Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatric Surgeon — Balance Foot & Ankle, Howell & Bloomfield Hills, MI. Last updated April 2026.

Heel pain is the most common foot complaint seen by podiatrists — but not all heel pain is plantar fasciitis. At least 15 distinct conditions cause heel pain, and the treatments differ significantly. Giving the wrong treatment for the wrong diagnosis wastes months and may worsen the underlying condition. This guide covers the full differential diagnosis of heel pain, from the most common to the most critical not-to-miss diagnoses. At Balance Foot & Ankle in Howell and Bloomfield Hills, Michigan, Dr. Tom Biernacki, DPM diagnoses the exact cause of heel pain — not just the most likely cause — before recommending any treatment.

Quick Answer: Why Accurate Heel Pain Diagnosis Matters

Plantar fasciitis accounts for approximately 70–80% of heel pain presentations, but the remaining 20–30% represent other conditions that require different treatment. A cortisone injection is appropriate for plantar fasciitis but contraindicated in fat pad atrophy. A stretching protocol helps plantar fasciitis but won’t address Baxter’s neuropathy. A boot resolves most heel stress fractures but does nothing for tarsal tunnel syndrome. The most common reasons heel pain doesn’t respond to treatment: the wrong diagnosis was made, or multiple concurrent conditions were not identified. See a podiatrist before starting any treatment program for heel pain that has lasted more than 4 weeks.

1. Plantar Fasciitis — Most Common (70–80%)

Plantar fasciitis is inflammation at the origin of the plantar fascia on the medial plantar heel. Classic presentation: sharp pain with the first few steps in the morning that improves with walking, then returns after prolonged sitting. Point tender at the medial plantar heel. Windlass test (dorsiflexing the big toe) reproduces pain. Responds to stretching, orthotics, shockwave therapy. See our comprehensive Plantar Fasciitis Guide.

2. Calcaneal Stress Fracture — Must Not Miss

A calcaneal stress fracture must not be missed and treated as plantar fasciitis — continued loading converts a partial fracture to a complete fracture. Key differentiator: positive squeeze test (medial-lateral heel compression reproduces pain). Pain worsens throughout the day (not best with first steps). Common in runners with rapid mileage increases. MRI diagnostic. Non-weight-bearing required. See our Calcaneal Stress Fracture Guide.

3. Baxter’s Neuropathy (Inferior Calcaneal Nerve Entrapment)

Baxter’s neuropathy compresses the first branch of the lateral plantar nerve (Baxter’s nerve) between the abductor hallucis muscle and the medial head of the quadratus plantae. It mimics plantar fasciitis but presents with burning or tingling quality pain at the medial heel and sometimes extending into the lateral arch. Tinel’s sign may be positive at the medial calcaneal nerve. Key: doesn’t improve with plantar fascia stretching. Responds to nerve-specific treatment (orthotics to reduce muscle belly compress

ion, steroid injection at the nerve, and surgical decompression when needed). See our Baxter’s Neuropathy Guide.

4. Fat Pad Atrophy

Fat pad atrophy causes diffuse central heel pain from thinning of the calcaneal fat pad. Pain is worst on hard floors barefoot, not with first morning steps. Heel bone feels prominently palpable. Common in older adults and after repeated cortisone injections. Cortisone injection is absolutely contraindicated — it accelerates atrophy. Treated with gel heel cups and cushioned footwear. See our Fat Pad Atrophy Guide.

5. Heel Spur

Heel spurs (calcaneal enthesophytes) are bony outgrowths at the plantar fascia origin, visible on X-ray in approximately 15% of adults. They are present in 50% of plantar fasciitis patients but also in 15% of pain-free individuals — meaning the spur is often incidental. Treating the spur rather than the plantar fascia is the most common surgical mistake. See our Heel Spur Guide.

6. Insertional Achilles Tendinopathy / Haglund’s Deformity

Insertional Achilles tendinopathy causes posterior heel pain — at the back of the heel — rather than plantar. The tendon insertion on the calcaneus becomes painful from calcification and degeneration. Haglund’s deformity is a bony prominence at the posterosuperior calcaneus that causes “pump bump” — aggrava

ted by rigid heel counter shoes. Responds to heel lifts, activity modification, and ESWT. See our Haglund’s Deformity Guide.

