Heel pain is most commonly caused by plantar fasciitis, a degenerative condition of the thick band of tissue that runs along the bottom of your foot. But several other conditions can produce nearly identical symptoms, and knowing where the pain is located, when it strikes, and how it feels helps narrow down what’s actually going on.
Plantar Fasciitis: The Most Common Cause
The plantar fascia is a tough band of connective tissue stretching from your heel bone to your toes. When it’s subjected to repetitive stress, tiny tears develop where the fascia attaches to the heel. Over time, those microtears don’t heal properly. Instead of recovering through normal repair, the tissue degenerates: collagen fibers become disorganized, blood supply to the area decreases, and the cells responsible for rebuilding tissue can’t keep up. The term “fasciitis” actually oversells the role of inflammation. Tissue samples from people with chronic heel pain often show no inflammatory cells at all, just degraded, poorly organized tissue. Some researchers prefer the term “fasciosis” to reflect this.
The hallmark symptom is sharp pain on the bottom of the heel with your first steps in the morning or after sitting for a long time. It often eases once you’ve walked for a few minutes as the tissue warms up, then returns after prolonged standing or activity. On ultrasound, a fascia thicker than 4.0 millimeters at its heel attachment is considered a sign of the condition.
Most people recover within several months using conservative measures: icing, consistent calf and foot stretching, supportive footwear, and avoiding activities that aggravate it. Recovery isn’t fast, and the biggest mistake people make is returning to full activity too soon.
Heel Fat Pad Syndrome
Your heel bone sits on a specialized cushion of fatty tissue that absorbs shock with every step. When that fat pad thins out or loses its elasticity, the heel bone essentially loses its padding. The result is a deep, bruise-like pain in the center of your heel that gets worse when you walk barefoot on hard surfaces, stand for long periods, or do high-impact activities like running or jumping.
This condition is easy to confuse with plantar fasciitis because both cause heel pain. The key difference is location: fat pad pain is felt directly under the center of your heel and can be reproduced by pressing firmly into the middle of it. Plantar fasciitis pain tends to concentrate more toward the inner side of the heel, where the fascia attaches.
Fat pad thinning happens naturally with age, but it can also result from repeated trauma to the heel, wearing shoes with poor cushioning, or even as a side effect of repeated corticosteroid injections into the heel for other foot conditions. Those injections, while effective for short-term pain relief, can accelerate breakdown of the fat pad over time.
Achilles Tendon Problems
The Achilles tendon connects your calf muscles to the back of your heel bone, and pain here falls into two distinct patterns depending on where the damage occurs.
Non-insertional tendinitis affects the middle portion of the tendon, typically in younger, more active people. The tendon fibers break down, swell, and thicken. You’ll feel pain and stiffness a few inches above the heel, often worse during or after exercise.
Insertional tendinitis affects the lower portion where the tendon anchors into the heel bone itself. This type can strike anyone, including people who aren’t particularly active, though it’s most common in those who overuse the tendon through activities like long-distance running. Pain is felt right at the back of the heel and can be aggravated by something as simple as pressing the back of a shoe against that spot.
Nerve Entrapment
A commonly overlooked cause of heel pain is compression of a small nerve branch on the inner side of the heel, sometimes called Baxter’s neuropathy. This nerve runs through a narrow space between muscles in the foot, and it can become pinched as it makes a sharp turn near the heel bone.
The pain from nerve entrapment has a distinct quality: it’s often sharp and radiating rather than dull and achy, and it tends to be worse at night and after activity like walking. Some people notice tingling or a burning sensation along the inner heel. Over time, the small muscle on the outer edge of the foot can visibly shrink from lack of nerve input. People with flat feet or overpronation (feet that roll inward) are more susceptible because their foot structure puts extra pressure on the nerve’s path.
This condition is frequently misdiagnosed as plantar fasciitis, since both produce medial heel pain. If standard plantar fasciitis treatments aren’t working after several months, nerve entrapment is worth investigating.
Stress Fractures of the Heel Bone
The calcaneus, your heel bone, can develop tiny cracks from repetitive impact. This is different from the soft tissue problems above because the bone itself is injured. Stress fractures are most common in runners, military recruits, and anyone who suddenly ramps up high-impact activity.
A simple clinical test involves squeezing the heel from both sides. If this reproduces pain, it suggests a stress fracture rather than a soft tissue problem like plantar fasciitis (which hurts when you press on the bottom of the heel, not the sides). Swelling and bruising around the heel are additional clues. Another telling sign: if you can’t hop on the affected foot without significant pain, a stress fracture becomes more likely.
Heel Spurs: Less Important Than You Think
Heel spurs are bony growths that develop on the underside of the heel bone, and they’re one of the most misunderstood findings in foot care. About 15% of the general population has them, and most people with heel spurs feel no pain at all. When spurs do coincide with pain, it’s typically the surrounding soft tissue damage (like plantar fasciitis) causing the symptoms, not the spur itself. Removing the spur surgically without addressing the underlying tissue problem rarely solves the pain.
Autoimmune and Inflammatory Diseases
Heel pain that develops without an obvious mechanical trigger, particularly in younger adults, can be an early sign of a systemic inflammatory condition. Ankylosing spondylitis and other forms of inflammatory arthritis target entheses, the points where tendons and ligaments attach to bone. The heel has two major entheses (the Achilles tendon attachment and the plantar fascia attachment), making it one of the most commonly affected sites.
This type of heel pain behaves differently from mechanical causes. It’s often worse in the morning and improves with movement rather than rest, can affect both heels, and may be accompanied by lower back stiffness or pain in other joints. Imaging can reveal not just soft tissue swelling but bone marrow edema (fluid buildup inside the bone near the attachment point), a pattern that distinguishes inflammatory enthesitis from ordinary overuse. If your heel pain came on gradually, doesn’t respond to typical treatments, and you also have unexplained back stiffness, an inflammatory condition is worth exploring.
Heel Pain in Children and Teens
In kids between ages 9 and 13, the most common cause of heel pain is Sever’s disease, an irritation of the growth plate at the back of the heel bone. This growth center is where both the Achilles tendon and the plantar fascia attach, making it a stress concentration point during growth spurts.
It’s especially common in young athletes who play running and jumping sports like soccer, basketball, football, baseball, and gymnastics. The pain tends to be worse in cleated shoes or footwear with minimal heel cushioning and arch support. Sever’s disease isn’t dangerous and resolves on its own once the growth plate closes, but managing activity levels and improving footwear can make a significant difference in comfort during the process.
How Location Helps Identify the Cause
- Bottom of the heel, toward the inner side: plantar fasciitis or nerve entrapment
- Dead center of the heel pad: fat pad atrophy
- Back of the heel: Achilles tendon insertional problems or Sever’s disease in children
- Pain when squeezing the heel from both sides: calcaneal stress fracture
- Bilateral heel pain with morning stiffness and back pain: inflammatory arthritis
Paying attention to exactly where it hurts, what makes it worse, and when it started gives you useful information before you ever get imaging or a formal diagnosis. Most heel pain responds well to conservative care, but conditions that mimic plantar fasciitis, like nerve entrapment, stress fractures, or inflammatory disease, require different approaches entirely.