions” are Achilles tendinopathy and plantar fasciitis. Less common are a bursitis (retrocalcaneal or retroachilles) or a fracture. Given the posterior location of the spur (and most likely the posterior location of the “pulling”), Achilles tendinopathy is the most likely diagnosis. The term Achilles tendinopathy reflects a disorganized cellular process within the tendon, as opposed to an inflammatory process (tendinitis). The most common cause of a tendinopathy is repetitive tendon overload without adequate rest. This is most commonly encountered due to a rapid increase in training quantity and intensity, but can also be affected by a change in training conditions, such as training surface, foot-strike pattern, or shoe type.

The Achilles tendon originates from the gastrocnemius and soleus muscles (calf) and inserts into the calcaneus (posterior heel). It acts to plantarflex the ankle (as in performing toe raises or during the toe-off phase of running). 

Treatment is eccentric loading and Achilles stretches. Eccentric loading exercises, as originally studied and described by Hakan Alfredson, incorporate tendon lengthening during active contraction, and should be performed in 3 sets of 15, twice daily. Achilles stretches should be performed for up to 2-3 minutes, 2-3 times per day. Most Achilles tendinopathies can be treated successfully with stretches and eccentric exercise. However, literature suggests that up to 40% may not respond to stretching and eccentric loading alone² and require additional treatment, such a heel lift, a night splint, a walking boot, soft tissue manipulation, nitric oxide patches, ultrasound, phonopheresis (corticosteroid delivery via ultrasound), iontopheresis (corticosteroid delivery via ion transfer), extracorporeal shockwave therapy (ESWT), or injections. Recent literature has focused on ESWT, which utilizes sound waves to promote tendon healing, and regenerative injections, such as platelet-rich plasma (PRP) injections. Scientific studies are mixed regarding the efficacy of either treatment.

Prevention of recurrence can be achieved through continued Achilles stretches and a review of one’s training protocol. Avoid rapid increases in training quantity and intensity, especially if experimenting with different foot-strike pattern or a change in shoe type. Avoid frequent changes in training surface.

Mark Kasmer, MD
Sports Medicine Fellow
Cleveland Clinic

Carly Day, MD
Sports Medicine Physician
Cleveland Clinic

1. Moroney PJ, O’Neill BJ, Khan-Bhambro K, O’Flanagan SJ, Keogh P, et al. The conundrum of calcaneal spurs: do they matter? Foot Ankle Spec. 2014; 7(2); 95-101.
2. Longo UG, Ronga M, and Maffulli N. Achilles tendinopathy. Sports Med Arthrosc Rev. 2009; 17; 112 – 126.

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date: June 8, 2014