Heel pain most often comes from plantar fasciitis, a degenerative condition affecting the thick band of tissue that runs along the bottom of your foot. But it’s far from the only cause. About 11% of U.S. adults report experiencing heel pain, and that number climbs to roughly one in three people over age 65. The source of the pain depends on where exactly you feel it, what makes it worse, and whether it developed gradually or after an injury.
Plantar Fasciitis: The Most Common Cause
The plantar fascia is a strong band of connective tissue stretching from your heel bone to the base of your toes. It acts like a bowstring supporting your arch with every step. When this tissue breaks down from repetitive stress, you get plantar fasciitis. Despite the name (which implies inflammation), the condition is primarily degenerative. Microscopic tears accumulate over time, and the tissue shows collagen disarray, thickening, and abnormal blood vessel patterns rather than the classic signs of inflammation.
The hallmark symptom is sharp pain with your first few steps out of bed in the morning. That “first-step” pain happens because the fascia tightens overnight, then gets abruptly stretched when you stand. The pain typically eases as you move around, only to return and worsen later in the day as you spend more time on your feet. If the condition progresses far enough, the pain can occur even during rest or sleep.
Risk factors include prolonged standing, excess body weight, tight calf muscles, high arches or flat feet, and activities that pound the heel repeatedly. About one million Americans visit a doctor for plantar heel pain each year.
Achilles Tendon Problems
If your pain is in the back of your heel rather than the bottom, the Achilles tendon is a likely culprit. This tendon connects your calf muscles to your heel bone, and it can break down in two distinct patterns. Insertional tendinopathy affects the spot where the tendon attaches to the heel bone itself. Non-insertional tendinopathy strikes the midsection of the tendon, roughly 2 to 6 centimeters above the heel. Both types cause stiffness and pain that worsen with activity, but the location of your tenderness tells you which type you’re dealing with.
Insertional problems are more common in people who are less active or who have recently increased their activity level. Non-insertional tendinopathy tends to show up in younger, more active individuals. In either case, the underlying process is similar to plantar fasciitis: repetitive strain causes tiny tears that outpace the body’s ability to repair them.
Heel Fat Pad Syndrome
Your heel has a built-in shock absorber: a pad of specialized fat tissue that cushions the bone with every step. Over time, this pad can thin out or become damaged, leaving the heel bone less protected. The pain feels like a deep bruise in the center of the heel, and it gets worse when you walk barefoot on hard surfaces like concrete or tile, stand for long stretches, or do high-impact activities like running or basketball.
Age is the biggest risk factor. The fat pad naturally loses elasticity and thickness as you get older. But wearing shoes with poor cushioning, spending long hours on your feet, and repeated pounding from sports can all accelerate the process. Unlike plantar fasciitis, this pain tends to feel diffuse across the middle of the heel rather than concentrated at one sharp point. Pressing your fingers firmly into the center of the heel reproduces it.
Stress Fractures
A calcaneal stress fracture is a hairline crack in the heel bone itself, caused by repetitive impact rather than a single traumatic event. The pain develops gradually over days to weeks and gets worse with weight-bearing activity. One distinguishing feature: squeezing both sides of your heel at the same time reproduces the pain. This “squeeze test” is a key indicator that the bone, not the soft tissue, is the problem.
Stress fractures are more common in runners, military recruits, and anyone who has suddenly ramped up their activity level. People with low bone density, including postmenopausal women, are also at higher risk. If rest doesn’t improve your heel pain after a couple of weeks, or if the pain is severe enough that you’re limping, a stress fracture is worth investigating.
Nerve Entrapment
Not all heel pain is musculoskeletal. Tarsal tunnel syndrome occurs when a nerve running along the inside of your ankle gets compressed, sending pain, burning, tingling, or numbness into the bottom of your foot and heel. The sensation is often described as electric or pins-and-needles, which is a clear distinction from the sharp, localized ache of plantar fasciitis. Plantar fasciitis does not cause numbness or tingling, so if you’re experiencing those symptoms, nerve involvement is more likely.
Nerve pain can be tricky because it sometimes mimics other conditions or overlaps with them. The burning or tingling may come and go, worsen at night, or radiate from the ankle downward. Anything that increases pressure on the nerve, including flat feet, swelling from an ankle injury, or a cyst near the nerve, can trigger it.
The Heel Spur Myth
Many people assume a bony heel spur is causing their pain. In reality, heel spurs are surprisingly common in people who feel perfectly fine. About 11 to 16% of the general adult population has a visible heel spur on X-ray with no symptoms at all. Among people who do have heel spurs, less than 5% actually experience pain from them. The spur itself is usually a byproduct of long-term tension on the plantar fascia, not the direct source of pain. Treating the underlying soft tissue problem almost always matters more than addressing the spur.
Inflammatory and Autoimmune Conditions
Heel pain can also be an early sign of a systemic inflammatory condition. Diseases like ankylosing spondylitis and reactive arthritis cause enthesitis, which is inflammation at the points where tendons and ligaments attach to bone. The heel is one of the most common sites affected. This type of heel pain tends to be more severe, can occur in both heels, and is often accompanied by stiffness that’s worse in the morning and improves with movement.
Rheumatoid arthritis more commonly causes bursitis, a swelling of the fluid-filled sac near the Achilles tendon, particularly in women. This tends to produce milder heel pain compared to enthesitis. If your heel pain comes with other joint symptoms, back stiffness, or eye inflammation, an inflammatory condition may be driving it.
Heel Pain in Children
In kids between 8 and 15 years old, the most common cause of heel pain is Sever’s disease, a condition affecting the growth plate at the back of the heel bone. It’s the single most frequent musculoskeletal complaint in active children within that age range. The growth plate is softer and more vulnerable to stress than mature bone, so repetitive running, jumping, and cutting motions can irritate it.
The classic diagnostic test involves squeezing both sides of the child’s heel. If this reproduces the pain, Sever’s disease is the likely diagnosis. The condition is self-limiting, meaning it resolves once the growth plate fully hardens, but managing activity levels and using supportive footwear helps control pain in the meantime.
How to Narrow Down Your Cause
Where you feel the pain is the single most useful clue. Pain on the bottom of the heel, especially with those first morning steps, points strongly to plantar fasciitis. Pain at the back of the heel suggests Achilles tendon issues. A deep, bruise-like ache across the center of the heel, particularly on hard surfaces, fits fat pad syndrome. Tingling, burning, or numbness anywhere in the heel or sole signals nerve involvement.
How the pain behaves also matters. Pain that’s worst in the morning and loosens up with walking is classic for plantar fasciitis. Pain that builds steadily over weeks and hurts when you squeeze the sides of your heel raises concern for a stress fracture. Pain that worsens at night or includes electric sensations leans toward nerve entrapment. And heel pain that shows up alongside joint stiffness or swelling elsewhere in the body warrants evaluation for an inflammatory condition.
Heel pain that doesn’t respond to a few weeks of rest and basic home care, pain so severe you can’t walk normally, or heel pain accompanied by fever, swelling, or numbness all warrant a medical evaluation. Sudden, severe heel pain immediately after an injury, or the inability to bend your foot or rise onto your toes, needs prompt attention.