The most common cause of heel pain is plantar fasciitis, a degenerative condition affecting the thick band of tissue on the bottom of your foot. Achilles tendonitis, which strikes the back of the heel, is the second most frequent cause. But several other conditions can produce heel pain, and where exactly you feel it, what it feels like, and when it flares up all point to different underlying problems.
Plantar Fasciitis: The Most Common Cause
The plantar fascia is a tough band of connective tissue running from your heel bone to the base of your toes. It acts like a bowstring supporting your arch with every step. When this tissue breaks down, the result is a sharp pain at the bottom and inner edge of the heel that most people notice first thing in the morning.
Despite its name (the “-itis” suffix implies inflammation), plantar fasciitis is primarily a degenerative process. Tissue samples from affected patients show microtears, disorganized collagen fibers, and granulation tissue rather than the classic signs of inflammation. What’s actually happening is cumulative damage: the repetitive stress of standing and walking creates tiny tears faster than the body can repair them. Over time, the fascia deteriorates, thickens, and becomes painful.
The hallmark symptom is a stabbing pain with your first steps out of bed. During sleep, the fascia contracts and partially heals in a shortened position. When you stand up and stretch it again, those fragile repair sites tear. The pain typically fades after a few minutes of walking as the tissue warms up, then returns after long periods of sitting or standing. In advanced cases, the pain can persist during rest or even wake you at night.
People with a BMI over 30 are roughly 2.7 times more likely to develop plantar fasciitis compared to those at a healthy weight. But it’s not limited to any single group. Active athletes, military personnel, and people who spend long hours on their feet are all at higher risk, yet it also affects sedentary individuals. Inadequate arch support, poor footwear cushioning, and prolonged standing on hard surfaces are contributing factors regardless of activity level. Both flat feet and unusually high arches change how force distributes across the plantar fascia, increasing vulnerability.
Achilles Tendonitis: Pain at the Back of the Heel
If your pain is behind the heel rather than underneath it, the Achilles tendon is the likely culprit. This is the largest tendon in the body, connecting your calf muscles to the heel bone, and it absorbs tremendous force during walking, running, and jumping.
Achilles tendonitis comes in two forms based on where the damage occurs. Insertional tendonitis affects the point where the tendon attaches to the heel bone. It tends to occur in more physically active people and can involve calcification or bone spur formation at the attachment site. Noninsertional tendonitis targets the middle portion of the tendon, roughly 2 to 6 centimeters above the heel. This type is more common in older, less active, and overweight individuals, where the tendon fibers begin to break down and thicken.
Both types produce stiffness and pain that worsen with activity, particularly running, climbing stairs, or pushing off during a sprint. You may notice swelling along the tendon, and the area can feel tender to the touch. Unlike plantar fasciitis, which peaks with your first morning steps, Achilles pain often builds gradually during exercise and lingers afterward.
Heel Spurs and Why They’re Often Harmless
Many people worry that a heel spur is causing their pain, especially if one shows up on an X-ray. A heel spur is a small calcium deposit that forms on the underside of the heel bone, often in response to the same mechanical stresses that cause plantar fasciitis. But studies consistently show that between 10% and 63% of people with no heel pain at all have visible spurs on imaging. The spur itself is rarely the source of the problem. It’s a sign that the area has been under stress, not necessarily the reason it hurts. Treatment for heel pain with an associated spur focuses on the soft tissue damage, not the bony growth.
Nerve-Related Causes
When heel pain comes with burning, tingling, numbness, or a “pins and needles” sensation, a nerve problem is more likely than a mechanical one. Tarsal tunnel syndrome is the most recognized nerve-related cause. It occurs when the tibial nerve gets compressed as it passes through a narrow channel on the inner side of the ankle. The resulting pain typically radiates into the bottom of the foot and can be accompanied by muscle weakness. This compression can come from swelling, a cyst, varicose veins, or an injury that narrows the tunnel.
Peripheral neuropathy, where nerve damage causes pain and numbness in the extremities, can also produce heel symptoms. This is more common in people with diabetes or other conditions affecting nerve health. The key difference from plantar fasciitis is the quality of the pain: burning and electric rather than sharp and mechanical, and often present at rest or at night rather than triggered by your first steps.
Heel Pain in Children and Teens
Children and adolescents develop heel pain for a completely different reason. Sever’s disease (calcaneal apophysitis) is the most common cause of heel pain in growing kids. During a growth spurt, the heel bone grows faster than the surrounding muscles and tendons, which become tight and pull on the growth plate at the back of the heel. Weight-bearing sports and activities put additional stress on the area, eventually causing pain.
Girls typically develop Sever’s disease between ages 8 and 10, while boys are more commonly affected between 10 and 12, corresponding to the timing of their growth spurts. By age 15, the growth plate in the heel has fused and hardened in most children, which is why the condition resolves on its own. Diagnosis usually requires nothing more than a physical exam and a health history. Treatment centers on reducing activity, stretching the calf and Achilles tendon, and using heel cushions until the growth plate finishes developing.
Other Structural Causes
Bursitis involves inflammation of the small fluid-filled sacs (bursae) that cushion the bones, tendons, and muscles near joints. In the heel, bursitis typically develops between the Achilles tendon and the heel bone or between the skin and the tendon. It produces a deep, achy pain and sometimes visible swelling at the back of the heel, and can be triggered by tight shoes or repetitive pressure.
Haglund’s deformity is a bony enlargement on the back of the heel bone. The bump itself can irritate the surrounding soft tissue when it rubs against rigid shoe backs, leading to bursitis and pain. It’s sometimes called “pump bump” because it’s associated with stiff-backed shoes, including pumps and dress shoes.
When Heel Pain Signals Something Systemic
Most heel pain stems from local mechanical problems. But in some cases, it’s a symptom of a body-wide condition. Autoimmune diseases, certain types of inflammatory arthritis, and infections can all present as heel pain. Clues that something systemic is involved include pain that comes and goes without any clear connection to activity, pain that doesn’t improve with standard conservative care, or heel pain accompanied by symptoms in other parts of the body like joint swelling, digestive issues, or skin changes.
Autoimmune conditions like scleroderma and its variants can cause burning heel pain and swelling that mimics plantar fasciitis. These cases are uncommon, but they’re worth considering when the usual treatments aren’t working. Blood tests for autoimmune markers can help identify or rule out these causes. Heel pain that appears alongside unexplained fatigue, morning stiffness lasting more than 30 minutes, or swelling in multiple joints warrants a broader evaluation beyond the foot itself.