Shockwave Therapy for Heel Spurs: Differentiating Heel Spurs vs Plantar Fasciitis and Effective Treatments

KEY TAKEAWAYS

• A heel spur is a small bony growth on the underside of the heel bone. Heel spurs are common on X-rays in people who have no pain at all, so a spur on your imaging is not automatically the cause of your heel pain.
• Chronic heel pain almost always comes from the soft tissue near the heel, most commonly plantar fasciitis (also called plantar fasciopathy), not from the spur itself.
• The 2023 Clinical Practice Guideline for plantar heel pain from the Journal of Orthopaedic and Sports Physical Therapy recommends a stepped-care approach starting with education, load management, stretching, and orthotic support. Shockwave therapy is included as an intervention with supporting evidence, particularly for cases that have not responded to first-line care.
• A 2017 meta-analysis of randomised controlled trials by Sun and colleagues found that extracorporeal shock wave therapy (ESWT) reduced pain and improved function in chronic plantar fasciitis, with a favourable safety profile.
• Shockwave therapy is not a cure and is not appropriate for every patient. It works best as one part of a plan that also includes stretching, strengthening, and load management. A proper assessment is what determines whether shockwave belongs in your case.

IN THIS ARTICLE

• What is a heel spur, and how is it different from plantar fasciitis?
• Why the heel spur is usually not the pain generator
• What does the research say about shockwave therapy for chronic heel pain?
• How does shockwave therapy compare with other heel pain treatments?
• How does shockwave therapy work in the body?
• How does treatment for heel spurs work at Unpain Clinic Edmonton?
• What can you safely do at home between visits?
• Frequently asked questions

INTRODUCTION

If you have been told you have a heel spur, and if that word has been carrying most of the blame for months of morning heel pain, this article was written for you.

Heel spurs are one of the most misunderstood findings in musculoskeletal medicine. They show up on X-rays, they have a memorable-sounding name, and it is easy to look at a jagged little hook of bone in a picture of your foot and decide that is where the pain is coming from. Except the research does not really support that story. Most spurs do not hurt, and most heel pain has a different source that responds to a different treatment.

The purpose of this article is to walk through what a heel spur actually is, why it is usually not the villain, and where shockwave therapy fits in the picture of chronic heel pain. It is a long read because the topic warrants it. If you want the short version, the Key Takeaways above cover the essentials.

This information is provided by Unpain Clinic in Edmonton for educational purposes. It is not a substitute for a one-on-one physiotherapy assessment. Physiotherapy services in Alberta are regulated by the College of Physiotherapists of Alberta, and the standards of practice require the care that follows an assessment to be tailored to the individual client.

WHAT IS A HEEL SPUR, AND HOW IS IT DIFFERENT FROM PLANTAR FASCIITIS?

A heel spur (medical term: calcaneal spur) is a small bony growth on the heel bone. In most people who have one, it forms on the underside of the heel where the plantar fascia attaches, and it develops slowly over years in response to repeated tension on that attachment. Less commonly, a spur can form on the back of the heel where the Achilles tendon attaches.

Plantar fasciitis is a different thing entirely, even though it often shows up alongside a spur. The plantar fascia is a thick band of connective tissue that runs from the heel to the base of the toes and helps hold up the arch of your foot. When it gets overloaded (too much walking on hard floors, a jump in running mileage, a change in footwear, standing all day at a job that used to involve more sitting), the tissue develops small areas of wear. In the first few weeks, there is some inflammation. Past a certain point, the picture shifts into a more degenerative pattern that is not really about active inflammation anymore. This is why you will sometimes see the condition called plantar fasciopathy or plantar fasciosis in the physiotherapy literature.

The distinction that matters clinically is this. The heel spur is bone. The plantar fascia is soft tissue. They can coexist, and they often do, but the source of pain is almost always the soft tissue, not the bone. Studies of X-rays taken for reasons unrelated to heel pain have shown that a substantial proportion of people have heel spurs and no symptoms. Conversely, plenty of people have textbook plantar fasciitis symptoms and no spur visible on imaging. If the spur were the pain generator, neither of those patterns would exist.

WHY THE HEEL SPUR IS USUALLY NOT THE PAIN GENERATOR

Bone by itself does not have the kind of nerve endings that would produce the sharp first-step pain patients describe. A spur that has formed slowly over years is a structural adaptation, not an injury. The tissue that does have those nerve endings, and that responds to load, and that gets inflamed and then degenerative, is the fascia (and sometimes the surrounding fat pad, small nerves, and adjacent tendon).

