Heel Pain: Causes, Symptoms & Effective Treatment

What Causes Heel Pain?

Heel pain is most commonly caused by overuse or strain of the structures in the heel, including the plantar fascia, Achilles tendon, heel fat pad, and bursae. Poor footwear, obesity, high-impact activities, and age-related changes are major contributing factors.

The heel is a remarkably robust structure designed to absorb the impact of walking and running, withstanding forces many times your body weight with each step. Despite this durability, the heel can become painful when subjected to excessive stress, improper loading, or direct injury. Understanding the underlying cause of your heel pain is essential for effective treatment and prevention of recurrence.

Most people who develop heel pain have overloaded their heel over an extended period. This cumulative stress leads to microscopic damage in the tendons, fascia, or other soft tissues that exceeds the body's ability to repair itself. The result is chronic pain and inflammation that can persist for months if not properly addressed.

Footwear plays a critical role in heel health. Shoes with inadequate arch support, worn-out cushioning, or poor heel stability can alter the biomechanics of walking and running, placing abnormal stress on the heel. Even well-designed shoes that are not appropriate for your foot type or activity level can contribute to heel problems.

Plantar Fascia Overload

The plantar fascia is a thick band of connective tissue that runs along the bottom of the foot, connecting the heel bone to the toes. When this structure is repeatedly strained through activities like running, prolonged standing, or walking on hard surfaces, it can develop microtears and chronic inflammation. This condition, known as plantar fasciitis, is the most common cause of heel pain under the heel bone, affecting approximately 1 in 10 people at some point in their lives.

The pain from plantar fascia overload is typically most severe with the first steps in the morning or after prolonged sitting. This occurs because the fascia shortens during rest and is suddenly stretched when weight is placed on the foot. Over time, the body may respond to chronic inflammation by depositing calcium at the fascia's attachment point, creating a heel spur visible on X-ray, though the spur itself rarely causes pain.

Achilles Tendon Problems

The Achilles tendon connects the calf muscles to the heel bone and is essential for walking, running, and jumping. When this tendon is overloaded through increased activity, sudden changes in training intensity, or repetitive stress, it can develop tendinopathy - a condition characterized by pain, swelling, and stiffness at the back of the heel.

Achilles tendinopathy commonly affects recreational athletes, particularly runners and those who participate in sports involving jumping. The pain typically worsens during and after physical activity and may be accompanied by visible thickening of the tendon. In severe cases, the tendon can rupture completely, causing sudden, severe pain and inability to push off with the affected foot.

Bursitis

Bursae are small, fluid-filled sacs that cushion the joints and reduce friction between bones, tendons, and muscles. The heel contains several bursae, including one between the Achilles tendon and the heel bone (retrocalcaneal bursa) and one between the skin and the Achilles tendon. When these bursae become inflamed through overuse, direct trauma, or pressure from footwear, they can cause significant pain and swelling.

Heel bursitis often develops from repetitive activities like running or from wearing shoes that rub against the back of the heel. It can also occur as part of inflammatory conditions such as rheumatoid arthritis or gout. The pain typically worsens with activity and when pressing on the affected area.

Haglund's Deformity

Haglund's deformity, sometimes called "pump bump," is a bony enlargement on the back of the heel bone. This prominence can irritate the soft tissues when they rub against rigid shoe backs, leading to painful bursitis and inflammation. People with naturally prominent heel bones, tight Achilles tendons, or high arches are more susceptible to this condition.

The condition earned its nickname from its association with rigid-backed shoes, including pumps and certain athletic footwear. Over time, chronic irritation can lead to a visible and palpable bump on the heel, along with redness, swelling, and pain that worsens with activity.

Heel Fat Pad Problems

The heel fat pad is a specialized cushion of fatty tissue that sits beneath the heel bone, absorbing shock and protecting the underlying structures. As we age, this fat pad can thin and lose its elasticity, reducing its shock-absorbing capacity. This deterioration is accelerated in people with diabetes and those who are overweight.

When the heel fat pad becomes compromised, you may experience a deep, bruise-like pain directly under the heel bone that worsens with prolonged standing or walking on hard surfaces. Unlike plantar fasciitis, the pain from heel fat pad atrophy is typically constant rather than worse in the morning.

