Heel pain most often comes from plantar fasciitis, a condition where the thick band of tissue on the bottom of your foot develops tiny tears from repetitive stress. But where exactly your heel hurts, when it hurts, and how the pain feels all point to different causes. The location of the pain is the single most useful clue for figuring out what’s going on.
Pain on the Bottom of Your Heel
Plantar fasciitis is the most common cause of pain on the underside of the heel, typically felt on the inner edge near the front of the heel bone. The plantar fascia is a thick band of tissue that runs from your heel to your toes, supporting your arch and absorbing shock with every step. When that tissue is overloaded, small tears develop where it attaches to the heel bone, triggering a cycle of degeneration and pain.
The hallmark symptom is sharp pain with your first few steps in the morning. You get out of bed, put your foot down, and it feels like stepping on a nail. The pain typically eases after a few minutes of walking as the tissue loosens up, but it comes back after long periods on your feet or after sitting for a while and then standing. If the condition progresses, the pain can start showing up even during rest or sleep.
Several things raise your risk. Flat feet put extra strain on where the fascia connects to the heel. Very high arches do the opposite: your foot can’t absorb shock well, so the heel takes more impact. Limited ankle flexibility, prolonged standing, running and jumping activities, and rolling your feet inward or outward excessively all contribute. The condition is self-limiting in most people, with over 90% getting full relief within 3 to 6 months using conservative approaches like stretching, supportive footwear, and insoles.
Pain at the Back of Your Heel
If the pain is behind your heel rather than underneath it, the Achilles tendon is the likely source. Achilles tendinopathy comes in two forms based on location. Insertional tendinopathy causes pain right where the tendon meets the heel bone, and it tends to affect active people. Non-insertional tendinopathy causes pain a few centimeters higher up the tendon and is more common in older, less active, or overweight individuals.
Both types typically cause stiffness and tenderness that worsens with activity. You might notice the back of your heel is swollen or that pushing off while walking or climbing stairs is painful. Unlike plantar fasciitis, which hits hardest at the bottom of the heel first thing in the morning, Achilles tendon pain tends to be more noticeable during and after physical activity, particularly anything that involves pushing off the ground.
Heel Spurs: Less Important Than You Think
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 bony growth on the heel bone that develops over time from chronic tension on the surrounding tissue. But here’s the key point: heel spurs frequently appear in people who have no pain at all. They can show up alongside plantar fasciitis or Achilles tendinopathy, but the spur itself often isn’t the source of the problem. The soft tissue irritation around it is what hurts. Removing a spur surgically without addressing the underlying tissue issue rarely solves the pain on its own.
Nerve Compression in the Heel
Up to 20% of chronic heel pain cases involve a compressed nerve called Baxter’s nerve, the first branch of a nerve that runs along the inner side of your foot. This condition is frequently misdiagnosed as plantar fasciitis because the pain is in a similar location, on the inner bottom of the heel. The difference is in the quality of the pain: nerve compression tends to cause a burning sensation and may include tingling or numbness, while plantar fasciitis feels more like a sharp, stabbing ache.
If your heel pain hasn’t responded to typical plantar fasciitis treatments after several months, nerve entrapment is worth investigating. Ultrasound imaging and nerve conduction studies can help pin down the diagnosis. Treatment starts with physical therapy, orthotics, and sometimes targeted injections, with surgery reserved for cases that don’t improve.
Stress Fractures of the Heel Bone
A calcaneal stress fracture is a small crack in the heel bone caused by repetitive impact. Unlike a sudden break from an injury, stress fractures develop gradually over days to weeks. The pain is more generalized across the heel rather than focused on one spot, and it gets worse with any weight-bearing activity.
One distinguishing feature: if you squeeze both sides of your heel with your hands and it produces pain, that points toward a stress fracture rather than plantar fasciitis. Plantar fasciitis pain is reproduced by pressing on the bottom of the heel, not by squeezing the sides. Stress fractures are more common in runners, military recruits, and anyone who has recently ramped up their activity level quickly. They require a period of rest and reduced weight-bearing to heal properly.
Heel Pain in Children and Teens
In kids between ages 8 and 15, the most common cause of heel pain is Sever’s disease, an overuse condition affecting the growth plate at the back of the heel bone. It’s not actually a disease. It happens when repetitive impact from running and jumping irritates the growth plate before it has fully hardened into solid bone.
Children with Sever’s disease typically have pain at the back of the heel that gets worse during and after sports. They may limp or walk on their toes to avoid putting pressure on the heel. The diagnosis is straightforward: squeezing the heel from both sides reproduces the pain. Risk factors include participation in running or jumping sports, excess body weight, and poorly cushioned shoes. The condition resolves on its own once the growth plate closes, but reducing activity and using heel cushions can manage pain in the meantime.
When Heel Pain Signals Something Else
Most heel pain is mechanical, caused by overuse, poor footwear, or biomechanical issues. But when heel pain doesn’t improve with standard treatments, or when it affects both heels, comes with joint pain elsewhere, or is accompanied by fever or unexplained weight loss, systemic conditions enter the picture. Reactive arthritis, gout, and inflammatory bowel disease can all cause heel pain as part of a broader inflammatory process in the body. These conditions typically involve other symptoms beyond the heel itself, such as swollen joints, skin changes, or digestive problems.
How to Tell Your Causes Apart
- Sharp pain under the inner heel, worst with first morning steps: plantar fasciitis
- Pain at the back of the heel, worse during activity: Achilles tendinopathy
- Burning or tingling on the inner heel that won’t resolve: possible nerve compression
- Diffuse heel pain that hurts when you squeeze the sides: possible stress fracture
- Heel pain in an active child aged 8 to 15: likely Sever’s disease
- Heel pain with joint swelling or systemic symptoms: inflammatory or autoimmune condition
For the vast majority of people, heel pain is plantar fasciitis and will resolve with consistent stretching (particularly of the calves and the plantar fascia itself), supportive shoes, and avoiding prolonged barefoot walking on hard surfaces. If your pain hasn’t meaningfully improved after three months of these measures, the diagnosis itself may need a second look.