The most common cause of heel pain is plantar fasciitis, a condition where the thick band of tissue running along the bottom of your foot breaks down from repetitive stress. About 1% of U.S. adults are diagnosed with it each year, making it the leading reason people seek care for heel pain. But plantar fasciitis isn’t the only possibility. Where exactly you feel the pain, when it strikes, and how it started all point toward different causes.
Plantar Fasciitis: The Most Common Cause
The plantar fascia is a tough strip of connective tissue that runs from your heel bone to the base of your toes. It acts like a bowstring, storing energy when your heel lifts off the ground and releasing it as your toes push off. Every step you take loads this tissue with force, and over time, repetitive microtrauma can cause the fibers to degenerate.
Despite the name (which implies inflammation), plantar fasciitis is largely a degenerative problem. The blood supply to the damaged fascia becomes impaired, and without adequate blood flow, cells can’t produce the building materials needed to repair and remodel the tissue. This is why plantar fasciitis tends to linger: the tissue isn’t just inflamed, it’s struggling to heal itself.
The hallmark symptom is a sharp or stabbing pain on the underside of your heel, especially with your first steps in the morning or after sitting for a while. The pain often eases once you’ve been walking for a few minutes as the tissue loosens up, then returns after long periods on your feet. Risk factors include running, being on your feet all day for work, tight calf muscles, higher body weight, and flat feet or very high arches.
Clinical guidelines from the Journal of Orthopaedic & Sports Physical Therapy recommend stretching as a frontline treatment. Stretches targeting the plantar fascia itself, along with the calf muscles, have strong evidence for reducing pain in both the short and long term. Orthotics (shoe inserts) are not recommended as a standalone treatment, but they can help when combined with stretching and other therapies.
Heel Spurs: Not the Villain They Seem
Many people with heel pain get an X-ray and learn they have a heel spur, a small bony growth on the underside of the heel bone. It’s natural to assume the spur is stabbing into soft tissue and causing the pain, but that’s not what’s happening. According to the American Academy of Orthopaedic Surgeons, most people who have bone spurs on their heels do not have heel pain at all.
Heel spurs form gradually as a result of long-standing tension where the plantar fascia attaches to the bone. They’re a consequence of the same mechanical stress that causes plantar fasciitis, not an independent source of pain. This is why plantar fasciitis can be treated successfully without ever removing the spur.
Achilles Tendinitis: Pain at the Back of the Heel
If your pain is at the back of the heel rather than the bottom, the Achilles tendon is the more likely culprit. This tendon connects your calf muscles to your heel bone, and it comes in two varieties of trouble.
Insertional Achilles tendinitis affects the lower portion of the tendon right where it anchors into the heel bone. Tight calf muscles are a frequent cause, since they place extra stress on that attachment point. Bone spurs can also develop on the back of the heel with this type. It can happen at any activity level, though runners are most susceptible.
Noninsertional Achilles tendinitis targets the middle portion of the tendon, above the heel. Over time, the fibers develop tiny tears, and the tendon may swell and thicken. This type is more common in younger, active people. In both forms, damaged tendon fibers can eventually harden with calcium deposits if left untreated.
Fat Pad Atrophy: A Commonly Missed Diagnosis
Your heel bone sits on a specialized cushion of fat that absorbs shock with every step. When this fat pad thins out or breaks down, the heel bone loses its natural padding, and the result is a deep, bruise-like pain in the center of your heel. Fat pad atrophy is considered the second leading cause of heel pain after plantar fasciitis, and it is frequently misdiagnosed as plantar fasciitis.
The key difference is location: fat pad pain tends to center in the middle of the heel and can be reproduced by pressing a finger firmly into that spot. It worsens with prolonged standing, high-impact activities like running or jumping, and walking barefoot on hard surfaces like concrete or hardwood floors. Mild cases may only bother you occasionally, while more advanced thinning can make every step uncomfortable. Age, repeated steroid injections into the heel, and years of high-impact activity all contribute to fat pad breakdown.
Stress Fractures in the Heel Bone
A calcaneal stress fracture is a small crack in the heel bone that develops gradually from repetitive loading rather than a single injury. The pain typically starts as a faint twinge that slowly becomes more noticeable over days or weeks. It gets worse when you put pressure on the heel (standing, walking, stretching the foot) and eases when you rest.
Other signs include tenderness or warmth when you touch the heel, stiffness, and sometimes bruising. Stress fractures don’t always show up on standard X-rays, especially early on. An MRI is often needed to confirm the diagnosis, since it can detect bone damage that X-rays miss. Stress fractures are more common in runners, military recruits, and anyone who rapidly increases their activity level. Reduced bone density also raises the risk.
A traumatic calcaneal fracture, by contrast, is hard to miss. It typically follows a fall from height or a severe impact and causes sudden, intense pain, visible swelling, bruising on the sole of the foot, and difficulty bearing any weight at all.
Tarsal Tunnel Syndrome: Nerve-Related Heel Pain
The tarsal tunnel is a narrow passageway on the inner side of your ankle, formed by bones and ligaments. The tibial nerve runs through it on its way to the sole of your foot. When that nerve gets compressed or damaged, you can develop burning pain, numbness, or tingling (“pins and needles”) on the inside of your ankle or along the bottom of your foot, including the heel.
Tarsal tunnel syndrome is less common than plantar fasciitis, but it’s worth considering if your heel pain comes with sensory changes like burning or numbness. Anything that takes up space in the tarsal tunnel or puts pressure on the nerve can be a trigger: swelling from an ankle sprain, a cyst, flat feet that cause the ankle to roll inward, or varicose veins near the tunnel.
Heel Pain in Children and Teens
When a child complains of heel pain, the most likely cause is Sever’s disease (calcaneal apophysitis). It has nothing to do with the adult causes listed above. In growing children, the heel bone has an active growth plate at its back end, and repetitive stress from running and jumping can irritate that growth plate before it fully hardens.
Girls are most vulnerable around ages 8 to 10, while boys typically develop it between ages 10 and 12, both windows coinciding with early puberty growth spurts. By age 15, the growth plate has usually closed, and Sever’s disease becomes rare. Diagnosis is straightforward: a health history and physical exam are usually enough. The condition resolves on its own once the growth plate matures, though rest, heel cushions, and stretching can manage discomfort in the meantime.
How to Narrow Down Your Cause
Pain location is the single most useful clue. Bottom of the heel, especially with your first morning steps, points toward plantar fasciitis. A deep central bruise feeling on weight-bearing suggests fat pad problems. Pain at the back of the heel implicates the Achilles tendon. Burning or tingling signals nerve involvement.
Timing matters too. Pain that’s worst at the start of activity and fades as you warm up is classic for plantar fasciitis. Pain that steadily worsens the longer you’re on your feet, without easing, leans more toward fat pad atrophy or a stress fracture. A gradual onset over weeks in a runner or someone who recently ramped up training raises suspicion for a stress fracture.
Your age and activity level round out the picture. A 10-year-old soccer player almost certainly has Sever’s disease. A middle-aged runner with bottom-of-heel pain most likely has plantar fasciitis. An older adult who has lost the cushiony feel of their heel pad may be dealing with fat pad atrophy. None of these causes are emergencies, but persistent heel pain that doesn’t improve after a few weeks of rest, stretching, and supportive footwear warrants a professional evaluation to get the diagnosis right and avoid months of misdirected self-treatment.