A Guide to the Causes of Heel Pain 

The Most Common Heel Pain: 

Bottom or Back of the Heel 

The plantar fascia is a strong, thick band of tissue that runs along the bottom of your foot, connecting your heel bone to your toes. It acts like a shock absorber and supports the arch of your foot. The problem starts when too much stress from overuse causes tiny tears in this tissue (Thomas & Christensen, 2024).

Although it's called 'fasciitis' (which implies inflammation), in long-term ('chronic') cases, the tissue isn't just inflamed; it's actually started to break down and degrade. This is a failed healing process known as 'fasciosis' (Thomas & Christensen, 2024).

Symptoms and Risk Factors: The symptoms are very distinct. People usually feel a sharp, stabbing pain on the bottom of their heel (Thomas & Christensen, 2024). The most famous symptom is 'first-step pain': it's worst for the first few steps after you get out of bed in the morning or after you've been sitting for a long time (Thirunavukkarasu et al., 2023).

Some Potential causes:

At Clinical Touch Podiatry we specialize in managing and getting rid of the pain from plantar fasciitis using evidence based treatments. Book an Appointment today!

Achilles Tendinopathy is caused by repeated strain, often in athletes who suddenly do 'too much, too soon' (Mach-Lutsen et al., 2024). The pain can be in the middle of the tendon ('non-insertional') or right where it attaches to the heel bone ('insertional') (Mach-Lutsen et al., 2024).

Symptoms and Risk Factors: The main symptom is pain at the back of the heel (American Academy of Family Physicians, 2018a). Risk factors include age, your foot's shape (like flat feet), and too much exercise (Mach-Lutsen et al., 2024). 

At Clinical Touch Podiatry we specialize in managing and getting rid of the pain from Achilles Tendinopathy using evidence based treatments. Book an Appointment today!

Find out more about Achilles Tendinopathy here:

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How Your Foot Shape and Habits Contribute to Pain

Overuse injuries like plantar fasciitis and Achilles tendinopathy don't just happen. They are often caused by underlying problems with how your foot moves or by outside factors.

Gait Abnormalities (How You Walk)

A healthy foot needs a balance. It needs to be flexible enough to roll inwards slightly to absorb shock, but also rigid enough to be stable and push off the ground. Too much or too little of either motion causes problems (Bar-David & M, 2005).

• Overpronation (Flat Feet): This is when your foot rolls inward too much as you walk. This excessive rolling puts a major strain on the plantar fascia (Agrawal & Jeyaprakash, 2022; Bar-David & M, 2005; Li et al., 2024). Although flat feet are common and family influence may play a part, a fallen arch can also be due to posterior tibialis dysfunction and lack of mobility in the big toe (Molina-García et al., 2024). 

• Underpronation (High Arches): This is the opposite problem, often seen in people with very high, rigid arches (Agrawal & Jeyaprakash, 2022). The foot is too stiff and doesn't roll inward enough to absorb shock (Bar-David & M, 2005). This means all the impact force from walking or running slams directly into the heel bone and plantar fascia (Bar-David & M, 2005).

Extrinsic Risk Factors (External Factors)

• Poor Footwear: This is a major, and fixable, problem. Shoes that lack good arch support, cushioning, or have worn-out soles put extra stress on your heel (Naeem et al., 2022). One 2022 study found that 83.2% of people with plantar fasciitis wear 'inappropriate shoes' (like those with very thin, hard soles) and that this was linked to how severe their pain was (Naeem et al., 2022). People with heel pain often report having a hard time finding shoes that are comfortable (Risk & Buldt, 2015).

• Sudden Changes in Activity: A 'too much, too soon' approach is a classic trigger for these injuries, especially stress fractures (American Academy of Family Physicians, 2018a).

Bone-Related Heel Problems 

Sometimes, the pain comes from the heel bone (calcaneus) itself. This can be an overuse injury, like a small fracture, or something seen on an X-ray, like a heel spur, which is often mistakenly blamed for the pain (Thomas & Christensen, 2024).

