Heel pain is an exceptionally common complaint that can affect people of all ages and activity levels. While it is rarely a sign of a life-threatening condition, its impact on daily activities like walking, standing, and exercising can be significant and frustrating . The pain can manifest at the bottom of the heel, the back of the heel, or deep within the foot, and its causes are diverse. Understanding these causes is the first step toward effective management and relief.
The Usual Suspects: Overuse and Mechanical Stress
The vast majority of heel pain cases are not caused by a single traumatic event but rather by repetitive stress and biomechanical issues that gradually damage the soft tissues and bones of the foot.
Plantar Fasciitis: The Leading Cause of Bottom-of-the-Heel Pain
By far, the most frequent cause of heel pain is plantar fasciitis, which affects the bottom of the heel . The plantar fascia is a thick band of tissue that runs along the bottom of the foot, connecting the heel bone to the toes and supporting the arch. Contrary to its name, which implies inflammation (“-itis”), research suggests the condition is often more degenerative than inflammatory, leading some experts to prefer the term “plantar fasciosis” .
The pain of plantar fasciitis is typically caused by repetitive stretching and microtearing of the fascia at its attachment point on the heel bone . This results in a characteristic sharp, stabbing pain with the first few steps in the morning or after periods of rest, which often lessens as the tissue warms up with activity . Several factors increase the risk of developing this condition. A shortened or tight Achilles tendon is a primary culprit, as it places extra tension on the plantar fascia . Biomechanical factors such as having very high or low arches, obesity, and occupations that require prolonged standing on hard surfaces are also significant contributors . Furthermore, a sudden increase in activity level, common among runners and weekend warriors, can overload the fascia and trigger pain .
Achilles Tendinitis: The Primary Cause of Back-of-the-Heel Pain
When pain is felt at the back of the heel, the Achilles tendon is often involved. This largest tendon in the body connects the calf muscles to the heel bone and is essential for pushing off the foot during walking, running, and jumping . Achilles tendinitis is typically an overuse injury resulting from repetitive or intense strain on the tendon . It is common in runners who have suddenly increased the intensity or duration of their runs and in middle-aged individuals who engage in high-impact sports only on weekends .
Similar to plantar fasciitis, the problem often involves degenerative changes in the tendon tissue, sometimes referred to as Achilles tendinopathy . The pain usually begins as a mild ache after activity and can progress to a more persistent, severe pain accompanied by stiffness and tenderness, especially in the morning . Risk factors include age-related tendon weakening, tight calf muscles, and training errors such as running in worn-out shoes or on hills . Interestingly, emerging research also highlights the role of metabolic health, linking conditions like obesity and insulin resistance to an increased risk and chronicity of Achilles tendinopathy, possibly due to their creation of a pro-inflammatory environment .
Bursitis: Inflammation of the Cushioning Sacs
Heel pain can also stem from bursitis, the inflammation of a bursa—a fluid-filled sac that cushions bones and tendons. The retrocalcaneal bursa, located behind the heel bone between the Achilles tendon and the calcaneus, is particularly vulnerable . When this bursa becomes irritated and inflamed, often due to overuse from excessive walking, running, or jumping, it leads to pain at the back of the heel . This condition, retrocalcaneal bursitis, is frequently linked with Achilles tendinitis . It can also be triggered by a rapid increase in activity without proper conditioning or by wearing ill-fitting shoes . Symptoms include pain that worsens when pressing on the area or standing on tiptoes, and sometimes redness and warmth over the back of the heel .
The following table summarizes the key differences between these three common causes of heel pain:
| Cause of Heel Pain | Primary Location of Pain | Typical Description of Pain | Key Contributing Factors |
|---|---|---|---|
| Plantar Fasciitis | Bottom of the heel | Sharp, stabbing pain with first steps in the morning | Tight Achilles tendon, high/low arches, obesity, prolonged standing |
| Achilles Tendinitis | Back of the heel | Aching, burning pain along the tendon, stiffness | Overuse, tight calf muscles, sudden increase in activity, age |
| Retrocalcaneal Bursitis | Back of the heel | Pain with pressure or rising on toes, possible swelling/redness | Overuse, rapid activity increase, improper footwear |
Beyond Overuse: Other Structural and Medical Causes
While overuse is the most common theme, other factors can cause or contribute to heel pain.
Heel Spurs and Bone Fractures
A heel spur is a bony growth on the heel bone. For a long time, these spurs were thought to be a primary cause of pain. However, it is now understood that they are often a result, not the cause, of the problem. A heel spur frequently forms in response to the chronic traction and pulling of the plantar fascia on the heel bone . Consequently, many people with heel spurs experience no pain at all, with the spur being an incidental finding on an X-ray .
In contrast, a fracture of the heel bone (calcaneus) is an unmistakably painful event. These fractures are usually the result of high-impact trauma, such as a fall from a height or a car accident, and are often accompanied by other injuries to the knee or spine . The pain is severe, the foot and ankle swell significantly, and the individual is unable to bear weight . A less severe but more insidious type of fracture is a stress fracture, an incomplete crack caused by repetitive force. This is common in long-distance runners and athletes who dramatically increase their training intensity, leading to localized pain that worsens with activity .
Systemic Diseases and Nerve Issues
Occasionally, heel pain can be a symptom of a broader medical condition. Inflammatory forms of arthritis, such as rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis, can involve the heel, causing pain at the points where tendons and ligaments attach to the bone . Gout, a condition caused by the buildup of uric acid crystals, can also manifest as acute, severe pain and inflammation at the back of the heel . Furthermore, nerve-related problems can mimic heel pain. Tarsal tunnel syndrome, where a nerve is compressed on the inside of the ankle, or a pinched nerve in the lower back (sciatica) can radiate pain down the leg and into the heel .
Pain in the heel is a multifaceted symptom with a wide range of potential causes. It most commonly arises from mechanical overload and overuse, leading to conditions like plantar fasciitis and Achilles tendinitis. However, it is crucial to recognize that acute injuries, systemic inflammatory diseases, and nerve entrapments can also be responsible. While many cases of mild heel pain will resolve with simple home care such as rest, ice, and proper footwear , persistent or severe pain warrants a professional evaluation. A thorough understanding of the underlying cause is essential for guiding effective treatment and ensuring a return to pain-free movement.