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Heel Spur or Plantar Fasciitis? How to Tell the Difference
Heel pain sends more people to a podiatrist than almost any other foot complaint, and two conditions get blamed for it more than anything
Medically Reviewed by
Dr. Paul Hanna, DO, RPVI
Board Certified Vascular Surgeon
Roughly 80 percent of lower limb amputations in the United States happen because of complications from diabetes. Most of them trace back to the same root problem, blood flow to the leg or foot has dropped so low that tissue starts to die. What a lot of patients don’t realize is that amputation is often a last resort, not the first option. Limb salvage surgery exists specifically to avoid it.
Limb salvage is the term vascular surgeons use for the combination of procedures aimed at restoring circulation and healing damaged tissue so a leg or foot can be saved. For a multispecialty practice like ours, it sits at the intersection of vascular surgery, podiatry, and wound care, and it’s one of the areas where early referral makes the biggest difference in outcome.
Amputation rates have also become a health equity issue worth naming directly. Diabetes related amputations nearly doubled in the United States between 2009 and 2019, and they don’t fall evenly across the population. People living in the Southern United States have the highest rates, often tied to limited access to care in rural areas, and Black adults with diabetes face substantially higher amputation rates than White or Hispanic adults with diabetes.
Limited health literacy and other social barriers to care compound the problem further. None of that changes the medical facts of any individual case, but it’s part of why early screening and access to a vascular surgeon matter so much.
Limb salvage isn’t a single operation. It’s a treatment approach built around one goal, restore enough blood flow to a leg or foot that its tissue can heal and function stays intact. Depending on the patient, that might mean opening a blocked artery with a stent, building a new pathway for blood with a bypass graft, clearing away dead or infected tissue, or some combination of all three.
The underlying condition that drives most limb salvage cases is called chronic limb threatening ischemia, or CLTI. It’s an advanced stage of peripheral artery disease, the same disease that causes leg cramping when walking in its earlier stages. In CLTI, artery blockages become severe enough that blood barely reaches part of the leg or foot even at rest. About 1 or 2 out of every 10 people with peripheral artery disease eventually develop CLTI, and once they do, the risk of amputation, heart complications, and death all rise sharply.
Peripheral artery disease narrows the arteries that carry blood to the legs and feet, usually because of plaque buildup along the artery walls. As that plaque accumulates, less oxygen-rich blood reaches the tissue below the blockage. A small cut or blister that would heal in days for most people can instead sit open for weeks, since the tissue around it doesn’t have the blood supply it needs to repair itself.
Diabetes complicates this picture further. High blood sugar over time damages nerves in the feet, a condition called peripheral neuropathy, so a patient may not even feel a cut, sore, or ulcer forming. Telling this kind of nerve pain apart from circulation pain is its own challenge, one we cover in more detail in PAD vs. peripheral neuropathy.
Combine reduced blood flow with reduced sensation, and a minor injury can progress to a serious infection before anyone notices it. That combination, poor circulation plus poor sensation, is the primary pathway that leads to amputation, which is why diabetes and peripheral artery disease together account for the overwhelming majority of cases we see.
The hallmark symptom of chronic limb threatening ischemia is pain in the foot or leg that happens at rest, not just with activity. It often gets worse when the leg is raised or when lying flat, and it can be intense enough to wake a patient up at night. Some people find that hanging the affected leg off the edge of the bed, or getting up and walking a short distance, temporarily eases the pain because gravity helps pull a small amount of extra blood down to the foot.
Not everyone feels pain, though. Some patients notice non-healing wounds, or skin that looks purple, gray, or black in the affected area, a sign that tissue has started to die. Any of these signs, rest pain, a non-healing wound, or visible tissue death, should prompt an urgent evaluation rather than a wait and see approach. The condition is called chronic because symptoms tend to persist for more than two weeks, but that doesn’t mean it’s safe to delay care while waiting to see if things improve on their own.
Diagnosis usually starts with a physical exam checking the pulses in the legs and feet, since a weak or missing pulse is often the first clue. 
From there, a vascular surgeon typically orders a few noninvasive tests to measure exactly how much blood is reaching the limb.
These tests give a surgeon a clear picture of how severe the blockage is and where it sits, which shapes every decision that follows about how to restore blood flow.
Once testing confirms the location and severity of a blockage, treatment focuses on getting blood back to the tissue that needs it. Most patients need some form of revascularization, the general term for procedures that reopen or reroute blood flow around a blocked artery.
For many blockages, a minimally invasive approach works well. A surgeon threads a thin catheter with a small balloon to the site of the blockage as part of an angiogram, angioplasty, or stenting procedure, inflates it to widen the artery, and often places a small mesh tube called a stent to help keep the artery open afterward. This can frequently be done without a large incision, which usually means a shorter recovery than open surgery.
When a blockage is too long, too calcified, or otherwise not a good fit for angioplasty, bypass surgery creates a new route for blood to travel around it. A surgeon uses a healthy blood vessel, sometimes taken from elsewhere in the patient’s own body, or a synthetic graft, and connects it above and below the blocked segment. Blood then flows through the new pathway instead of the diseased artery. We’ve written more about how the two approaches compare in angioplasty vs. bypass surgery.
Restoring blood flow is often only half the job. If a foot or leg wound has already developed, it needs direct attention too. That usually involves debridement to remove dead or infected tissue, targeted antibiotics if infection is present, and a structured wound care plan to support healing once circulation has improved. This is where close coordination between vascular surgery and podiatry tends to matter most, since podiatrists managing diabetic foot ulcers often handle the day to day wound care that follows a revascularization procedure.
