The most common cause of heel pain is plantar fasciitis, an irritation of the thick band of tissue running along the bottom of your foot. But several other conditions can produce heel pain depending on exactly where it hurts, how old you are, and what activities you do. Understanding the location and timing of your pain is the fastest way to narrow down what’s going on.
Plantar Fasciitis: The Most Common Cause
Plantar fasciitis accounts for the majority of heel pain cases. The plantar fascia is a tough strip of connective tissue stretching from your heel bone to your toes, acting like a bowstring that supports the arch of your foot. When repeated stress causes small tears in this tissue, it becomes inflamed and painful.
The hallmark symptom is a stabbing pain with your first few steps after waking up. During sleep, the fascia tightens in a shortened position. When you stand and stretch it suddenly, the damaged tissue protests. The same pattern happens after sitting for a long time. Pain typically eases once you’ve been moving for a few minutes, but it can flare again after extended periods on your feet.
Several factors raise your risk. People with a BMI above 30 are significantly more likely to develop plantar fasciitis than those at a healthy weight. Prolonged standing, reduced ankle flexibility, and a sedentary lifestyle all show associations with chronic heel pain. Interestingly, the typical patient in research studies is female, has had pain for about a year, and has a sedentary to moderate activity level. Less active people actually develop heel pain more often than regular exercisers.
Most people recover within several months using conservative measures: icing, stretching the calf and foot, and backing off activities that aggravate the pain.
Heel Spurs Are Rarely the Problem
If you’ve been told you have a heel spur, you might assume that’s what’s causing your pain. It probably isn’t. Heel spurs are small bony growths on the underside of the heel bone, and they show up on X-rays in about 15% of people who have zero heel pain. Among those who do have spurs, less than 5% experience any symptoms from them.
Medical consensus has shifted considerably on this. Spurs were once considered the primary source of heel pain, but current evidence shows they’re a consequence of chronic inflammation and abnormal forces on the foot, not a cause. The tight fascia and altered mechanics that produce plantar fasciitis also stimulate bone growth over time. Treating the underlying soft tissue problem, not the spur itself, is what resolves the pain.
Fat Pad Syndrome: Pain in the Center of Your Heel
Underneath your heel bone sits a specialized cushion of fatty tissue that absorbs shock with every step. Over time, this fat pad can thin out or lose its elasticity, leaving the bone with less protection against hard surfaces. The result is a deep, bruise-like ache right in the center of your heel.
Fat pad syndrome feels different from plantar fasciitis. While plantar fasciitis pain concentrates near the front of the heel where the fascia attaches, fat pad pain sits directly under the heel bone. You can often reproduce it by pressing firmly into the center of your heel. It gets worse when walking barefoot on hard floors, standing for long stretches, or doing high-impact activities like running or basketball.
Age is the biggest risk factor, as the fat pad naturally loses volume and springiness over time. Walking or running barefoot on concrete accelerates the breakdown. Previous steroid injections into the heel, sometimes given for other foot conditions, can also cause the fat pad to shrink as a side effect. Repeated injections increase this risk further.
Achilles Tendon Problems: Pain Behind the Heel
If your pain is at the back of the heel rather than the bottom, the Achilles tendon is the likely culprit. This is the large tendon connecting your calf muscles to your heel bone, and it can become painful from overuse, sudden increases in activity, or tight calf muscles.
Achilles tendonitis produces pain along the tendon itself, typically an inch or two above where it meets the heel bone, though it can also hurt right at the attachment point. The area may feel stiff in the morning and tender to the touch.
A related but distinct condition is retrocalcaneal bursitis, which involves inflammation of a small fluid-filled sac nestled between the Achilles tendon and the heel bone. Bursitis tends to cause swelling and pain right where the tendon meets the bone, and research shows it involves significantly higher pressure in this space compared to Achilles tendonitis alone. The two conditions can occur together, making the back of the heel both swollen and painful with movement.
Nerve Compression: Tingling and Burning
Not all heel pain comes from bones, tendons, or ligaments. Tarsal tunnel syndrome occurs when the tibial nerve, which runs along the inside of the ankle into the foot, gets compressed or damaged. Think of it as similar to carpal tunnel syndrome in the wrist, but in your ankle.
The pain from nerve compression feels distinct. Rather than a deep ache or sharp stab, you’ll notice burning sensations, numbness, or tingling (“pins and needles”) in the heel or sole of the foot. These sensations may radiate outward and often worsen with activity. An MRI is typically used to visualize the nerve entrapment, sometimes along with nerve conduction studies to confirm the diagnosis.
Stress Fractures: Gradual Pain That Won’t Quit
A calcaneal stress fracture is a small crack in the heel bone caused by repetitive impact rather than a single injury. It’s most common in runners and people who suddenly ramp up their activity level. Unlike an acute fracture from a fall or accident, stress fractures develop gradually over days to weeks, with pain that steadily worsens.
One distinguishing feature is the “squeeze test.” If squeezing both sides of your heel between your hands produces tenderness, that points toward a stress fracture rather than plantar fasciitis or fat pad problems. Standard X-rays often miss stress fractures, so a bone scan, CT, or MRI may be needed to confirm one.
Sever’s Disease in Children and Teens
Heel pain in kids has its own common cause. Sever’s disease is inflammation of the growth plate at the back of the heel bone, and it’s especially prevalent between ages 8 and 14 during growth spurts. Despite the name, it’s not actually a disease. It’s a temporary overuse condition.
Children’s bones are still developing, and the ends where growth occurs are made of cartilage that’s softer and more vulnerable to stress than mature bone. An overly tight Achilles tendon often contributes by pulling on the heel bone during activity. Active kids who play running and jumping sports are most susceptible. The condition resolves on its own once the growth plate matures and hardens, though managing activity levels and pain in the meantime matters. X-rays typically appear normal, which can be reassuring for worried parents.
How Location Helps Identify the Cause
Where exactly your heel hurts is one of the most useful clues:
- Bottom of the heel, toward the arch: plantar fasciitis
- Dead center of the heel bottom: fat pad syndrome
- Back of the heel: Achilles tendonitis or bursitis
- Both sides of the heel (with squeezing): possible stress fracture
- Inside of the ankle radiating to the heel: tarsal tunnel syndrome
- Back of the heel in a child aged 8 to 14: Sever’s disease
Most heel pain doesn’t require imaging to diagnose. A physical exam is sufficient for plantar fasciitis in particular. But when pain persists, doesn’t match a clear pattern, or follows an injury, imaging like X-rays, ultrasound, or MRI can help rule out fractures, nerve problems, or less common conditions. Stress fractures are especially easy to miss on standard X-rays, so more advanced imaging is often warranted if one is suspected.
Risk Factors That Cut Across Conditions
Certain factors make heel pain of any type more likely. Carrying extra weight tops the list. Research consistently links higher BMI to chronic heel pain, with a BMI of 25 or above representing a reasonable threshold where risk begins to climb. People with heel pain averaged a BMI of about 30 in one study, compared to 28 in pain-free controls.
Tight calves and limited ankle flexibility show up as risk factors across multiple conditions, from plantar fasciitis to Achilles tendonitis to Sever’s disease. Prolonged standing, especially on hard surfaces, wears down the fat pad and stresses the fascia simultaneously. And footwear that lacks adequate cushioning or arch support leaves your heel absorbing more force with every step than it’s designed to handle.