Calcaneal Stress Fractures

This is a small crack in the heel bone that happens from overuse—not from a single bad injury, but usually from repeated stress (American Academy of Family Physicians, 1999). It's an important diagnosis to make because it can feel like other heel problems but needs different treatment (Alshami & Babri, 2024; American Academy of Family Physicians, 1999). It's often triggered by a sudden increase in activity, like starting a new running routine on a hard surface (American Academy of Family Physicians, 2018a).

Symptoms: The pain from a stress fracture is different from plantar fasciitis. It gets worse as you are active and feels better when you rest (American Academy of Family Physicians, 2018a). A key sign is the 'squeeze test': if squeezing the sides of your heel bone hurts, it points to a possible stress fracture (Alshami & Babri, 2024).

Heel Spurs (Calcaneal Spurs)

A heel spur is a small, bony lump that can form on the heel bone (Agrawal & Jeyaprakash, 2022).

The Truth About Heel Spurs and Pain:

 It's very important to clear up a common myth. People often get an X-ray for heel pain and see a 'heel spur,' so they assume the spur is poking into their foot and causing the pain.

Medical evidence shows this is not true (Thomas & Christensen, 2024).

• First, most people who have heel spurs on an X-ray have no pain at all.

• Second, the pain is not caused by the spur. It's caused by the underlying plantar fasciitis (Thomas & Christensen, 2024).

The spur is just a result of the long-term stress. The body builds that extra bit of bone in response to the constant pulling from the damaged plantar fascia (Agrawal & Jeyaprakash, 2022; Thomas & Christensen, 2024). Think of the spur as a sign that the plantar fasciitis has been there for a long time, not as the thing causing the pain. 

At Clinical Touch Podiatry we specialize in diagnosing  calcaneal stress fractures and we can manage and get rid of the pain from plantar fasciitis caused by heel spurs using evidence based treatments. 

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Inflammatory Causes of Heel Pain 

Sometimes, heel pain is caused by inflammation. This can be a local problem, like a swollen fluid sac ('bursitis'), or it can be a sign of a body-wide ('systemic') disease. 

Local Inflammation: 

Bursitis and Haglund's Deformity

Retrocalcaneal Bursitis is when a small, fluid-filled cushion (a 'bursa') at the back of the heel gets inflamed (National Library of Medicine, 2024). This bursa is meant to reduce friction between the tendon and the bone. The pain can feel very similar to Achilles pain (National Library of Medicine, 2024).

Haglund's Deformity isn't an inflammatory problem itself, but it causes one. It's a bony lump on the back of the heel, sometimes called a 'pump bump' (American Academy of Family Physicians, 2018a), ice hockey players refer to this as a 'Bauer bump'. This lump rubs against the Achilles tendon and the bursa, causing irritation and bursitis (American Academy of Family Physicians, 2018a). 

Body-Wide Inflammatory Diseases

In some cases, heel pain isn't just a foot problem, but a sign of an illness affecting your whole body.

Ankylosing Spondylitis (AS) is a long-term inflammatory disease that mainly affects the spine (Cuesta-Vargas & Roldán-Jiménez, 2024). Heel pain is a common symptom (Cuesta-Vargas & Roldán-Jiménez, 2024).

This happens because of 'enthesitis,' which is inflammation right where tendons and ligaments attach to the bone. In the heel, AS can inflame both the Achilles tendon attachment and the plantar fascia attachment (Cuesta-Vargas & Roldán-Jiménez, 2024).

If you have heel pain along with other 'red flags'—like back pain that's worse in the morning, a family history of similar issues, or eye inflammation (uveitis)—you should be checked for this type of condition (Frontiers in Medicine, 2021).

