Heel pain is one of the most common reasons patients seek podiatric care, but “heel pain” is not a diagnosis — it is a symptom with several distinct causes that require different treatment approaches. The two most common are plantar fasciitis (pain under the heel and arch) and Achilles tendinopathy (pain at the back of the heel and lower leg). Getting the diagnosis right determines whether your treatment actually works. At Balance Foot & Ankle in Southeast Michigan, Dr. Tom Biernacki diagnoses heel pain precisely to ensure every patient gets the right treatment the first time.

Plantar Fasciitis: Pain Under the Heel

Plantar fasciitis is inflammation at the origin of the plantar fascia — the thick band of tissue that runs from the heel bone (calcaneus) across the arch to the toes. The classic symptom is sharp, stabbing pain on the bottom of the heel, worst with the first steps in the morning or after prolonged sitting (the “start-up pain” phenomenon). Pain typically improves somewhat with walking as the fascia warms up, but worsens again with prolonged activity. Tenderness on palpation is maximal at the medial calcaneal tubercle — the inside of the bottom of the heel where the fascia attaches. Heel spurs may be visible on X-ray but are usually not the source of pain. Ultrasound confirms fascial thickening (>4mm) and neovascularization at the enthesis.

Achilles Tendinopathy: Pain at the Back of the Heel

Achilles tendinopathy causes pain at the back of the heel, not underneath. It can be insertional (pain where the Achilles attaches to the calcaneus) or mid-portion (pain in the tendon body 2–6 cm above the insertion). Insertional Achilles tendinopathy is associated with Haglund’s deformity (a bony prominence on the posterior superior calcaneus) and retrocalcaneal bursitis. Mid-portion tendinopathy involves degenerative changes (tendinosis) within the tendon body, typically at the zone of relative avascularity 2–6 cm above the insertion. The pain is reproduced by pressing the back of the heel or the tendon body and by resisted plantarflexion. Ultrasound shows tendon thickening, hypoechoic areas of degeneration, and neovascularization on power Doppler.

Key Differences and Overlaps

The location of pain is the primary distinguishing feature: plantar fasciitis = bottom of heel; Achilles tendinopathy = back of heel or lower leg. However, they can coexist, and both are associated with tight calf muscles (gastrocnemius and soleus tightness increases both plantar fascial tension and Achilles loading). Treatment approaches differ significantly: plantar fasciitis responds to plantar fascia-specific stretching, calf stretching, and custom orthotics with heel padding; Achilles tendinopathy requires eccentric strengthening (the Alfredson protocol for mid-portion; modified eccentric for insertional) and specific footwear management. Corticosteroid injection is useful for plantar fasciitis but is avoided in the Achilles tendon itself due to rupture risk. Shockwave therapy (ESWT) is effective for both conditions but with different treatment parameters.

Frequently Asked Questions

The right treatment starts with the right diagnosis. Contact Balance Foot & Ankle to schedule a heel pain evaluation with Dr. Biernacki in Southeast Michigan.

Dr. Tom Biernacki, DPM

Dr. Tom Biernacki, DPM is a double board-certified podiatrist and foot & ankle surgeon at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has reached over one million views.