Heel pain most often comes from plantar fasciitis, a condition where the thick band of tissue running along the bottom of your foot breaks down where it attaches to the heel bone. But several other conditions can cause heel pain too, and the location, timing, and quality of your pain are the best clues to figuring out which one you’re dealing with.
Plantar Fasciitis: The Most Common Cause
Plantar fasciitis accounts for the majority of heel pain cases. Despite the name (which implies inflammation), the condition is actually a degenerative process. Tissue samples from people who’ve had surgery for it show breakdown and fragmentation of the plantar fascia rather than active inflammation. It’s more of a wear-and-tear injury than a flare-up.
The hallmark symptom is stabbing pain on the bottom of the heel with your first steps in the morning. After you’ve walked around for a few minutes, the pain typically fades, only to return at the end of the day or after long periods of standing. The pain is concentrated at the front-inside edge of the heel bone, right where the fascia connects. Pressing on that spot usually reproduces the pain, and bending your toes back toward your shin while someone stabilizes your ankle can also trigger it.
Several factors raise your risk. People with heel pain have a higher average BMI (around 30) compared to those without it (around 28), and a BMI of 25 or above appears to be a meaningful threshold. Reduced ankle flexibility, stiff big toe joints, and prolonged standing throughout the day also show associations with chronic heel pain. Interestingly, people with heel pain tend to be less active overall. In one study, only about 25% of heel pain patients exercised three or more times per week, compared to 51% of people without heel pain. The typical patient is female, has had symptoms for about a year, and leads a sedentary to moderately active lifestyle.
Achilles Tendon Problems
If your pain is at the back of the heel rather than the bottom, the Achilles tendon is the likely culprit. There are two types. Insertional Achilles tendinitis affects the lower portion of the heel where the tendon connects to the bone, and it can hurt even without much physical activity. Noninsertional Achilles tendinitis involves the middle section of the tendon, where fibers start to break down, swell, and thicken. This type is more common in active people and causes pain a few inches above the heel bone rather than right at it.
Both types tend to worsen with activity and improve with rest, which is one way to distinguish them from plantar fasciitis (where the worst pain hits after rest, not during activity).
Heel Fat Pad Syndrome
Your heel has a built-in cushion: a fat pad normally 1 to 2 centimeters thick that absorbs shock with every step. When that pad thins or loses its elasticity, you feel a deep, bruise-like ache directly under the center of the heel. The pain tends to get worse with barefoot walking on hard surfaces.
Age is the primary driver. The fat pad naturally loses volume and resilience over time. Repeated corticosteroid injections into the heel, sometimes given to treat other foot conditions, can also cause the fat pad to shrink or break down. Unlike plantar fasciitis, this pain doesn’t have the classic “first step in the morning” pattern. It tends to build gradually throughout the day and worsens with impact.
Stress Fractures
A stress fracture in the heel bone (calcaneus) causes pain that’s harder to pinpoint and doesn’t improve with the usual stretching or rest strategies that help soft tissue injuries. The pain typically worsens with any weight-bearing activity and may ache even at rest. Squeezing the sides of the heel bone together often reproduces the pain, which is a key clinical sign that distinguishes a fracture from a soft tissue problem like plantar fasciitis.
Stress fractures are more common in runners, military recruits, and anyone who recently increased their activity level dramatically. They also occur more frequently in people with low bone density.
Nerve-Related Heel Pain
Tarsal tunnel syndrome occurs when the main nerve running behind the inner ankle bone gets compressed. It produces a distinctly different type of pain: burning, tingling, numbness, or “pins and needles” sensations along the inside of the ankle or the bottom of the foot. You may also notice weakness in the small muscles of your foot. Tapping on the nerve behind the ankle bone can reproduce the symptoms, which is one way clinicians identify the condition.
The key distinction is the quality of the pain. Plantar fasciitis and fat pad syndrome cause mechanical, aching, or stabbing pain. Nerve compression causes electrical sensations: burning, buzzing, or shooting pain, sometimes with numb patches. If your heel pain comes with tingling or numbness, a nerve issue is worth investigating.
Heel Pain in Children
Children and preteens get heel pain for a completely different reason. Sever’s disease is a growth-related condition that happens because the heel bone is one of the first parts of the body to reach full size during a growth spurt. The muscles and tendons can’t grow fast enough to keep up, which puts excess stress on the growth plate at the back of the heel. It typically affects girls between ages 8 and 10, and boys between 10 and 12, especially those who play sports or do other weight-bearing activities. The condition resolves on its own once growth slows, though reducing activity and using heel cushions can help manage pain in the meantime.
Systemic Conditions That Affect the Heel
Less commonly, heel pain can be a symptom of a broader condition rather than a local injury. Gout, rheumatoid arthritis, and a group of inflammatory conditions called seronegative spondyloarthropathies (which include ankylosing spondylitis and psoriatic arthritis) can all cause heel pain. Fibromyalgia can as well. One clinical red flag is bilateral heel pain, meaning both heels hurt at the same time. Most mechanical causes like plantar fasciitis and nerve compression tend to affect one foot. When both heels are involved, an underlying systemic condition is more likely and worth ruling out.
What Actually Helps
For plantar fasciitis specifically, the most recent clinical practice guidelines from 2023 offer some surprising findings about a popular treatment. Custom orthotics and prefabricated (over-the-counter) insoles perform about the same, and neither type produces significant pain reduction on its own compared to flat insoles within the first 12 weeks. The current recommendation is not to use orthotics as a standalone treatment. They can help when combined with other approaches like stretching, strengthening, and activity modification, but they’re not a fix by themselves.
For most types of heel pain, the practical first steps are similar: reduce the activities that aggravate it, stretch the calf and foot regularly, wear supportive shoes, and give it time. If your pain isn’t improving after a few weeks, is getting worse, involves tingling or numbness, affects both heels, or came on suddenly after increased activity (raising concern for a stress fracture), those are all good reasons to get it evaluated further.