Practically, this means two things.

• First, the goal of treatment is almost never to remove the spur. Surgery to cut out a spur is now considered a last resort in cases where every other conservative option has failed, and even then it is uncommon. The 2023 Clinical Practice Guideline for plantar heel pain from the Journal of Orthopaedic and Sports Physical Therapy organises treatment around education, load management, stretching, strengthening, foot orthoses, and adjunct modalities. Surgical intervention is not the recommended starting point.
• Second, the goal of treatment is almost always to fix the soft tissue. That means changing the load coming into it (through activity modification, better shoes, and sometimes orthotic support), rebuilding the tissue itself (through stretching and progressive strengthening), and, when appropriate, adding a modality that can help the tissue remodel (which is where shockwave therapy comes in).

WHAT DOES THE RESEARCH SAY ABOUT SHOCKWAVE THERAPY FOR CHRONIC HEEL PAIN?

Extracorporeal shock wave therapy (ESWT) uses high-energy acoustic waves, delivered through a handpiece pressed against the skin, to stimulate the tissue underneath. In musculoskeletal medicine, the intention is to nudge the body's own repair processes forward in tissue that has stalled.

For chronic plantar heel pain (which is the modern umbrella term for what most patients mean when they say "heel spur pain" or "plantar fasciitis"), the evidence base has grown substantially in the last decade. The 2017 systematic review and meta-analysis by Sun and colleagues, published in Medicine, pooled multiple randomised controlled trials of shockwave therapy for chronic plantar fasciitis and concluded that ESWT was safe and effective for reducing heel pain and improving function, particularly in patients whose symptoms had not settled with basic conservative care. More recent narrative reviews and clinical practice guidelines have reached similar conclusions.

The 2023 JOSPT Clinical Practice Guideline referenced above is currently the most authoritative reference for how to sequence heel pain care. It recommends starting with education, load management, stretching, and orthotic support. Shockwave therapy is included as an intervention with supporting evidence for cases that have not responded to first-line care, and it is discussed as an option that carries a favourable safety profile.

Two things worth taking from this. First, shockwave therapy is not a first-line treatment for every heel pain patient. If you have not tried the simpler self-care steps outlined later in this article, and if your pain is only a few weeks old, most of the improvement is likely to come from those steps. Second, shockwave therapy is not a cure and is not universally effective. Response varies from patient to patient, and the biggest predictors of response are proper assessment, correct patient selection, and integration with an active rehabilitation program.

"The most common misconception I see in the clinic is that the spur on the X-ray is the pain generator. It rarely is. Once we look at how the foot is loading, how the calf is moving, and how the arch is being supported through the day, the treatment plan almost writes itself. Shockwave therapy fits into that plan when the tissue has stalled, and the results tend to hold because the plan is not just about the modality." Uran Berisha, PT, RMT, Founder of Unpain Clinic, International Educator in Shockwave Therapy

HOW DOES SHOCKWAVE THERAPY COMPARE WITH OTHER HEEL PAIN TREATMENTS?

A useful way to think about heel pain options is to compare what each one is actually doing. Some treatments quiet pain quickly and fade. Some try to rebuild tissue slowly. They are not the same job and they age differently over weeks and months.

REST, ICE, AND ANTI-INFLAMMATORIES What it is doing: Lowers symptoms and calms any early inflammation. How fast: Days. How long it tends to hold: The pain often returns when normal activity resumes, because the underlying tissue has not been rebuilt and the loading pattern has not been changed.

SUPPORTIVE SHOES AND FOOT ORTHOSES What it is doing: Reduces load through the fascia and supports the arch. How fast: Days to weeks. How long it tends to hold: Recommended by the 2023 JOSPT Clinical Practice Guideline as part of first-line care. Useful as a bridge while the tissue heals. Not a substitute for load management or strengthening.

STRETCHING AND STRENGTHENING What it is doing: Restores tissue mobility and rebuilds the load capacity of the fascia and surrounding musculature. How fast: Weeks to months. How long it tends to hold: The DiGiovanni 2003 trial established that a plantar-fascia-specific stretch outperforms an Achilles-tendon stretch for chronic heel pain. The Rathleff 2015 trial showed that a high-load strength program had better outcomes at three months than stretching alone. These form the backbone of durable improvement.