What Are the Symptoms of Heel Pain?

Heel pain symptoms vary based on the underlying cause but commonly include sharp or aching pain under or behind the heel, morning stiffness, pain that worsens with activity or prolonged standing, swelling, and tenderness when pressing on the heel.

The specific characteristics of your heel pain can provide valuable clues about its underlying cause. Different conditions produce distinct patterns of pain, and recognizing these patterns helps guide diagnosis and treatment. Most people experience a combination of symptoms that evolve over time as the condition progresses or responds to treatment.

Understanding when your pain occurs, what makes it better or worse, and exactly where it is located helps healthcare providers determine the most likely diagnosis and appropriate treatment approach. Keeping track of these details can make your medical appointment more productive.

Pain Under the Heel

Pain located on the bottom of the heel is most commonly associated with plantar fasciitis or heel fat pad problems. This type of pain is often described as a sharp, stabbing sensation that can feel like stepping on a stone or nail. The intensity may range from mild discomfort to severe pain that significantly limits walking.

A hallmark feature of plantar fasciitis is the "first-step pain" experienced upon getting out of bed in the morning or standing after prolonged sitting. This pain typically diminishes after a few minutes of walking as the plantar fascia stretches and warms up, though it may return after extended periods of standing or walking.

Some people notice that their heel pain worsens throughout the day, particularly if their job requires prolonged standing or walking on hard surfaces. The cumulative stress on the plantar fascia leads to increased inflammation and pain that may peak in the evening.

Pain at the Back of the Heel

Pain at the posterior heel, where the Achilles tendon attaches to the heel bone, suggests problems with the tendon or surrounding structures. This pain is often associated with visible or palpable changes such as swelling, thickening of the tendon, or a bony bump. The pain may extend up into the lower calf.

Achilles tendon pain typically worsens during and immediately after physical activity, especially activities involving pushing off or jumping. Morning stiffness is common, with the tendon feeling tight and painful until it warms up with gentle movement. Unlike plantar fasciitis, Achilles pain often persists throughout activity rather than improving with use.

Swelling and Tenderness

Visible swelling around the heel may indicate bursitis, Achilles tendinopathy, or acute injury. The swelling may be localized to a specific area or more diffuse, depending on the underlying condition. Warmth and redness accompanying swelling suggest active inflammation.

Tenderness to touch is present in most heel conditions and helps localize the problem. Pressing on different areas of the heel while noting where pain is reproduced can help distinguish between conditions. For example, tenderness at the inside bottom of the heel suggests plantar fasciitis, while tenderness at the back of the heel points to Achilles problems.

When Should You See a Doctor for Heel Pain?

See a doctor if heel pain persists for more than 2 weeks despite self-care, if you have severe pain or difficulty walking, if pain occurred after an injury, or if you notice numbness, tingling, fever, or significant swelling. Seek immediate care if you cannot bear weight on your foot.

While most heel pain responds well to home treatment and resolves within weeks to months, certain situations warrant professional medical evaluation. Knowing when to seek help ensures you receive appropriate diagnosis and treatment, preventing chronic problems and unnecessary suffering.

Most healthcare providers recommend trying conservative self-care measures for approximately two weeks before seeking medical attention for heel pain. However, the severity of symptoms and their impact on your daily activities should guide this decision. Pain that significantly limits your mobility or prevents you from working deserves earlier evaluation.

Signs You Should Seek Medical Care

Persistent heel pain that has not improved after two weeks of rest, ice, stretching, and appropriate footwear changes should be evaluated by a healthcare provider. This timeframe allows for natural healing of minor strains while identifying cases that need professional intervention.

Pain that awakens you from sleep, prevents you from performing normal activities, or is accompanied by systemic symptoms such as fever or unexplained weight loss requires prompt medical evaluation. These features may indicate infection, inflammatory arthritis, or other conditions requiring specific treatment.

If you have underlying health conditions such as diabetes, peripheral neuropathy, or rheumatoid arthritis, you should see a healthcare provider sooner rather than later. These conditions can complicate healing and increase the risk of serious complications from foot problems.

