Your calcaneus, the heel bone, hurts most commonly because of plantar fasciitis, a condition where the thick band of tissue on the bottom of your foot becomes damaged where it anchors to the bone. But several other conditions cause pain in the same spot, and telling them apart matters because the right response depends on the cause. The location, timing, and quality of your pain are the best clues.
Plantar Fasciitis: The Most Common Cause
A tough sheet of connective tissue runs from your heel bone to the base of your toes, acting like a bowstring that supports your arch. Where this tissue attaches to the calcaneus, repetitive stress causes tiny tears and degeneration of the tissue fibers. This is plantar fasciitis, and it accounts for the majority of heel pain cases.
The signature symptom is a throbbing pain on the inner side of the bottom of your heel, worst with your first steps in the morning or after sitting for a while. The tissue stiffens during rest, and when you stand up, those first few steps stretch it before it has warmed up. The pain typically eases after a few minutes of walking, then returns after prolonged time on your feet. Bending your toes upward can reproduce the pain because it pulls directly on the attachment point at the heel.
Imaging is rarely needed. The diagnosis is almost always made based on symptoms and a physical exam alone. X-rays, ultrasound, or MRI are typically reserved for cases where the diagnosis is unclear or the pain hasn’t improved with treatment.
Heel Fat Pad Syndrome
Beneath your heel bone sits a specialized cushion of fatty tissue that absorbs shock with every step. Over time, this pad can thin out or lose its elasticity, leaving the bone less protected. The result is a deep, bruise-like pain right in the center of the heel, distinct from plantar fasciitis pain, which tends to sit more toward the inner edge.
Age is the biggest risk factor. The fat pad naturally shrinks as you get older. But other things accelerate the process: walking barefoot on hard surfaces like concrete or tile, high-impact sports such as basketball or gymnastics, standing for long hours, and wearing shoes with poor cushioning. Interestingly, having plantar fasciitis can lead to fat pad syndrome because the injured fascia redistributes weight unevenly, putting extra pressure on the heel pad. Previous steroid injections into the heel also increase the risk of the fat pad breaking down.
You can test this at home in a rough way: press firmly into the very center of your heel with your thumb. If that recreates the deep, bruise-like pain you’ve been feeling, fat pad syndrome is a likely contributor. The pain also tends to worsen the longer you’re on your feet, unlike plantar fasciitis, which often improves somewhat as you walk.
Calcaneal Stress Fractures
A stress fracture is a hairline crack in the bone caused by cumulative overload rather than a single injury. In the calcaneus, this usually happens after a sudden increase in weight-bearing activity, like ramping up running mileage, starting a new job that requires standing, or switching from soft to hard walking surfaces.
The pain develops gradually over days to weeks, starting as discomfort only during activity and potentially progressing to pain even at rest. A hallmark test is the squeeze test: if squeezing both sides of your heel between your palms reproduces the pain, a stress fracture is more likely than a soft tissue problem. Standard X-rays can miss early stress fractures, so an MRI may be needed if one is suspected.
Achilles Tendinopathy
Your Achilles tendon connects the calf muscles to the back of the calcaneus, and it can become painful in two distinct locations. Non-insertional tendinopathy affects the middle portion of the tendon, a few centimeters above the heel. Insertional tendinopathy affects the point where the tendon meets the bone itself, producing pain right at the back of the heel.
The pain is typically achy, occasionally sharp, and worsens with increased activity or direct pressure. If your pain is at the back of the heel rather than the bottom, the Achilles is the more likely culprit. You might notice stiffness in the morning or after sitting, similar to plantar fasciitis, but the location is distinctly different: back of the heel versus the sole.
Nerve Entrapment
A small nerve branch runs along the inside of the heel and can become compressed or irritated, producing pain that feels distinctly different from the other conditions on this list. The telltale signs are burning, tingling, or numbness alongside the pain, often radiating outward across the heel. The pain tends to be worse at night and after physical activity like walking.
This condition, sometimes called Baxter’s nerve entrapment, is frequently misdiagnosed as plantar fasciitis because the pain overlaps in location. The key differences are the nerve-type sensations (burning, tingling) and the nighttime worsening. People with flat feet or overpronation are at higher risk because the altered foot mechanics put more pressure on the nerve.
Sever’s Disease in Kids and Teens
If the person with heel pain is between ages 8 and 14, the most likely cause is Sever’s disease. During growth spurts, the heel bone’s growth plate is still open and vulnerable to stress. Repetitive pounding from sports or even normal walking inflames this growth plate, causing pain in the back of the heel.
High-impact activities on hard surfaces are the most common trigger, but sometimes everyday walking is enough. The condition is very common, resolves on its own once the growth plate closes, and doesn’t cause long-term damage. Reducing activity levels and wearing supportive shoes typically manages the pain until growth is complete.
How to Tell These Apart
- Bottom of the heel, inner side, worst with first morning steps: plantar fasciitis
- Center of the heel, deep bruise-like feeling, worse the longer you stand: fat pad syndrome
- Generalized heel pain after increasing activity, painful when you squeeze the heel sides: stress fracture
- Back of the heel, achy with activity: Achilles tendinopathy
- Burning, tingling, or numbness along the inner heel, worse at night: nerve entrapment
What Actually Helps
For plantar fasciitis, the foundation is stretching the calf and the plantar fascia itself, combined with supportive footwear. Rolling your foot over a frozen water bottle can address both stretching and inflammation. Most cases resolve within several months with consistent effort, though it can feel slow.
For stubborn plantar fasciitis that hasn’t responded to stretching and orthotics, shockwave therapy has strong evidence behind it. It works by sending pulsed sound waves into the tissue, stimulating blood vessel growth and new collagen production. Studies show it outperforms placebo, physical therapy alone, orthotics, and steroid injections. Platelet-rich plasma injections showed even better pain reduction than shockwave therapy in clinical trials, though the procedure is more involved.
Fat pad syndrome responds best to cushioned insoles and avoiding barefoot walking on hard surfaces. Unlike plantar fasciitis, the tissue doesn’t regenerate, so the goal is protecting what remains. Heel cups that keep the fat pad compressed under the bone can make a noticeable difference.
Stress fractures require rest. Continued weight-bearing on a fractured calcaneus risks turning a hairline crack into a complete fracture. A period of reduced activity, sometimes with a walking boot, is typically necessary.
For Achilles tendinopathy, eccentric calf exercises (slowly lowering your heels off a step) have the most evidence. These load the tendon in a controlled way that promotes remodeling of the damaged tissue. For nerve entrapment, treatment focuses on reducing compression through orthotics, stretching, and sometimes nerve-gliding exercises. Cases that don’t improve may benefit from a procedure to release the compressed nerve.