CORTISONE INJECTION What it is doing: Suppresses local inflammation and pain. How fast: Days to weeks. How long it tends to hold: Can provide short-term relief for severe pain, but is not a tissue-remodeling treatment. Repeated cortisone injections into the heel have been associated with fat pad atrophy and, rarely, plantar fascia rupture. If cortisone is being considered, it is best used as a bridge into a rehabilitation program, not as a stand-alone solution.

FOCUSED SHOCKWAVE THERAPY What it is doing: Stimulates tissue remodeling, new small blood vessel growth, and pain modulation in the affected fascia. How fast: Builds over weeks. How long it tends to hold: In the Sun 2017 meta-analysis, shockwave therapy produced significant pain and function improvements in chronic plantar fasciitis. Included in the JOSPT guideline as an evidence-supported adjunct for cases that have not settled with first-line care.

SURGERY What it is doing: Structural intervention (plantar fascia release or, rarely, spur removal). How fast: Weeks to months of recovery. How long it tends to hold: Reserved for the small minority of cases that have failed six to twelve months of well-delivered conservative care. Not a first-line treatment for heel spurs or plantar fasciitis.

HOW DOES SHOCKWAVE THERAPY WORK IN THE BODY?

The mechanism has been studied in detail. A 2020 mechanism review by Simplicio and colleagues in the Journal of Clinical Orthopaedics and Trauma summarised the biological effects across a physical phase (acoustic wave interaction with tissue), a physicochemical phase (cellular signalling), a chemical phase (ion channel activity and calcium mobilization), and a biological phase (new blood vessel growth, tissue remodeling, and pain modulation).

Practically, the effects that matter clinically fall into three categories.

Local biological effects. Improved local blood flow through the reopening of small blood vessels and the growth of new ones (a process called angiogenesis). Increased production of collagen and other structural proteins that make up the fascia. Modulation of the local inflammatory environment in a way that supports repair rather than suppressing it.

Pain modulation. Shockwave therapy influences local nerve endings and reduces the transmission of pain signals in the treated area.

Effects on stalled tissue. This is what matters most in chronic heel pain. Tissue that has been in a low-grade degenerative state for months can be re-engaged in a repair process by the mechanical stimulus of the acoustic wave. This is why shockwave tends to be more useful in chronic cases than in fresh acute ones, where the body is already mounting its own repair response.

To be clear about what shockwave therapy does not do. It does not remove the heel spur. It does not correct anatomical alignment. It does not replace stretching, strengthening, or good clinical reasoning. It is a targeted mechanical stimulus that supports the local biology of tissue repair.

HOW DOES TREATMENT FOR HEEL SPURS WORK AT UNPAIN CLINIC EDMONTON?

At Unpain Clinic in Edmonton, the goal on your first visit is not to zap your heel. It is to figure out what has been keeping your heel from healing.

Your first appointment is a 60-minute physiotherapy assessment. The physiotherapist will take a full history of how the pain started, what aggravates it, what calms it, what you have already tried, and what you actually want to get back to. This is followed by orthopedic testing of the foot, ankle, and lower limb, palpation to identify the specific tender structures, and a movement analysis of how you walk, stand, and load through the day. Screening for red flags (nerve entrapment, stress fracture, systemic inflammatory disease, or anything else that would need a physician referral first) is part of the process.

At the end of the assessment, you receive a physiotherapy diagnosis, an explanation of what is driving the pain, and a personalized plan. Your consent is obtained before any treatment begins.

From there, treatment sessions are built around a small set of evidence-informed tools.

The core, when it is indicated, is focused shockwave therapy, delivered to the plantar fascia at the heel and along the arch. Focused shockwave penetrates deeper than radial devices, which matters for reaching the fascia insertion at the heel bone. A typical course is six to eight sessions, once or twice weekly, with re-assessment along the way. The intensity is adjustable during each session, and the sensation is a strong tapping over the treatment area rather than a sharp pain.

Alongside shockwave, the plan includes a progressive stretching and strengthening program (based on the DiGiovanni fascia-specific stretch and the Rathleff high-load protocol referenced above), manual therapy where the ankle is stiff or the calf is loaded up, and load management education for how you walk, stand, and train in the weeks that follow. In some cases we pair shockwave with EMTT in the same visit for broader tissue coverage.

WHAT CAN YOU SAFELY DO AT HOME BETWEEN VISITS?

This is general education, not individual medical advice, and results vary. A few things are safe to start on your own if your heel pain has been dragging on.

