Why Does My Heel Hurt? 6 Common Causes (and How to Tell Them Apart)
Share
If your heel hurts, you've probably already done what most people do: searched for the pain, landed on "plantar fasciitis," and assumed that's what you have. Maybe it is. Plantar fasciitis is the most common cause of heel pain. But there are five other conditions that cause very similar symptoms and require different treatment — and treating one condition as though it's another is one of the most common reasons heel pain doesn't resolve.
The location of your pain, when it hurts, and how it feels are the most useful pieces of information for telling these conditions apart. Here's a breakdown of the six most common causes.
1. Plantar Fasciitis
Location: Under the heel, often toward the inside (medial side). Pain may extend forward into the arch.
Timing: Worst with the first steps in the morning or after sitting for extended periods. Tends to ease after a few minutes of walking, then may return after prolonged activity.
Character: Sharp, stabbing, or burning. Some describe it as stepping on a nail.
Cause: The plantar fascia — a thick band of connective tissue connecting the heel bone to the base of the toes — becomes inflamed and develops micro-tears at its heel attachment point. Overuse, inadequate arch support, and sudden increases in activity level are common triggers.
Plantar fasciitis is the most thoroughly documented cause of heel pain, representing roughly 80% of heel pain diagnoses. For detailed information on plantar fasciitis specifically, see our complete guide →
2. Heel Spurs
Location: Under the heel, typically at the same site as plantar fasciitis pain.
Timing: Similar to plantar fasciitis — often worse in the morning or after rest.
Character: Aching, diffuse, sometimes sharp.
What they actually are: A heel spur is a calcium deposit on the underside of the heel bone that forms over time in response to stress at the plantar fascia attachment. They appear on about 50% of plantar fasciitis X-rays — but they also appear on about 20% of X-rays of people with no heel pain. The spur is usually not the source of pain. The surrounding inflamed tissue is.
This distinction matters because heel spur surgery (removing the spur) has a poor evidence base when the underlying plantar fascia inflammation isn't addressed. Most people diagnosed with "heel spurs" actually have plantar fasciitis and respond to the same conservative treatment. See the full explanation of heel spurs →
3. Achilles Tendinopathy
Location: Back of the heel, either where the Achilles tendon inserts into the heel bone (insertional) or 2–6 cm above the insertion (mid-portion).
Timing: Stiffness and aching in the morning; pain that worsens with running or jumping and persists afterward. Unlike plantar fasciitis, it often doesn't ease with light walking.
Character: Aching, stiff, sometimes swollen or thickened. Tenderness is directly on the tendon, not under the heel.
Cause: Repetitive loading that exceeds the tendon's capacity to recover. More common in runners, jumping athletes, and people who suddenly increase their activity volume. Tight calves and inadequate foot support are contributing factors.
Achilles tendinopathy is distinct from a partial or complete Achilles tear, which presents with sudden sharp pain and significant weakness. If you can't rise onto your toes, see a clinician urgently.
4. Retrocalcaneal Bursitis
Location: Back of the heel, between the Achilles tendon and the heel bone. Can feel like Achilles tendinopathy but the tenderness is slightly deeper and higher.
Timing: Worse after activity; swelling may be visible or palpable at the back of the heel.
Character: Aching, pressure, sometimes burning. The back of the heel may feel warm.
Cause: Inflammation of the small fluid-filled sac (bursa) that cushions the junction between the Achilles tendon and the heel bone. Often triggered by rigid, tight footwear (the back of the shoe pressing into the heel), sudden training load increases, or repetitive heel impact.
Haglund's deformity — a bony prominence on the back of the heel bone — is a common structural contributor. The bump creates chronic friction against the bursa and tendon.
5. Heel Fat Pad Syndrome
Location: Directly under the center of the heel, rather than the inside arch area.
Timing: Worse with impact activities. Unlike plantar fasciitis, it doesn't follow the morning stiffness pattern as reliably — the pain often comes on with activity rather than with first steps.
Character: Deep, bruised, diffuse aching rather than sharp stabbing. Like stepping on a pebble that's always there.
