The most common medical term for heel pain is plantar fasciitis, which accounts for roughly 80% of heel pain cases and affects about 10% of the population at some point in their lives. But “heel pain” isn’t a single diagnosis. Depending on where exactly it hurts and what’s causing it, your pain could have one of several different names.
Plantar Fasciitis: The Most Common Diagnosis
Plantar fasciitis is inflammation or degeneration of the plantar fascia, a thick band of connective tissue that runs along the bottom of your foot from your heel bone to your toes. This band acts like a bowstring, supporting your arch and absorbing shock with every step. When it’s overloaded, tiny tears develop at the point where the fascia attaches to the heel bone. That damage triggers inflammation, and the result is a sharp, stabbing pain on the underside of the heel.
The hallmark symptom is pain with the first step of the morning. You get out of bed, put your foot down, and feel a jolt of pain that gradually eases as you walk around. The same pattern repeats after any long period of sitting or inactivity. Pain tends to improve with movement but returns at the end of the day after hours on your feet. In the United States alone, plantar fasciitis drives roughly one million doctor visits each year.
If left untreated, the condition can follow one of two paths. Some people develop ongoing chronic inflammation. Others experience a degenerative process where the tissue breaks down and thickens without much active inflammation at all. This distinction matters because treatments that target inflammation won’t always help the degenerative form.
Achilles Tendinitis: Pain at the Back of the Heel
When the pain is at the back of the heel rather than the bottom, the most likely diagnosis is Achilles tendinitis (sometimes called Achilles tendinopathy). The Achilles tendon connects your calf muscles to your heel bone, and repetitive strain from running, jumping, or sudden increases in activity can irritate or damage it. You’ll typically feel a deep ache or stiffness along the back of the heel or just above it, especially after exercise or first thing in the morning.
A related condition is posterior Achilles tendon bursitis, which involves inflammation of a small fluid-filled sac that forms between the skin and the Achilles tendon. This is especially common in young women and is often triggered by rigid shoe backs or high heels. A bony bump on the heel called a Haglund deformity can make bursitis more likely by increasing friction against footwear.
Heel Spurs and Bone-Related Causes
A calcaneal spur (heel spur) is a bony growth on the underside of the heel bone. Heel spurs develop gradually from repeated stress on the foot and are frequently found alongside plantar fasciitis. Many people with heel spurs have no pain at all, which is why the spur itself isn’t always considered the source of the problem. The inflammation of the surrounding soft tissue is usually what hurts.
A calcaneal stress fracture is a less common but more serious possibility. These hairline cracks in the heel bone result from repetitive impact, often in runners or military recruits. Standard X-rays frequently miss stress fractures, so an MRI or bone scan may be needed to confirm the diagnosis.
Heel Fat Pad Syndrome
Your heel has a built-in cushion: a pad of fatty tissue between the skin and the bone that absorbs impact when you walk. Over time, this pad can thin out or lose its elasticity, a condition called heel fat pad syndrome (or fat pad atrophy). The result is a deep, bruise-like ache in the center of the heel that worsens with prolonged standing or walking on hard surfaces.
A normal heel pad measures 1 to 2 centimeters thick. Doctors can assess this by comparing the thickness of your heel pad when you’re standing versus when you’re not. A heel that feels noticeably hard or stiff when pressed suggests the fat pad has lost its cushioning ability. This condition is more common in older adults and people who spend years on their feet.
Tarsal Tunnel Syndrome: Nerve-Related Heel Pain
Not all heel pain comes from bones, tendons, or ligaments. Tarsal tunnel syndrome occurs when the tibial nerve, which runs through a narrow passage on the inside of the ankle, gets compressed or damaged. Instead of the typical aching or stabbing quality of other heel conditions, nerve-related pain tends to feel like burning, tingling, or “pins and needles” along the inside of the ankle or bottom of the foot. You may also notice numbness or weakness in the foot muscles.
MRI is the preferred imaging test for tarsal tunnel syndrome, though nerve conduction studies can also help pinpoint the problem. This condition is sometimes misdiagnosed as plantar fasciitis because the pain location overlaps, but the burning and tingling sensations are key distinguishing features.
Sever’s Disease: Heel Pain in Children
In children and adolescents, the most common cause of heel pain is Sever’s disease (calcaneal apophysitis). It typically affects kids between ages 9 and 13 who play running or jumping sports like soccer, basketball, and gymnastics. The growth plate at the back of the heel is still developing at this age, and repeated traction from the calf muscle irritates that growth center.
The telltale sign is tenderness when squeezing the sides of the heel, with no pain in the Achilles tendon or plantar fascia. Calf tightness is a common contributing factor. X-rays aren’t required for diagnosis and can’t confirm the condition on their own, though they may be ordered to rule out stress fractures or bone cysts. Sever’s disease resolves on its own once the growth plate fully matures, typically by age 14 or 15.
Systemic Conditions That Cause Heel Pain
Occasionally, heel pain isn’t a foot problem at all. It’s a signal from a whole-body condition. Rheumatoid arthritis, an autoimmune disease affecting about 1% of the population, attacks joints throughout the body, and the heel region is a frequent target. In about 20% of people with rheumatoid arthritis, foot and ankle symptoms are the very first sign of the disease. Over the course of the illness, more than 90% of patients develop foot or ankle involvement.
Other systemic conditions that can present as heel pain include ankylosing spondylitis (a type of inflammatory arthritis that primarily affects the spine and large joints) and reactive arthritis. These conditions tend to cause heel pain that doesn’t follow the classic morning-step pattern of plantar fasciitis and may come with joint pain or swelling in other parts of the body.
How Location Helps Identify the Cause
Where exactly you feel the pain is one of the most useful clues for narrowing down the diagnosis:
- Bottom of the heel, near the arch: plantar fasciitis or heel spur
- Center of the heel pad: fat pad atrophy or calcaneal stress fracture
- Back of the heel: Achilles tendinitis, bursitis, or Haglund deformity
- Inside of the ankle radiating to the heel: tarsal tunnel syndrome
- Sides of the heel in a child: Sever’s disease
Imaging is not always necessary. Plantar fasciitis, the most common cause, is typically diagnosed through a physical exam alone. When the pain pattern is unusual, doesn’t improve with standard treatment, or involves nerve symptoms like tingling and burning, imaging with ultrasound or MRI can help rule out less common causes and guide the next steps.