Do the plantar-fascia-specific stretch first thing in the morning, before you put weight on the foot. This is the stretch established as more effective for chronic heel pain than an Achilles-tendon stretch in the DiGiovanni 2003 trial. Sit on the edge of the bed, cross the affected foot over the opposite knee, grip your toes, and gently pull them back toward your shin until you feel a stretch along the arch. Hold about ten seconds, repeat ten times, and do it two or three times a day.

Add progressive calf and foot strengthening once acute pain has settled. The Rathleff 2015 trial used single-leg heel raises done slowly on a step, with a towel rolled under the toes to keep the fascia stretched. Start with two sets of ten, progress gradually. Sharp pain during the exercise, or pain that lingers for more than 24 hours afterward, means the load was too much.

Look at your shoes. If your daily shoes are more than a year old with visible wear at the heel, a supportive pair of runners with a decent arch and heel counter will help. Avoid walking around the house barefoot on hard floors while you are flaring. A supportive slipper or indoor pair of runners is kinder to the fascia.

Adjust the load. If your steps per day, running mileage, or standing hours jumped in the weeks before the pain started, ease those back to where they were and build up gradually.

Stay active in ways that do not flare it. Cycling, swimming, and rowing let you keep your fitness while the fascia settles. Walking is usually fine in moderation, with good shoes, on softer surfaces.

Some symptoms are not "wait and see" symptoms. Get medical attention if you develop sudden severe heel pain after a specific injury or fall, numbness or tingling in the foot, fever with heel pain, unexplained weight loss with heel pain, or pain that gets worse at rest without weight-bearing. Those can indicate conditions that need a physician assessment.

FREQUENTLY ASKED QUESTIONS

What is a heel spur, and does it hurt on its own?

A heel spur is a small bony growth on the heel bone that develops slowly in response to repeated tension at a tendon or ligament attachment. On its own, a heel spur usually does not hurt. Studies of X-rays have shown that many people have heel spurs and no pain at all. When someone with a heel spur has heel pain, the pain is almost always coming from the surrounding soft tissue, most commonly the plantar fascia, not from the bone itself.

What is the difference between a heel spur and plantar fasciitis?

A heel spur is a bony growth on the heel bone. Plantar fasciitis (also called plantar fasciopathy) is a load-related condition of the plantar fascia, the thick connective tissue running along the bottom of the foot from the heel to the base of the toes. The two often show up together on the same patient, but they are not the same thing. When treatment successfully relieves heel pain, it is almost always because the soft tissue has recovered, not because the spur has changed.

Do I need surgery to remove the spur?

For most patients with chronic heel pain, no. Surgery is not a first-line treatment for heel spurs, and current clinical practice guidelines recommend a stepped-care approach starting with education, load management, stretching, orthotic support, and evidence-supported adjuncts such as shockwave therapy. Surgery is reserved for the small minority of cases that have not responded to six to twelve months of well-delivered conservative care.

How does shockwave therapy help chronic heel pain?

Shockwave therapy uses acoustic waves to stimulate the local biology of tissue repair, including improved blood flow, new small blood vessel growth, and effects on pain-signalling nerve endings. It is intended to help stalled tissue restart its repair process. The Sun 2017 meta-analysis of randomised controlled trials found that shockwave therapy reduced pain and improved function in chronic plantar fasciitis, and the 2023 JOSPT Clinical Practice Guideline includes it as an evidence-supported intervention.

Is shockwave therapy safe, and does it hurt?

Shockwave therapy is generally well tolerated. Most patients describe the sensation as a strong tapping or pulsing over the treatment area. The intensity is adjustable during the session, and it stops the moment the device is off. Mild soreness for a day or two afterward is common and typically feels like post-workout tenderness. Contraindications include treatment over a pregnancy, active infection, active blood clots, significant bleeding disorders, or active malignancy in the treatment area. The physiotherapist screens for these during the assessment.

How many shockwave sessions will I need for heel pain?

A common plan is six to eight weekly sessions, with re-assessment along the way. Some patients notice early improvement after the first two or three sessions. Most of the change tends to build in the four to eight weeks after the last session as the tissue remodels. The specific number of sessions depends on the assessment findings and how you are responding.

Is shockwave therapy covered by Alberta Health Care?

