Heel Pain: Common Causes and How to Tell Them Apart

Start with the map

Heel pain is a symptom rather than a single condition, and the fastest way to narrow it down is to notice exactly where it hurts and when it hurts most [1].

• Under the heel, toward the arch, worst with the first steps of the morning. Most often plantar fasciitis.
• Under the heel, right in the middle, worse on hard floors. Often a bruised or thinned heel pad.
• Back of the heel, where the tendon attaches, stiff in the morning. Usually the Achilles tendon.
• A tender bump at the back of the heel that rubs against shoes. Often bursitis or a bony prominence.
• A deep ache that builds with mileage and never fully rests. Think stress fracture until proven otherwise.
• Burning, tingling or numbness in the heel. A nerve may be involved rather than the tissue.

The sections below take each group in turn, and if your pattern does not fit any of them comfortably, that mismatch alone is a reasonable reason to have the heel examined rather than to keep guessing.

Pain under the heel

Plantar fasciitis

The plantar fascia is the band of tissue that runs from the heel bone to the toes and supports the arch, and overload frays it where it meets the heel. The result is sharp first-step pain that eases with movement and returns after rest or a long day [5]. It is the most common cause of pain under the heel in adults [3], fed by long hours standing, a tight calf, extra weight and unsupportive shoes. Our full page on plantar fasciitis covers it in depth.

Heel spurs

An X-ray of a sore heel often shows a small bony point where the fascia attaches, and it is tempting to blame it. Yet spurs appear in many feet that never hurt, and removing them is rarely the answer [5]. Care for a so-called heel spur is really care for the soft tissue around it.

Heel pad bruising or thinning

The fat pad under the heel is a natural shock absorber. A hard landing can bruise it, and with age or after years on concrete it can thin so that the bone sits closer to the floor. The pain is central and worse barefoot on hard surfaces, and cushioned heel cups and shoes with real padding make an obvious difference [4].

Nerve pain

A small nerve runs along the inside of the heel, and when it is pinched the pain burns or tingles and can extend toward the outside of the heel. It does not follow the morning pattern of plantar fasciitis, and it needs a clinician to sort out.

Stress fracture

Runners, military recruits and people who suddenly increase their load can crack the heel bone. The ache is deep, it builds with activity, and squeezing the heel from both sides hurts. This calls for imaging and rest rather than more miles.

Pain at the back of the heel

Achilles tendon

The largest tendon in the body attaches to the back of the heel, and when its load outruns its recovery it thickens and aches. Pain and stiffness are worst in the morning and at the start of activity [2]. Hill running, a sudden jump in training, tight calves and years of flat shoes all contribute. Pain right at the bone behaves a little differently from pain a few centimeters up the tendon, and the distinction changes which stretches and heel lifts are appropriate, so a clinician’s examination is worth having before you commit to a routine.

Bursitis and bony bumps

Between the tendon and the bone sits a small fluid sac that stiff shoe backs can irritate. Some people also have a prominent heel bone that pushes against the shoe. Either way you get a tender, sometimes red bump, and open-backed shoes, soft heel counters and a small heel lift usually calm it.

Growing children

Heel pain in active children between roughly eight and fourteen is often the growth plate at the back of the heel reacting to sport. It settles with rest, calf stretching and cushioned heels, but a clinician should confirm the cause first.

Why heel pain lingers

Two habits keep heel pain going long after the original overload has passed. The first is intermittent rest: a person stops running for a week, feels better, returns at full volume, and restarts the cycle, when the tissue needed a gradual ramp measured across a month or more. The second is regarding the shoe as an afterthought, so that a supportive insole spends its day inside a collapsed sneaker that undoes the support with every step. Body weight, a stiff calf and a job that keeps you standing on concrete each add a steady background load, which is why the measures below work slowly and together rather than quickly and alone.

How clinicians tell them apart

A careful history and a hands-on examination usually settle the question, because where you point, what makes it worse, and how the pain behaves in the morning together narrow the possibilities considerably before any imaging is ordered. Guidelines for heel pain describe a stepwise approach: confirm the pattern, try the simple measures for several weeks, and reserve imaging and procedures for pain that does not follow the expected course [6]. Imaging enters the picture when the story does not fit the expected pattern, when a fracture or a tendon tear is a realistic possibility, or when nothing has changed after a fair trial of the conservative measures described below, and even then an ultrasound or X-ray is chosen to answer a specific question rather than to survey the whole foot.

What helps most heel pain

Most heel pain responds to the same short list, applied for weeks at a time rather than days [2] [1]:

1. Shoes with a firm heel counter and real cushioning. Retire worn pairs and avoid barefoot time on hard floors during a flare.
2. Calf stretching twice daily, because a tight calf loads both the fascia and the Achilles.
3. Support under the arch and heel. For pain under the heel, a supportive insole with a cushioned heel cup; for pain at the back, a small heel lift for a few weeks.
4. Load management, swapping some standing and running for cycling or swimming and then building back gradually.
5. Ice after long days, for about ten minutes a few times a week.
6. Patience, since improvement shows over weeks and should be tracked monthly rather than daily.

For pain under the heel, pooled trials show that foot orthoses reduce pain more than sham devices over roughly two to three months, with custom and prefabricated devices performing similarly [8]. Current practice guidelines recommend orthoses together with stretching and, in stubborn cases, taping, night splints or manual therapy [7].

When to see a clinician

• Pain after a fall, a twist or a snapping sensation.
• Swelling, redness, warmth, or fever.
• You cannot bear weight on the heel.
• Numbness, tingling or burning.
• Pain at night or at rest.
• Diabetes, poor circulation, or a wound on the foot.
• No improvement after two months of steady care.

EvenStep does not examine you. This page can help you describe heel pain clearly to someone who does; it cannot tell you which cause is yours.

How EvenStep fits in

EvenStep orthotics for heel pain are designed to do two things at once: cushion and cup the heel so it lands softly and stays centered, and support the arch so the tissue that anchors at the heel carries less strain. Because they are shaped from the impression you make with our at-home foam impression kit rather than from a stock last, the heel-cup depth and arch height match your foot, and they may relieve symptoms associated with pain under the heel when used with the care above.

Your pair is at your door in under 10 business days from the day your impression arrives — or a full refund. The first pair is $189 and each additional pair is $139, shipping is free both ways, and every pair carries our guarantee: 180-day 100% money-back guarantee — no deductions, free return shipping. FSA/HSA eligible — pay with your FSA/HSA card at checkout or submit our itemized receipt. We don't bill insurance.