The most common reason your heel hurts is plantar fasciitis, an irritation of the thick band of tissue that runs along the bottom of your foot from your heel to your toes. But several other conditions cause heel pain too, and where exactly you feel the pain, when it’s worst, and how it started can help you narrow down what’s going on.
Plantar Fasciitis: The Most Likely Cause
Plantar fasciitis accounts for the majority of heel pain cases. The hallmark symptom is pain with your first steps in the morning or after sitting for a while. That initial sharp or achy feeling in your heel typically eases up after a few minutes of walking as the tissue loosens. Moving around might temporarily relieve your pain, but it often comes back as soon as you stop or after prolonged time on your feet.
The pain tends to sit near the inner part of your heel, closer to your arch, rather than dead center. It can extend into the arch itself. You’ll usually notice it in one foot, though both can be affected. People who spend long hours standing, have recently increased their activity level, or have tight calf muscles are especially prone to it.
Most people recover in several months with conservative measures: icing, stretching, and dialing back activities that aggravate the pain. A structured calf and heel raise program can speed things along. One well-studied approach starts with isometric heel raises (lifting your heels an inch or two off the floor and holding for 30 to 60 seconds, three sets), then progresses to full heel raises on a flat surface, then on a step, and eventually single-leg heel raises on a step. Each rep follows a slow tempo: three seconds up, a two-second hold at the top, and three seconds back down, for 12 reps per set, performed every other day. Keeping your knees slightly bent throughout loads the tissue more effectively.
Pain at the Back of the Heel
If your pain is at the back of your heel rather than the bottom, the Achilles tendon is the more likely culprit. Insertional Achilles tendonitis affects the spot where the tendon attaches to the heel bone and can happen at any activity level, though runners are most susceptible. Tight calf muscles place extra stress on this attachment point, and bone spurs sometimes develop there over time. You might also notice a bony bump at the back of the heel, a condition called Haglund’s deformity, where the enlarged bone rubs against the tendon and causes inflammation.
Non-insertional Achilles tendonitis sits higher, in the middle portion of the tendon above the heel. It tends to show up in younger, active people. In either case, the pain typically worsens with activity and may feel stiff first thing in the morning.
Fat Pad Atrophy: A Bruise-Like Ache
Your heel has a built-in shock absorber: a pad of fatty tissue normally 1 to 2 centimeters thick. Over time, or with repetitive impact, this pad can thin out or lose its elasticity. The result is a deep, bruise-like pain right in the center of your heel when you walk, stand, or run. You can often reproduce it by pressing firmly into the middle of your heel with your thumb.
This condition differs from plantar fasciitis in a few important ways. The pain location is more centered rather than toward the inner heel. It gets worse when you walk barefoot on hard surfaces like hardwood or concrete. It’s also more likely to bother you at night and at rest, and it tends to affect both feet. Plantar fasciitis pain, by contrast, is worst with those first morning steps and typically improves initially with movement.
Nerve Entrapment
Up to 20% of chronic heel pain cases are caused by a compressed nerve near the heel, a condition often called Baxter’s nerve entrapment. It’s frequently overlooked because the symptoms overlap with plantar fasciitis. The key differences: the pain tends to be sharp and radiating rather than purely achy, it often worsens at night and after physical activity, and you may feel tingling or numbness spreading toward the outer edge of your foot. Tenderness is typically along the inner side of the heel bone, and pressing on that area can trigger pain that shoots laterally.
Stress Fractures
A stress fracture of the heel bone is less common but worth knowing about, especially if your pain developed gradually over days to weeks and doesn’t match the typical morning-pain pattern of plantar fasciitis. The pain is more generalized across the heel and tends to worsen with any weight-bearing activity. A simple test that often points toward a stress fracture: squeeze both sides of your heel with your hands. If that side-to-side compression reproduces your pain, a stress fracture is a real possibility and imaging is warranted.
What About Heel Spurs?
Many people worry that a heel spur is causing their pain, but the relationship between spurs and symptoms is much weaker than you’d expect. Studies of people with no heel pain at all have found that 11 to 16% of them have plantar heel spurs on X-ray, and some research puts that number as high as 30%. A spur showing up on an image doesn’t mean it’s the source of your problem. In most cases, the soft tissue irritation around the spur is what actually hurts, and treatment focuses on that inflammation and tension rather than the spur itself.
Insoles and Orthotics
Shoe inserts are one of the most common recommendations for heel pain, and they do help many people. What might surprise you: there’s no strong evidence that expensive custom orthotics work better than good-quality prefabricated insoles for plantar fasciitis. The research comparing the two has significant gaps, and multiple experts in podiatric sports medicine have acknowledged that while orthotics play a role in managing heel pain, the published evidence doesn’t support custom devices being superior to well-made over-the-counter options. Starting with a quality prefabricated insert is a reasonable first step before investing in custom-molded ones.
How to Tell What You’re Dealing With
A few patterns can help you sort through the possibilities:
- Pain on the bottom of the heel, worst with first morning steps, easing with movement: plantar fasciitis
- Deep, bruise-like pain in the center of the heel, worse barefoot on hard floors: fat pad atrophy
- Pain at the back of the heel, especially with activity: Achilles tendonitis
- Sharp, radiating pain worse at night, with tingling: possible nerve entrapment
- Generalized heel pain that developed over weeks, worse with the squeeze test: possible stress fracture
Heel pain that responds to rest, stretching, icing, and supportive footwear within a few weeks is likely soft tissue inflammation that will resolve with continued conservative care. Pain that persists beyond two to three months, wakes you at night, involves numbness or tingling, or came on after a sudden increase in high-impact activity deserves a closer look with imaging or a specialist evaluation.