Heel pain is most commonly caused by overload or inflammation of the plantar fascia or Achilles tendon, but it can also arise from bony, neural, and systemic disorders. Because the heel tolerates significant ground reaction forces during weight-bearing, even subtle biomechanical or tissue changes can produce disabling symptoms. This essay outlines the principal causes of heel pain, grouped by anatomical region and mechanism, with reference to underlying pathophysiology and clinical context.
Plantar (inferior) heel pain
Plantar fasciitis
Plantar fasciitis is the single most common cause of heel pain. The plantar fascia is a thick aponeurosis that extends from the medial calcaneal tuberosity to the bases of the toes, acting as a dynamic stabiliser of the foot arch. Repetitive tensile loading—particularly with excessive pronation, tight calf muscles, or sudden increases in activity—produces microtrauma and degenerative changes at the fascial origin rather than purely inflammatory ones. Clinically, this manifests as sharp, focal pain at the medial inferior heel, often worst with the first steps after rest and improved with mild activity, then returning after prolonged standing.
Risk factors include obesity, flat feet or rigid high arches, abnormal gait (e.g. overpronation), prolonged standing on hard surfaces, and wearing shoes with poor cushioning or support. In chronic cases, traction at the calcaneal attachment may stimulate a plantar heel spur; the spur itself is often not painful, but reflects the same biomechanical overload that drives fasciitis.
Heel spur and fat pad atrophy
Heel spurs are bony projections that can develop on the inferior calcaneus in association with chronic plantar fasciitis or traction. While many patients with spurs are asymptomatic, some experience localized inferior heel pain, especially during weight-bearing after rest. Fat pad atrophy refers to thinning of the subcutaneous cushion beneath the calcaneus, commonly seen in older adults or after repeated steroid injections. Loss of this natural padding reduces shock absorption, producing deep, central heel pain that worsens with barefoot walking and improves when the patient walks on their toes, thereby shifting load away from the central heel.
Calcaneal stress fracture and bruising
Calcaneal stress fractures result from repetitive overload, often in runners, military personnel, or individuals who suddenly increase activity on hard surfaces. Pain is typically diffuse over the heel, present with weight-bearing, and may not improve with rest; compression of the calcaneus from side to side often reproduces pain. Early radiographs can be normal, necessitating MRI or bone scan for diagnosis. Acute heel bruise (contusion) occurs after a direct impact, such as landing from a jump or stepping on a hard object, causing localized pain and sometimes swelling.
Posterior (back of heel) pain
Achilles tendinitis and tendinopathy
Achilles tendinitis (more accurately, tendinopathy) is a common cause of posterior heel pain, affecting the tendon that connects the calf muscles to the calcaneus. Repetitive microtrauma from running, jumping, or abrupt increases in training load leads to degeneration and failed healing within the tendon, often with associated swelling and pain 2–6 cm above the calcaneal insertion. Pain is typically worse at the start of activity, may ease with warming up, and then recur after prolonged use. Risk factors include tight gastrocnemius–soleus muscles, poor footwear, and biomechanical abnormalities such as excessive pronation or hindfoot varus.
Retrocalcaneal bursitis and Haglund’s deformity
Retrocalcaneal bursitis involves inflammation of the bursa between the Achilles tendon and the anterior surface of the calcaneus, producing pain and swelling at the back of the heel, often with redness. It is frequently associated with Haglund’s deformity, a bony prominence on the posterosuperior calcaneus that impinges on surrounding soft tissues during ankle motion. The combination of bony enlargement and repetitive friction can cause significant pain, especially in active individuals or those wearing rigid-backed shoes.
Achilles tendon rupture
A complete or partial rupture of the Achilles tendon typically occurs after a sudden, forceful push-off or landing, often with a audible “pop” and immediate inability to calf-rise or walk normally. Pain may be severe initially but can become less intense as the tendon heals in a non-functional position, leading to persistent weakness and gait abnormality.
Medial, lateral, and neural causes
Tarsal tunnel syndrome and nerve compression
Tarsal tunnel syndrome results from compression of the posterior tibial nerve as it passes through the tarsal tunnel on the medial aspect of the foot, producing burning pain, tingling, or numbness in the heel and arch. Tenderness over the tunnel and a positive Tinel’s sign support the diagnosis. Baxter’s nerve compression, involving the first branch of the lateral plantar nerve, can mimic plantar fasciitis with medial plantar heel pain and is often under-recognized in runners. Peripheral neuropathy, particularly in diabetes, can also produce diffuse or burning heel pain, often with altered sensation and decreased protective reflexes.
Referred pain from lumbar radiculopathy
Pain on the lateral aspect of the foot and heel may be referred from an L5–S1 disc herniation compressing the S1 nerve root, leading to radicular symptoms that include pain, hypoesthesia, and sometimes weakness in the hamstring and calf muscles. In such cases, heel pain is part of a broader pattern of neuropathic symptoms rather than a local foot pathology.
Systemic and inflammatory conditions
A range of systemic diseases can present with heel pain. Rheumatoid arthritis, psoriatic arthritis, reactive arthritis, and ankylosing spondylitis may cause inflammatory pain in the Achilles tendon insertion, plantar fascia, or surrounding joints, often with morning stiffness and bilateral involvement. Paget’s disease of bone, osteomyelitis, and bone tumors are less common but important considerations, particularly when pain is persistent, progressive, and not clearly related to mechanical loading. Plantar warts can cause focal inferior heel pain, especially when located under the calcaneal area, and are distinguished by their characteristic surface appearance and tenderness with lateral compression.
Biomechanical and lifestyle contributors
Many causes of heel pain are strongly influenced by biomechanics and lifestyle. Abnormal walking patterns, such as overpronation or excessive supination, alter load distribution across the plantar fascia, Achilles tendon, and calcaneus, predisposing to overload injuries. Obesity increases ground reaction forces and tensile stress on the plantar fascia and fat pad, accelerating wear and tear. Ill-fitting shoes, particularly those with poor arch support, inadequate cushioning, or excessively rigid heel counters, fail to attenuate shock and can exacerbate local pathology. Activities involving repetitive jumping, running, or prolonged standing on hard surfaces are frequent precipitants of both plantar fasciitis and Achilles tendinopathy.
In children, Sever’s disease (calcaneal apophysitis) is a common cause of heel pain, resulting from stress on the growth plate of the calcaneus during periods of rapid growth and high activity levels. This condition is typically self-limiting but requires activity modification and appropriate footwear to prevent chronicity.[
Heel pain arises from a diverse set of causes, but the majority are mechanical in nature, involving the plantar fascia, Achilles tendon, calcaneal bone, or surrounding soft tissues. Plantar fasciitis and Achilles tendinopathy dominate the clinical picture, while stress fractures, fat pad atrophy, nerve compressions, and systemic inflammatory conditions represent important secondary categories. Understanding the anatomical location of pain, associated symptoms, and contributing biomechanical and lifestyle factors is essential for accurate diagnosis and targeted management. In a podiatric context, this knowledge supports both clinical assessment and the development of individualized treatment strategies, including footwear modification, orthotic prescription, gait retraining, and, where necessary, advanced imaging or referral.