For a small number of patients whose arteries can’t be reopened through angioplasty or bypass, a newer option called venous arterialization connects an artery to a vein to deliver oxygen rich blood to the foot through a different route entirely. It’s not the first choice for most patients, but it has extended limb salvage to people who previously had few options left.
Chronic limb threatening ischemia is not a condition where waiting tends to help. Without treatment, tissue damage generally progresses, and the data reflects that urgency. Up to 1 in 3 people with this condition need a major amputation, meaning above the ankle, within one year of diagnosis if it isn’t addressed. That statistic cuts the other way too. The majority of patients who get evaluated and treated promptly do not end up needing a major amputation.
Vascular surgeons are the only specialists trained and equipped to offer the full range of CLTI treatment, from medical management through minimally invasive procedures to open surgery. Medical societies that set the treatment standards for this condition recommend that anyone with suspected chronic limb threatening ischemia be referred urgently for evaluation rather than managed on a routine timeline. Early referral consistently leads to better outcomes, both for saving the limb and for the patient’s overall health.
Anyone with peripheral artery disease can potentially develop chronic limb threatening ischemia, but certain factors raise that risk further. Age over 75, continuing to smoke after a peripheral artery disease diagnosis, having diabetes, chronic kidney disease, or atherosclerosis elsewhere in the body such as the heart or brain arteries, all increase the likelihood of progression.
People managing several of these risk factors at once benefit from more frequent foot checks and closer monitoring, since catching a problem early gives far more treatment options than catching it late. Diabetic complications like Charcot foot can also mask or mimic circulation problems, which is another reason a coordinated podiatry and vascular evaluation matters for these patients.
Peripheral artery disease is most treatable in its earlier stages, well before it progresses to chronic limb threatening ischemia. Managing the condition early usually involves a combination of medication, structured exercise therapy supervised by a provider, heart healthy eating, and quitting smoking if you smoke. Each of these steps slows the plaque buildup that eventually narrows the arteries feeding the legs and feet.
Daily foot care deserves its own mention, especially for anyone with diabetes. Checking your feet every day for cuts, color changes, or swelling catches small problems while they’re still small. Washing and drying your feet fully, moisturizing to prevent cracked skin, wearing well fitting shoes, and having a podiatrist handle corns, calluses, or ingrown toenails all reduce the odds that a minor foot issue turns into the kind of wound that eventually threatens the limb.
Limb salvage doesn’t end once blood flow is restored. Most patients continue on medications that keep arteries open and lower the risk of future blockages, including antiplatelet drugs to prevent clotting and statins to slow plaque buildup. Diabetes and blood pressure management remain part of ongoing care as well, since these conditions drove the original blockage and will keep working against a patient’s arteries if left unmanaged.
Recovery also typically involves a team rather than a single provider. Vascular surgeons, podiatrists, wound care specialists, and sometimes physical therapists all play a role in helping a patient heal and stay mobile. Proper footwear, custom orthotics, and daily foot checks at home become part of the routine, aimed at preventing the next wound before it starts rather than treating one after the fact.
Anyone with foot or leg pain that occurs at rest, a wound on the foot or leg that hasn’t improved in a couple of weeks, or skin that has changed color or texture on the lower leg should be evaluated promptly. This is especially true for patients who already have diabetes or a known history of peripheral artery disease, since their margin for delay is smaller.
Getting evaluated doesn’t automatically mean surgery. Our limb salvage team can determine exactly how much blood flow is reaching the limb, explain which treatment options apply to your specific case, and build a plan around saving the leg whenever that’s medically possible. The earlier that conversation happens, the more options are usually still on the table.
It’s also worth saying plainly that in a small number of cases, tissue damage is too extensive for limb salvage to succeed, and amputation becomes the safer path forward for the patient’s overall health. When that happens, it’s a decision made carefully and never as a first option. Advances in prosthetics and physical therapy mean most people who need an amputation go on to live full, mobile lives afterward, and a good care team stays involved through that recovery too.
Not in every case, but many limbs that appear seriously at risk can be saved when blood flow is restored early. Outcomes depend on how much tissue damage has already occurred and how quickly treatment starts, which is why early evaluation matters so much.
Procedures are done with anesthesia, and pain afterward is managed with medication and typically improves within days to a couple of weeks depending on the specific procedure performed.
Recovery from open bypass surgery generally takes several weeks, while minimally invasive procedures like angioplasty often allow a quicker return to normal activity. Your surgical team will give you a recovery timeline specific to your procedure.
Yes. Some patients need repeat procedures over time if an artery narrows again or a new blockage develops elsewhere. Ongoing monitoring after the first procedure helps catch these issues early.
Limb salvage aims to restore blood flow and heal tissue so the leg or foot can be kept. Amputation removes damaged tissue that can’t be saved. Amputation is considered only when limb salvage isn’t medically possible or when it’s the safer option for the patient’s overall health.
Centers for Disease Control and Prevention, “Preventing Diabetes-Related Amputations”
Cleveland Clinic, “Chronic Limb-Threatening Ischemia (Formerly Known as Critical Limb Ischemia)”
Society for Vascular Surgery, “Patients with Chronic Limb-Threatening Ischemia (CLTI)”
Mayo Clinic, “Peripheral artery disease (PAD) – Diagnosis and treatment”
Dr. Paul Hanna is a board-certified vascular surgeon with specialized fellowship training in complex vascular interventions and minimally invasive endovascular techniques. He serves as Director of Vascular Surgery and General Surgery at South Florida Multispecialty Medical Group, with over a decade of experience treating vascular conditions affecting the limbs, aorta, and peripheral arterial system.
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