Gout (Metabolic Arthritis) is a very painful type of arthritis caused when tiny crystals (monosodium urate crystals) build up in your joints. This happens when you have high levels of uric acid in your blood (Dalbeth et al., 2021; Singh & T, 2024). Gout is famous for affecting the big toe ('podagra'), but it can definitely attack the heel and ankle too (Singh & T, 2024). A gout attack is impossible to ignore. It starts suddenly and intensely, often waking you up at night (Singh & T, 2024). The pain gets rapidly worse over 12 to 24 hours (Dalbeth et al., 2021; Singh & T, 2024). The affected heel or ankle will become extremely swollen, red, hot, and so tender that even a bedsheet touching it can be unbearable (Singh & T, 2024). This can look just like a bad infection (Singh & T, 2024), or mistaken for a swollen 'rolled ankle'.

Other body-wide conditions, like Psoriatic Arthritis and Reactive Arthritis, can also cause this type of inflammatory heel pain (Alshami & Babri, 2024).

At Clinical Touch Podiatry we specialize in diagnosing  Inflammatory Diseases and we can manage and get rid of the pain from Retrocalcaneal Bursitis or Haglund's Deformity using evidence based treatments. 

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Nerve Problems Causing Heel Pain 

A tricky, and often misdiagnosed, cause of heel pain is a trapped nerve. The pain isn't coming from the tissue, but from a nerve that is being squeezed. 

Tarsal Tunnel Syndrome (TTS)

This is when the posterior tibial nerve gets squeezed in a small passage on the inside of your ankle, known as the tarsal tunnel (American Academy of Family Physicians, 2018a; National Library of Medicine, 2022).

The symptoms feel like nerve pain: 'burning, tingling, or pins and needles' (American Academy of Family Physicians, 2018a), the pain isn't just in one spot; it travels ('radiates') down from the inner ankle to the heel and bottom of the foot (American Academy of Family Physicians, 2018a; National Library of Medicine, 2022). It usually gets worse with a lot of standing or walking (American Academy of Family Physicians, 2018a).

Baxter's Nerve Entrapment 

(Trapped Inferior Calcaneal Nerve)

This is a very common, but often missed, cause of heel pain (Fondazione Società Italiana di Neurologia, 2025). It's a specific nerve (Baxter's nerve) that gets trapped deep in the heel (Alshami & Babri, 2024; American Academy of Family Physicians, 1999). The "Great Mimic" of chronic plantar fasciitis, It's so easily mistaken for plantar fasciitis that it's thought to be the real problem in as many as 1 in 5 cases (up to 20%) of 'chronic' heel pain (Fondazione Società Italiana di Neurologia, 2025). 

The reason it's so tricky is that the pain is in the exact same spot as plantar fasciitis (Alshami & Babri, 2024; Fondazione Società Italiana di Neurologia, 2025). But there are clues to tell them apart:

How the pain feels: Plantar fasciitis is 'stabbing.' Baxter's nerve pain is 'burning, tingling, or shooting' (American Academy of Family Physicians, 1999; Fondazione Società Italiana di Neurologia, 2025).

How it reacts to activity: Plantar fasciitis might warm up and feel a bit better. This nerve pain just gets worse the longer you stand or walk, and it can even hurt when you're resting (American Academy of Family Physicians, 1999). 

At Clinical Touch Podiatry we specialize in diagnosing  nerve problems causing heel pain and we can manage and get rid of the pain using evidence based treatments. Book an Appointment today!

Heel Pain in Children and Teenagers 

Heel pain in children and teenagers is usually a different story. While it is possible for them to have plantar fasciitis, the most common cause is an issue with their growing bones. 

Calcaneal Apophysitis (Sever's Disease)

This is the number one cause of heel pain in active, growing children (Sha, 2023; T, 2025). It usually affects kids between 8 and 15 (Fares et al., 2021; James, 2024; T, 2025). An overuse injury of the 'growth plate' (the apophysis), which is an area of soft cartilage at the back of the heel bone that hasn't turned into hard bone yet (Fares et al., 2021; Sha, 2023). This soft area is easily irritated.

The problem is usually caused by repeated stress from two things:

Impact: Constant pounding from running and jumping (Fares et al., 2021).