What to Expect at Your Appointment

During your medical visit, the healthcare provider will take a detailed history of your symptoms, including when they started, what makes them better or worse, and how they affect your daily activities. They will examine your foot, observing how you walk and checking for tenderness, swelling, and range of motion.

In most cases, heel pain can be diagnosed through history and physical examination alone. Imaging studies such as X-rays or ultrasound may be ordered to rule out fractures, confirm tendon problems, or evaluate bony abnormalities. MRI is reserved for complex cases or when surgery is being considered.

How Is Heel Pain Diagnosed?

Heel pain is typically diagnosed through physical examination and medical history. The doctor examines the heel, tests range of motion, and assesses how you walk. Imaging tests like X-rays, ultrasound, or MRI may be ordered to rule out fractures or evaluate soft tissue damage.

Accurate diagnosis of heel pain begins with a thorough conversation about your symptoms. Your healthcare provider will want to know precisely where the pain is located, when it started, what activities trigger or worsen it, and what you have tried for relief. Details about your footwear, exercise habits, and occupation help identify potential contributing factors.

The physical examination provides crucial information about the cause of your heel pain. Your provider will observe your feet while standing and walking, noting any abnormalities in foot structure or gait. They will palpate (press on) various areas of the heel and foot to identify points of maximum tenderness, which helps localize the problem.

Physical Examination Findings

Specific examination maneuvers can help distinguish between different causes of heel pain. Stretching the toes upward while pressing on the plantar fascia reproduces pain in plantar fasciitis. Squeezing the sides of the heel can identify stress fractures. Range of motion testing of the ankle and foot reveals tightness that may contribute to heel problems.

Your provider may also examine your shoes, looking for wear patterns that suggest abnormal gait mechanics. Uneven wear on the soles can indicate overpronation, supination, or other biomechanical issues that contribute to heel pain.

Imaging Studies

X-rays are the most commonly ordered imaging study for heel pain. They can reveal stress fractures, heel spurs, Haglund's deformity, and other bony abnormalities. However, many causes of heel pain involve soft tissues that are not visible on X-ray, so a normal X-ray does not rule out significant pathology.

Ultrasound is particularly useful for evaluating the plantar fascia and Achilles tendon. It can show thickening, tears, and inflammation in these structures. Ultrasound has the advantage of being relatively inexpensive, readily available, and able to assess the structures in motion.

MRI provides the most detailed view of both bone and soft tissue and is typically reserved for complex cases, suspected stress fractures not visible on X-ray, or planning for surgery. It can reveal subtle abnormalities in tendons, ligaments, and bone that other imaging misses.

What Can You Do at Home for Heel Pain?

Effective home treatment for heel pain includes rest and activity modification, ice therapy for 15-20 minutes several times daily, gentle stretching exercises for the calf and plantar fascia, wearing supportive footwear, using over-the-counter insoles, and taking NSAIDs for pain relief if needed.

Self-care measures form the foundation of heel pain treatment and are effective for the majority of cases. Starting appropriate home treatment early can prevent minor heel problems from becoming chronic conditions. The key is consistency - performing these measures regularly over several weeks gives the best results.

Most people see improvement within 2-6 weeks of consistent self-care, though complete resolution may take several months. If you don't notice any improvement after 2 weeks of dedicated home treatment, or if symptoms worsen, consult a healthcare provider for further evaluation.

Rest and Activity Modification

Reducing stress on the heel is essential for healing. This doesn't necessarily mean complete rest, but rather avoiding activities that aggravate your pain. If running causes pain, switch to swimming or cycling temporarily. If prolonged standing is unavoidable, take frequent sitting breaks and shift your weight between feet.

Avoid walking barefoot, especially on hard floors, as this places maximum stress on the plantar fascia and heel fat pad. Even at home, wear supportive sandals or slippers with cushioning and arch support.

Ice Therapy

Applying ice to the painful area reduces inflammation and provides temporary pain relief. Use an ice pack wrapped in a thin towel for 15-20 minutes, 2-3 times daily. A particularly effective technique for plantar fasciitis is rolling the foot over a frozen water bottle, which combines cold therapy with gentle stretching.

