The most common reason your heel hurts is plantar fasciitis, a condition where the thick band of tissue running along the bottom of your foot becomes inflamed or overstretched. But it’s not the only possibility. Where exactly the pain is, when it shows up, and what it feels like can point to several different causes, some of which need very different treatment approaches.
Plantar Fasciitis: The Most Likely Cause
Plantar fasciitis accounts for the majority of heel pain complaints. The plantar fascia is a strong band of connective tissue that runs from your heel bone to the base of your toes, supporting your arch with every step. When it’s overused or stretched beyond what it can handle, it swells and becomes painful, typically right at the spot where it attaches to the bottom of the heel.
The hallmark symptom is pain during your first steps in the morning or after sitting for a long time. That’s because the fascia tightens while you’re off your feet, then gets yanked back into service before it’s ready. The pain often eases after a few minutes of walking as the tissue loosens up, only to return after extended time on your feet.
Body weight plays a significant role. A meta-analysis in the British Journal of Sports Medicine found that people with a BMI above 27 were roughly 3.7 times more likely to develop plantar fasciitis than those at a lower weight. That association was strongest in non-athletes, meaning everyday activity combined with extra load on the feet is a powerful driver. Other risk factors include jobs that require long hours of standing, a sudden increase in exercise intensity, and wearing flat, unsupportive shoes.
The good news is that up to 90% of cases resolve with non-surgical treatment within 6 to 12 months. Stretching your calves and strengthening the foot are the foundation of recovery. A simple wall-facing calf stretch (holding for 20 seconds, three repetitions per leg, once daily) can reduce tension on the fascia. Heel raises at the edge of a step, slowly lowering your heels below the step and rising back up (two sets of 10, once daily), build the tissue’s tolerance to load over time.
Heel Fat Pad Syndrome
Your heel has a built-in shock absorber: a cushion of fatty tissue about 1 to 2 centimeters thick. When that pad thins out or loses its elasticity, walking feels like stepping directly on bone. This condition is the second leading cause of heel pain after plantar fasciitis, and it’s frequently misdiagnosed as plantar fasciitis because the pain is in a similar area.
The difference is in the details. Fat pad pain feels like a deep bruise in the center of the heel rather than at the front edge. It gets worse on hard surfaces like concrete, hardwood floors, or tile, and it’s more painful when you’re barefoot. If you press firmly into the middle of your heel and can reproduce a deep, aching pain, that’s a strong clue. Unlike plantar fasciitis, the pain doesn’t follow a clear “worst in the morning, better after walking” pattern. It tends to build steadily the longer you’re on your feet.
Fat pad thinning is more common in older adults, people who spend years in high-impact activities, and those who frequently wear very thin-soled shoes. A healthcare provider can compare the thickness of your heel pad while standing versus sitting to assess whether the cushion has lost its structure.
Achilles Tendonitis
If your pain is at the back of the heel rather than the bottom, the Achilles tendon is the likely culprit. Insertional Achilles tendonitis involves inflammation right where the tendon attaches to the heel bone. You’ll notice tenderness when you press on the back of the heel, and there may be a noticeable bump from calcium buildup or a bone spur forming at the attachment point.
This type of heel pain tends to worsen with activity, especially running, climbing stairs, or pushing off while walking. It’s different from mid-tendon problems, which cause pain higher up in the back of the leg. Tight calves, a rapid increase in training volume, and shoes that press against the back of the heel all contribute.
Stress Fractures
A stress fracture in the heel bone (calcaneus) causes a more constant, worsening pain that doesn’t improve much with rest once it’s established. Unlike soft tissue injuries, the pain tends to increase steadily over days or weeks rather than following a predictable daily pattern.
One useful indicator is the squeeze test. If squeezing both sides of your heel with your hands produces sharp tenderness, that’s a classic sign of a calcaneal stress fracture. This kind of injury typically happens after a significant increase in weight-bearing activity, especially running or jumping on hard surfaces. Recovery generally takes 9 to 12 weeks and involves an initial period of staying off the foot, followed by a gradual return to activity.
Nerve Entrapment
When heel pain comes with burning, tingling, numbness, or “pins and needles” sensations, a nerve problem is likely involved. Tarsal tunnel syndrome occurs when the nerve that runs along the inside of your ankle gets compressed as it passes through a narrow space near the ankle bone. The resulting pain shows up on the inside of the ankle or the bottom of the foot, and it can radiate into the toes.
Nerve-related heel pain feels distinctly different from the aching or sharp mechanical pain of plantar fasciitis or a stress fracture. People describe it as electric, burning, or accompanied by a sensation of weakness in the foot muscles. It often worsens with prolonged standing or walking and may flare up at night.
Heel Pain in Children
If your child is complaining of heel pain, the most likely cause is Sever’s disease (calcaneal apophysitis), which is extremely common between ages 8 and 14. It’s not actually a disease. It’s an irritation of the growth plate at the back of the heel bone, and it happens because children’s bones are still forming. The ends of growing bones are made of cartilage, which is softer and more vulnerable to stress than mature bone.
During growth spurts, bones can lengthen faster than tendons. This creates a tight Achilles tendon that pulls on the heel bone with every step, irritating the growth plate. The pain typically shows up during or after sports, especially those involving running and jumping. It resolves on its own once the growth plate fully hardens, but rest from aggravating activities, supportive shoes, and heel cup inserts can make the process more comfortable.
How to Narrow Down Your Cause
Location and timing are your best diagnostic tools before you ever see a provider:
- Bottom of the heel, worst with first morning steps: plantar fasciitis
- Deep bruise feeling in the center of the heel, worse on hard floors: fat pad syndrome
- Back of the heel, worse with pushing off or climbing: Achilles tendonitis
- Pain when squeezing both sides of the heel: possible stress fracture
- Burning, tingling, or numbness: nerve entrapment
- Child aged 8 to 14, pain during sports: Sever’s disease
Most heel pain responds well to reducing the activity that triggered it, wearing shoes with adequate arch support and cushioning, and doing targeted stretching and strengthening exercises. Pain that persists beyond a few weeks, gets progressively worse, or comes with swelling, bruising, or nerve symptoms warrants a professional evaluation to rule out fractures or conditions that need more specific treatment.