Pulling: The Achilles tendon attaches right to this soft growth plate. During a growth spurt, the heel bone can grow faster than the calf muscle, making the Achilles tendon very tight. This tight tendon then constantly yanks on the sensitive growth plate, causing pain and inflammation (Fares et al., 2021; Sha, 2023).

The main symptom is pain at the back of the heel (Fares et al., 2021). Unlike adult plantar fasciitis (which hurts after rest), Sever's disease hurts during or after sports and activity, and feels better with rest (Fares et al., 2021; S, 2024). A doctor can often diagnose it with a 'squeeze test' on the back of the heel, which will be painful (James, 2024; Smith & Varacallo, 2024).

Other Causes in Children

While Sever's disease is the most common, it's not the only cause. A study found that plantar fasciitis was also responsible for 40% of children's heel pain cases (Thirunavukkarasu et al., 2023).

At Clinical Touch Podiatry we specialize in diagnosing  heel pain in children and teenagers and we can manage and get rid of the pain using evidence based treatments. Book an Appointment today!

Less Common Causes of Heel Pain

This group includes less common problems, as well as 'red flag' conditions like tumours and infections that are very important to find.

Heel Fat Pad Atrophy/Syndrome (Worn-Out Cushioning)

On the bottom of your heel, you have a special pad of fat that acts as your body's natural cushion. With age or repeated stress, this fat pad can wear thin, break down, and lose its bounce (Vicente-Sempere et al., 2022). This is called heel fat pad atrophy (Alshami & Babri, 2024).

Symptoms This is another problem that feels like plantar fasciitis, but with key differences:

• Location: The pain is usually a deep, "bruise-like" ache right in the middle of the heel (American Academy of Family Physicians, 2018a). Plantar fasciitis is usually more on the inner edge.

• What makes it worse: The pain is much worse when walking barefoot on hard floors (like tiles or wood) and from standing for a long time (Alshami & Babri, 2024).

Neoplastic Causes (Tumors and Cysts)

Although it's rare, heel pain can be caused by tumours or cysts inside the heel bone or nearby soft tissue (Alshami & Babri, 2024; Apreiss et al., 2023). These can be harmless ('benign') like simple bone cysts, or, much more rarely, cancerous ('malignant') like sarcomas (Apreiss et al., 2023).

Identifying "Red Flag" Symptoms A doctor will look for 'red flag' symptoms that don't fit a normal pattern. For a tumour, these would be:

• Pain that is severe or constant and doesn't get better with rest (Li et al., 2018).

• Pain at night that wakes you up.

• Swelling in the heel or ankle (Li et al., 2018).

• Pain that started for no clear reason (no new activity or injury) (Li et al., 2018).

These symptoms mean you need medical imaging (like an X-ray or MRI) right away (Li et al., 2018).

Infectious Causes (Calcaneal Osteomyelitis)

This is a serious bacterial infection in the heel bone (Lee & Kim, 2018).

How It Happens This isn't an overuse injury. It's almost always caused by something specific that lets bacteria into the bone:

• Injury: A deep puncture wound (Kumar & Pruthi, 2019).

• Ulcers: Most commonly, it starts from a heel ulcer (a non-healing sore), especially in people with diabetes (Kumar & Pruthi, 2019).

• After Surgery: An infection after an operation on the heel bone (Kumar & Pruthi, 2019).

• Injections: In very rare cases, it has happened after multiple steroid injections for plantar fasciitis, though this is extremely uncommon when done properly (Chae et al., 2019; Lee & Kim, 2018).

Symptoms The signs are those of an active infection: swelling on just one side, redness ('erythema'), pain, warmth in the area, and possibly an open sore or draining wound (Kumar & Pruthi, 2019). 

At Clinical Touch Podiatry we specialize in recognizing  less common sources of heel pain and we can manage and get rid of the pain using evidence based treatments or refer you to the appropriate specialist. 

Book an Appointment today!

References

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