Alberta Health Care does not cover shockwave therapy or private physiotherapy services. Many extended health benefit plans in Alberta reimburse physiotherapy under standard categories, and a Health Spending Account through your employer can usually be applied. Confirm coverage with your insurance provider before booking. A clear fee schedule is available on the clinic website and at reception.

When should I stop self-treating and book a physiotherapy assessment?

If your heel pain has lasted more than a few weeks despite good shoes, the fascia-specific stretch, and reduced load, or if it keeps returning every time you try to increase activity, that is the point where a proper assessment is likely to save you time. Persistent heel pain is one of the more identifiable conditions in physiotherapy when the assessment is done properly, and the right plan depends on knowing what is actually driving the pain.

PATIENT TESTIMONIAL

“Over the years shockwave has exceptionally improved various physical issues I suffered from. The first time I met Uran he got me walking again with 1 treatment after 5 months of suffering from plantar fasciatis. He then helped me with back, shoulder and neck pains that were the source of headaches. He helped me avoid a big surgery that would have caused other serious issues later on and after suddenly losing my ability to walk due to severe back pain, Uran found the source nobody else could find and got me walking again! I now swear by shockwave therapy!”- Nathalie Lacroix

ABOUT THE AUTHOR

Written by Uran Berisha, PT, RMT, Founder of Unpain Clinic and Medical Shockwave Institute in Edmonton. Uran is a physiotherapist based in Edmonton, Alberta, registered with the College of Physiotherapists of Alberta, and an International Educator in Shockwave Therapy. Medically reviewed by Uran Berisha, PT, RMT.

BOOK YOUR INITIAL ASSESSMENT

If chronic heel pain has been holding you back and you want a clear plan grounded in a proper assessment, the next step is a 60-minute physiotherapy assessment at Unpain Clinic Edmonton. The assessment identifies what is driving your pain, screens for anything that would need a physician referral first, and lets you make an informed decision about whether shockwave therapy fits your case. No referral is required in Alberta to see a physiotherapist. Book your initial assessment with Unpain Clinic.

WHAT WE DO NOT OFFER

We do not perform cortisone injections, prescribe medications, or perform surgery. We do not remove heel spurs. We do not sell or endorse specific orthotic or shoe brands. If your presentation suggests a condition outside our scope (nerve entrapment, stress fracture, systemic inflammatory disease, or anything requiring urgent medical evaluation), we will tell you plainly and help you find the right next step.

REFERENCES

1. DiGiovanni BF, Nawoczenski DA, Lintal ME, Moore EA, Murray JC, Wilding GE, Baumhauer JF. Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study. The Journal of Bone and Joint Surgery. American Volume. 2003;85(7):1270-1277. doi:10.2106/00004623-200307000-00013. PMID: 12851352. https://pubmed.ncbi.nlm.nih.gov/12851352/
2. Koc TA, Bise CG, Neville C, Carreira D, Martin RL, McDonough CM. Heel Pain - Plantar Fasciitis: Revision 2023. Journal of Orthopaedic & Sports Physical Therapy. 2023;53(12):CPG1-CPG39. doi:10.2519/jospt.2023.0303. PMID: 38037331. https://pubmed.ncbi.nlm.nih.gov/38037331/
3. Rathleff MS, Molgaard CM, Fredberg U, Kaalund S, Andersen KB, Jensen TT, Aaskov S, Olesen JL. High-load strength training improves outcome in patients with plantar fasciitis: a randomized controlled trial with 12-month follow-up. Scandinavian Journal of Medicine & Science in Sports. 2015;25(3):e292-e300. doi:10.1111/sms.12313. PMID: 25145882. https://pubmed.ncbi.nlm.nih.gov/25145882/
4. Simplicio CL, Purita J, Murrell W, Santos GS, Dos Santos RG, Lana JFSD. Extracorporeal shock wave therapy mechanisms in musculoskeletal regenerative medicine. Journal of Clinical Orthopaedics and Trauma. 2020;11(Suppl 3):S309-S318. doi:10.1016/j.jcot.2020.02.004. PMID: 32523286. https://pubmed.ncbi.nlm.nih.gov/32523286/
5. Sun J, Gao F, Wang Y, Sun W, Jiang B, Li Z. Extracorporeal shock wave therapy is effective in treating chronic plantar fasciitis: a meta-analysis of RCTs. Medicine (Baltimore). 2017;96(15):e6621. doi:10.1097/MD.0000000000006621. PMID: 28403111. PMCID: PMC5403108. https://pubmed.ncbi.nlm.nih.gov/28403111/