The most likely reason your heels hurt is plantar fasciitis, which accounts for roughly 80% of heel pain cases. It causes a stabbing pain in the bottom of your foot near the heel bone, and it’s typically worst with your first steps in the morning. But several other conditions can produce severe heel pain, and knowing which one you’re dealing with changes what you should do about it.
Plantar Fasciitis: The Most Common Cause
The plantar fascia is a thick band of tissue running along the bottom of your foot, connecting your heel bone to your toes. When it becomes irritated or develops small tears, you get plantar fasciitis. The hallmark symptom is pain that’s worst when you first get out of bed. While you sleep, the fascia tightens in a shortened position. When you stand up and stretch it under your full body weight, those first few steps feel like stepping on a nail.
The pain usually eases as you walk around and the tissue warms up, but it often returns after long periods of standing or when you get up from sitting. This “pain after rest” pattern is the single most reliable clue that plantar fasciitis is your problem. If stretching temporarily reduces the pain, that’s another strong indicator.
Risk factors include being on your feet all day (especially on hard surfaces), a sudden increase in activity, tight calf muscles, excess body weight, and shoes with poor arch support. It’s most common between ages 40 and 60, though runners and anyone who spends hours standing can develop it earlier.
Achilles Tendinitis: Pain at the Back of the Heel
If your pain is behind the heel rather than underneath it, Achilles tendinitis is a likely culprit. This comes in two forms. Insertional Achilles tendinitis affects the lower part of the heel where the tendon attaches directly to the bone, and it can hurt even without heavy activity. Non-insertional tendinitis involves the middle portion of the tendon, higher up from the heel, where fibers start to break down, swell, and thicken. You might notice a visible bump or thickening in the tendon itself.
Both types tend to worsen with activity rather than improve with it, which is one way to distinguish Achilles problems from plantar fasciitis. Stiffness in the morning is common, but the pain pattern through the day is different: it builds as you move more, rather than fading.
Heel Fat Pad Thinning
Your heel has a built-in shock absorber: a specialized fat pad that cushions the bone against the ground. This pad naturally thins with age, and when it does, every step transmits more impact directly to the bone. Research published in Pain Physician found that people without heel pain had fat pads averaging about 10.4 mm thick, while those with heel pain averaged just 7.2 mm. The critical threshold was roughly 8.8 mm overall, with slightly different cutoffs for men (9.2 mm) and women (8.2 mm).
Fat pad pain feels like a deep bruise directly under the center of your heel, and it tends to hurt more on hard surfaces and when barefoot. Unlike plantar fasciitis, it doesn’t have that dramatic “first step” pain pattern. It gets worse the longer you’re on your feet, period. Cushioned shoes and heel cups help because they replace some of the natural padding you’ve lost.
Stress Fractures and Nerve Entrapment
A calcaneal stress fracture is a small crack in the heel bone itself, usually from overuse or a sudden jump in activity. It can mimic plantar fasciitis, but there are key differences. Stress fracture pain gets worse as you move and improves when you stop, the opposite of plantar fasciitis. You may also notice swelling around the heel. A simple test: squeeze the sides of your heel bone between your thumb and fingers. If that side-to-side squeeze reproduces the pain, a stress fracture is more likely than a soft tissue problem.
Nerve entrapment is less common but worth knowing about. A condition called Baxter’s nerve entrapment involves a small nerve on the inner side of the heel getting compressed. It produces a sharp, radiating pain that’s often worse at night and after physical activity. You might feel tingling or numbness spreading outward from the inner heel. This pain doesn’t respond to typical plantar fasciitis treatments like stretching, which is often the first clue that something else is going on.
What Actually Helps
For the vast majority of heel pain (plantar fasciitis and related soft tissue problems), the first-line approach is straightforward: relative rest, calf and fascia stretching, and supportive footwear. Rolling a frozen water bottle under your foot for 15 to 20 minutes provides both stretch and ice at the same time. Calf stretches held for 30 seconds, repeated several times a day, address the tightness that pulls on the fascia.
If you’re considering orthotics, here’s something worth knowing: a Harvard Health analysis of 20 randomized controlled studies involving about 1,800 people found no difference in short-term pain relief between custom-made orthotics and store-bought versions. So before spending hundreds on custom insoles, try a well-made over-the-counter insert with good arch support. Many people get meaningful relief for under $40.
Most plantar fasciitis resolves within 6 to 12 months with consistent stretching, appropriate footwear, and activity modification. For cases that don’t respond, shockwave therapy is an option that works without surgery. Studies show a success rate of about 63% in the short term, climbing to 80% with longer follow-up. Sessions are typically once a week for six weeks and don’t require anesthesia.
How to Tell Your Pain Apart
The pattern of your pain is the most useful diagnostic clue you have:
- Worst with first morning steps, improves with walking: plantar fasciitis
- Worse with activity, better with rest: stress fracture or Achilles tendinitis
- Deep bruise feeling that worsens on hard floors: fat pad thinning
- Sharp, radiating pain worse at night with tingling: nerve entrapment
- Pain at the back of the heel with visible swelling: Achilles tendinitis
Signs That Need Prompt Attention
Most heel pain is manageable at home, but certain symptoms warrant immediate medical evaluation: severe pain and swelling near the heel right after an injury, inability to bend your foot downward or rise on your toes, inability to walk normally, or heel pain accompanied by fever and numbness or tingling. These can signal a ruptured tendon, a significant fracture, or an infection, all of which need treatment beyond rest and stretching.