Heel pain most often comes from plantar fasciitis, a condition where the thick band of tissue running along the bottom of your foot breaks down from repetitive stress. But several other conditions can cause pain in the same area, and the specific location and quality of your pain points toward the cause. Pain under the heel, behind the heel, and deep in the center of the heel each suggest different problems.
Plantar Fasciitis
The plantar fascia is a strong band of tissue connecting your heel bone to your toes. It supports the arch of your foot every time you stand or walk. When that tissue is stressed repeatedly, tiny tears develop where it attaches to the heel bone. Over time, the tissue degenerates rather than healing properly. Blood flow to the damaged area decreases, making it harder for your body to repair the tissue and rebuild its structure. This is why plantar fasciitis tends to linger: it’s less about active inflammation and more about tissue that can’t keep up with the damage it’s absorbing.
The hallmark symptom is a stabbing pain under the heel with your first steps in the morning or after sitting for a long time. It often improves once you’ve been walking for a few minutes, then worsens again after extended time on your feet. Runners are particularly prone to it, but anyone who spends long hours standing, has tight calf muscles, carries extra weight, or wears unsupportive shoes can develop it.
The good news is that up to 90% of cases resolve with nonsurgical treatment. A typical approach starts with six weeks of daily icing, stretching, and supportive insoles. If pain persists, night splints or injections may be added for another six weeks. Most people recover fully, though it can take several months.
Heel Spurs Are Rarely the Problem
Many people assume a bone spur on the heel is causing their pain, especially if one shows up on an X-ray. But heel spurs appear in 10% to 63% of people who have no foot pain at all. The spur itself is usually a byproduct of long-term stress on the plantar fascia, not an independent source of pain. If you’ve been told you have a heel spur, the underlying cause of your pain is almost always the soft tissue around it, not the spur itself.
Achilles Tendon Pain
If your pain is at the back of the heel rather than underneath it, the Achilles tendon is the likely culprit. This tendon connects your calf muscles to your heel bone and handles enormous force during walking, running, and jumping. Damage can develop in the middle portion of the tendon or right where it attaches to the heel bone. The attachment point (insertional tendinopathy) causes pain directly at the back of the heel and is common in people who are less active or who suddenly increase their activity level.
Achilles pain typically worsens with activity, especially pushing off while walking or climbing stairs. You may notice stiffness in the morning that loosens up as you move. Unlike plantar fasciitis, which hurts most with the first few steps, Achilles problems tend to build throughout the day.
Retrocalcaneal Bursitis
A small fluid-filled sac sits between the Achilles tendon and the heel bone, cushioning the two structures as they move against each other. When this sac becomes irritated, it swells and causes pain at the back of the heel that can easily be confused with Achilles tendon problems. The key differences: bursitis often produces visible redness and swelling on the back of the heel, and the pain tends to be more constant rather than activity-dependent. Stiffness and difficulty rotating the ankle are also common. Tight or rigid shoes that press against the back of the heel are a frequent trigger.
Fat Pad Syndrome
Your heel bone sits on a cushion of fat tissue that absorbs shock with every step. Over time, or due to certain medical treatments, this fat pad thins out or loses its elasticity. The result is a deep, bruise-like pain in the center of the heel that worsens when you walk on hard surfaces, go barefoot, or do high-impact activities like running or jumping.
Normal heel pad thickness is 1 to 2 centimeters. When the pad thins beyond this range or becomes stiff, it no longer protects the bone beneath it. Aging is the most common cause, but repeated corticosteroid injections into the heel (often given for other foot conditions) can accelerate the breakdown. A provider can check for this by comparing the thickness and firmness of your heel pad when you’re standing versus when weight is off the foot.
Fat pad pain and plantar fasciitis are easy to confuse because both cause pain under the heel. The difference is location: plantar fasciitis pain concentrates where the fascia attaches (slightly forward of center, toward the arch), while fat pad pain is reproduced by pressing directly into the center of the heel.
Nerve Compression
Tarsal tunnel syndrome occurs when a nerve in the ankle (the tibial nerve) gets compressed as it passes through a narrow passageway made of bones and ligaments. The pain shows up on the inside of the ankle or the bottom of the foot, but what sets it apart from other heel conditions is the quality of the sensation. Burning, tingling, pins-and-needles feelings, and numbness point toward nerve involvement rather than tissue or bone damage. Some people also notice weakness in the foot muscles. Because the symptoms can overlap with plantar fasciitis, tarsal tunnel syndrome is sometimes missed on an initial evaluation.
Stress Fractures
The heel bone (calcaneus) can develop small cracks from repetitive impact, particularly in runners, military recruits, and anyone who rapidly increases their activity level. A stress fracture causes pain that worsens steadily with weight-bearing activity and doesn’t improve with the stretching or insoles that help plantar fasciitis. Squeezing the sides of the heel often reproduces the pain, which is a useful clue since plantar fasciitis doesn’t respond to that kind of pressure. Standard X-rays can miss stress fractures, so an MRI is often needed to confirm the diagnosis.
Heel Pain in Children
Children between ages 9 and 13, especially those who are active in sports, can develop a condition called Sever’s disease. The heel bone has a growth plate that hasn’t fully hardened yet, and repetitive stress from running and jumping irritates it. The pain is at the back of the heel (not in the Achilles tendon or under the foot), and it’s tender when you press directly on it. X-rays aren’t necessary for diagnosis, though they may be ordered to rule out a stress fracture or bone cyst. Sever’s disease resolves on its own once the growth plate matures, but reducing activity and using heel cushions can help manage pain in the meantime.
Systemic Conditions
Sometimes heel pain isn’t caused by a local injury but by a condition affecting the whole body. Rheumatoid arthritis attacks joints on both sides of the body, and the feet and ankles are involved in more than 90% of people with the disease over its course. In roughly 20% of cases, foot and ankle symptoms are actually the first sign of rheumatoid arthritis. If you have heel pain in both feet, particularly with joint stiffness and swelling, a systemic cause is worth considering.
Gout can also strike the heel, causing sudden, intense pain and swelling when uric acid crystals accumulate in the joint. Ankylosing spondylitis, a type of inflammatory arthritis affecting the spine, frequently causes pain where tendons attach to bone, and the heel is one of the most common sites. These conditions are less common than plantar fasciitis, but they’re important to recognize because they require different treatment.
How Pain Location Narrows the Cause
- Under the heel, toward the arch: plantar fasciitis
- Dead center of the heel bottom: fat pad syndrome
- Back of the heel: Achilles tendinopathy or retrocalcaneal bursitis
- Sides of the heel (worse with squeezing): stress fracture
- Inside of the ankle or bottom of the foot with tingling: tarsal tunnel syndrome
- Both heels with joint stiffness: systemic inflammatory condition