Ice is most beneficial after activities that trigger pain and before bed. Never apply ice directly to the skin, and limit applications to 20 minutes to prevent cold injury.

Stretching Exercises

Regular stretching of the calf muscles, Achilles tendon, and plantar fascia is one of the most effective treatments for heel pain. Tight calf muscles are a major contributing factor to both plantar fasciitis and Achilles tendinopathy. Stretching should be performed gently and held for 30 seconds, repeated 3-5 times, at least twice daily.

Effective stretches include standing calf stretches against a wall, step stretches where you lower your heel below step level, and towel stretches for the plantar fascia performed before getting out of bed in the morning. Night splints that keep the foot in a slightly flexed position can help prevent morning pain by maintaining gentle stretch on the plantar fascia overnight.

• Wall calf stretch: Lean against wall with one leg behind, keeping back heel on floor, hold 30 seconds
• Towel stretch: Loop towel around ball of foot and pull toes toward you while seated, hold 30 seconds
• Step stretch: Stand on step with heels hanging off edge, slowly lower heels below step level, hold 30 seconds
• Plantar fascia stretch: Cross affected leg over knee, pull toes back toward shin, hold 30 seconds

Supportive Footwear and Insoles

Wearing shoes that provide adequate cushioning, arch support, and heel stability is crucial for heel pain recovery. Look for shoes with a firm heel counter (the back of the shoe), good shock absorption, and appropriate arch support for your foot type. Replace worn athletic shoes every 300-500 miles or when cushioning is noticeably compressed.

Over-the-counter heel cushions and arch supports can provide additional relief. Silicone heel cups cushion the heel fat pad, while arch supports reduce strain on the plantar fascia. More significant biomechanical problems may require custom orthotics prescribed by a podiatrist or orthopedic specialist.

What Are the Best Shoes for Heel Pain?

The best shoes for heel pain have good arch support, cushioned soles, a stable and reinforced heel counter, room for your toes, and are appropriate for your activity. Avoid flat shoes, flip-flops, and walking barefoot. Custom orthotics may be needed for persistent problems.

Proper footwear is both treatment and prevention for heel pain. The right shoes can reduce stress on the heel structures, support proper foot mechanics, and provide cushioning that protects against impact forces. Many people find that simply changing their footwear provides significant relief.

When selecting shoes for heel pain, prioritize function over fashion. While this may require some adjustments to your wardrobe, the investment in proper footwear pays dividends in reduced pain and faster healing.

Key Features of Good Shoes

A firm heel counter provides stability and prevents excessive motion that strains the plantar fascia and Achilles tendon. Test this by squeezing the back of the shoe - it should feel sturdy rather than collapsing easily. The heel counter should fit snugly around your heel without slipping or causing pressure points.

The sole should be cushioned but not overly soft, providing shock absorption without sacrificing stability. Look for shoes with proven cushioning technology and adequate thickness to protect against hard surfaces. The sole should also be relatively stiff and difficult to twist, providing support for the midfoot.

Adequate arch support helps distribute pressure evenly across the foot rather than concentrating it at the heel. People with flat feet or high arches may need additional arch support from insoles or custom orthotics. The shoe should have enough room in the toe box for your toes to spread naturally without crowding.

Shoes to Avoid

Flat shoes without arch support, including ballet flats, flip-flops, and many casual sandals, offer minimal protection for the heel and often worsen heel pain. High heels alter foot biomechanics and can strain the Achilles tendon and plantar fascia. Worn-out shoes with compressed cushioning provide inadequate support.

Avoid walking barefoot on hard surfaces, which places maximum stress on the heel. Even at home, wear supportive slippers or sandals with cushioning and arch support.

How Is Heel Pain Treated?

Heel pain treatment typically begins with conservative measures including rest, stretching, ice, supportive footwear, and sometimes physical therapy. Medications like NSAIDs can reduce pain and inflammation. Corticosteroid injections may be used for persistent cases. Surgery is rarely needed, reserved for cases that don't respond to other treatments.

The vast majority of heel pain responds to conservative treatment, with approximately 80% of cases resolving within one year without surgery. Treatment is typically stepwise, starting with simple measures and progressing to more intensive interventions only if initial approaches fail. The key is patience and consistency, as healing takes time.