Cause: The heel's natural fat pad — a specialized cushioning structure of fibrous tissue and fat — can thin, atrophy, or lose structural integrity with age, high mileage running, and prolonged standing on hard surfaces. The result is that the heel bone (calcaneus) transmits impact more directly to the skin and ground with less cushioning.
Fat pad syndrome is more common after age 40 and often coexists with plantar fasciitis. The distinction matters because treatment emphasizes heel cushioning rather than arch support or plantar fascia stretching.
6. Nerve Entrapment (Tarsal Tunnel or Baxter's Nerve)
Location: Inner heel, sometimes radiating into the arch or toes.
Timing: May occur with activity or at rest. Sometimes worse at night. Can be triggered by prolonged standing.
Character: Burning, tingling, numbness, or electric shooting sensations — neurological in character rather than musculoskeletal. This distinguishes it from the other causes listed above.
Cause: The posterior tibial nerve (tarsal tunnel syndrome) or the first branch of the lateral plantar nerve (Baxter's nerve entrapment) can become compressed or irritated at the inside of the ankle and heel. Flat feet and overpronation increase the risk by narrowing the tarsal tunnel.
Nerve entrapment is less common than plantar fasciitis but is frequently misdiagnosed as PF because the location overlaps. If stretching and orthotics haven't helped after several months, nerve entrapment is worth ruling out.
How to Tell What You Have
Most heel pain can be provisionally identified by location and timing before seeing a clinician:
| Symptom pattern | Most likely cause |
|---|---|
| Under heel, inner side, sharp in morning, eases with walking | Plantar fasciitis (or heel spur) |
| Back of heel, stiff after rest, worsens with running | Achilles tendinopathy |
| Back of heel, swollen, triggered by tight shoe backs | Retrocalcaneal bursitis |
| Under center of heel, deep bruised ache, no morning pattern | Heel fat pad syndrome |
| Inner heel, tingling/burning/numbness | Nerve entrapment |
When in doubt — especially if symptoms are severe, bilateral, or not improving after 6–8 weeks of conservative care — see a podiatrist or sports medicine physician. X-rays and ultrasound can rule out stress fractures and confirm soft tissue pathology.
Why Foot Structure Matters for All of Them
Regardless of which condition you have, the underlying mechanics are often similar: overpronation (the ankle rolling inward because the arch isn't providing adequate support) creates excessive stress on the plantar fascia, Achilles tendon, and heel structures with every step. Flat feet and low arches are the most common structural contributor.
Custom orthotics address this at the structural level — redistributing load away from the overloaded areas — rather than just managing symptoms. They're part of the conservative care stack for most of the conditions above.
Frequently Asked Questions
Can I have more than one cause of heel pain at the same time?
Yes. Plantar fasciitis and heel spurs almost always coexist. Plantar fasciitis and fat pad syndrome often coexist in older runners. Achilles tendinopathy and retrocalcaneal bursitis frequently occur together. If your heel pain has features of multiple conditions, a podiatrist can sort out which is dominant and what to address first.
How long does heel pain typically last?
For plantar fasciitis with appropriate treatment (stretching, orthotic support, load modification), most cases improve meaningfully within 6–8 weeks. Achilles tendinopathy takes longer — 3–6 months is typical. Bursitis responds faster with appropriate footwear changes and anti-inflammatory measures. Heel fat pad syndrome is the most persistent, as the structural change is more difficult to reverse.
Should I see a doctor before trying orthotics or stretching?
For most adults with typical heel pain patterns, a trial of conservative care — stretching, supportive footwear, custom orthotics — is reasonable without an immediate clinic visit. See a doctor sooner if: you have severe pain, significant swelling, heel pain after an injury (possible stress fracture), or symptoms that don't respond at all after 6–8 weeks of consistent conservative management.
Does running make heel pain worse?
It depends on the cause and severity. Light walking is generally fine and may even help maintain tissue health. Running through moderate to severe heel pain risks worsening the condition and extending recovery. If you run regularly, reducing volume and avoiding hard surfaces is advisable during acute flares.
Heel pain is rarely one simple thing. The first step toward fixing it is understanding what's causing it — and that starts with where it hurts, when it hurts, and what makes it better or worse.
Take the foot assessment to find out what's driving your heel pain →