Treatment selection depends on the specific diagnosis, symptom severity, and individual factors such as activity level, occupation, and underlying health conditions. Most people benefit from a combination of approaches rather than any single treatment.

Physical Therapy

Physical therapy is often an important component of treatment for heel pain, particularly for Achilles tendinopathy and persistent plantar fasciitis. A physical therapist can design a personalized exercise program that addresses your specific deficits and goals, ensuring proper technique and progression.

Physical therapy for heel pain typically includes stretching and strengthening exercises, manual therapy techniques, and modalities such as ultrasound or electrical stimulation. The therapist may also analyze your gait and recommend modifications to reduce stress on the heel. Education about activity modification and home exercise is an important part of the program.

Eccentric exercises, which involve slowly lowering the heel while bearing weight, have strong evidence for treating Achilles tendinopathy. These exercises stimulate tendon remodeling and strengthening when performed consistently over 12 weeks.

Medications

Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen can help reduce pain and inflammation. These medications work best when taken regularly for a short period rather than just when pain is severe. Follow package directions and don't exceed recommended doses.

NSAIDs can cause stomach irritation and other side effects, particularly with long-term use. Older adults and those with certain health conditions should use these medications cautiously and under medical supervision. Topical NSAIDs applied directly to the painful area may provide relief with fewer systemic side effects.

Corticosteroid Injections

For heel pain that doesn't respond to initial conservative measures, corticosteroid injections may provide relief. These injections deliver powerful anti-inflammatory medication directly to the affected area, reducing pain and swelling. However, they are not without risks and are typically used judiciously.

Repeated corticosteroid injections can weaken tendons and the plantar fascia, potentially increasing the risk of rupture. For this reason, most providers limit the number of injections and combine them with other treatments to address the underlying cause. Injections provide temporary relief and are not a cure on their own.

Surgery

Surgery for heel pain is reserved for cases that fail to respond to 6-12 months of comprehensive conservative treatment. Less than 5% of people with heel pain ultimately require surgery. Surgical options depend on the underlying condition and may include plantar fascia release, removal of bone spurs, debridement of damaged tendon tissue, or removal of the retrocalcaneal bursa.

Recovery from heel surgery varies depending on the procedure but typically requires several weeks of limited weight-bearing followed by a gradual return to activities. Physical therapy is usually needed to restore strength and flexibility. While most people experience significant improvement after surgery, complete pain relief is not guaranteed.

How Can You Prevent Heel Pain?

Prevent heel pain by wearing supportive, properly-fitting shoes, maintaining a healthy weight, stretching your calves and feet regularly, increasing activity levels gradually, replacing worn athletic shoes, and avoiding walking barefoot on hard surfaces.

Once you've experienced heel pain, you'll want to take steps to prevent it from returning. Prevention strategies focus on reducing stress on the heel structures, maintaining flexibility, and addressing risk factors that contribute to heel problems. Many of the same measures that treat heel pain also prevent its recurrence.

Footwear and Support

Investing in quality, supportive footwear is one of the most important preventive measures. Choose shoes appropriate for your activities, and don't wear the same pair day after day - rotating between shoes allows them to fully dry and recover their cushioning. Replace athletic shoes regularly, before they become visibly worn.

Consider using over-the-counter arch supports or heel cushions in all your shoes. If you have significant biomechanical issues, custom orthotics prescribed by a specialist may provide better prevention than over-the-counter options.

Exercise and Flexibility

Regular stretching of the calf muscles and plantar fascia should become part of your daily routine, even after pain resolves. A few minutes of stretching in the morning and evening can maintain flexibility and reduce the risk of recurrence. Strengthening exercises for the foot and ankle also provide protective benefits.

When increasing activity levels, do so gradually. Rapid increases in running mileage, walking distance, or time spent standing are common triggers for heel pain. Follow the "10% rule" - don't increase your weekly activity by more than 10% at a time.

Weight Management

Maintaining a healthy body weight reduces stress on all the structures of the foot, including the heel. Even modest weight loss can significantly reduce heel loading and decrease the risk of heel pain. If you're overweight and experiencing heel pain, weight loss should be part of your treatment and prevention plan.