7. Tarsal Tunnel Syndrome

Tarsal tunnel syndrome compresses the posterior tibial nerve behind the medial ankle, radiating burning and tingling into the heel and sole. Positive Tinel’s sign at the medial ankle. Distinct from plantar fasciitis by its neurological quality (burning/tingling rather than sharp), radiation pattern, and medial ankle Tinel’s. EMG confirms. Responds to orthotics and corticosteroid injection; surgical decompression when conservative care fails. See our Tarsal Tunnel Syndrome Guide.

8. Sever’s Disease (Pediatric Patients)

Sever’s disease is apophysitis of the calcaneal growth plate in children ages 8–14, causing posterior-inferior heel pain during and after sports. Pain with squeeze test at the posterior calcaneus. Responds to heel lifts, activity modification, and stretching. Self-limiting — resolves with skeletal maturity. See our Sever’s Disease Guide.

9. Plantar Fibromatosis

Plantar fibromas cause a firm nodule within the plantar fascia, usually in the mid-arch but sometimes extending to the heel insertion. Not tender on the heel directly — tenderness is the nodule. Managed with accommodation orthotics and cortisone injection for pain; surgery for large or progressive lesions. See our Plantar Fibroma Guide.

10. Systemic Causes of Heel Pain

Bilateral or atypical heel pain that doesn’t respond to mechanical treatment warrants evaluation for systemic causes:

• Ankylosing spondylitis and reactive arthritis — Enthesopathy (inflammation at tendon/ligament insertions) causes bilateral heel pain; ask about back pain, morning stiffness, uveitis
• Rheumatoid arthritis — Retrocalcaneal bursitis and plantar fascia involvement; symmetric; associated joint swelling
• Gout — Heel can be affected; acute severe attack with warmth and

  Urgent heel pain warning signs:

  • Sudden severe heel pain after a fall or high-impact activity (possible fracture)
  • Inability to bear any weight on the heel
  • Heel pain with fever, redness, or warmth (possible infection)
  • Night pain that wakes you from sleep (rule out tumor or systemic disease)
  • Bilateral heel pain with morning stiffness (evaluate for inflammatory arthritis)
  redness; uric acid elevated
• Paget’s disease of bone — Calcaneal involvement; X-ray shows typical cotton-wool appearance; elevated alkaline phosphatase

Red Flags: When Heel Pain Needs Urgent Evaluation

• Cannot bear weight at all — calcaneal fracture until proven otherwise
• Sudden onset with pop or crack — acute tendon rupture or fracture
• Heel pain at rest and at night — stress fracture, tumor, or infection
• Bruising without significant trauma — fracture in osteoporotic bone
• Diabetic patient with heel pain — Charcot arthropathy must be excluded immediately
• Fever with heel pain — septic arthritis, osteomyelitis
• Bilateral heel pain worse in the morning improving with activity — spondyloarthropathy

Heel Pain Evaluation in Michigan — Same-Day Available

Dr. Tom Biernacki, DPM at Balance Foot & Ankle provides comprehensive heel pain differential diagnosis at both our Howell and

Frequently Asked Questions About Heel Pain

Why does my heel hurt in the morning?

Morning heel pain is the hallmark of plantar fasciitis — the fascia tightens overnight and micro-tears when you take your first steps. However, morning stiffness in both heels may indicate inflammatory arthritis and warrants blood work.

Can heel pain be something other than plantar fasciitis?

Yes. At least 10 other conditions can cause heel pain, including stress fractures, nerve entrapment, fat pad atrophy, and Achilles tendinopathy. In our clinic, we find that roughly 20-30% of patients referred to us for “plantar fasciitis” actually have a different diagnosis.

When should I see a podiatrist for heel pain?

See a podiatrist if heel pain persists beyond 2 weeks of home treatment, if you cannot bear weight, if pain wakes you at night, or if you notice swelling, redness, or bruising around the heel.

Bloomfield Hills locations. Same-day evaluation available for acute presentations. Call (810) 206-1402 or book online.

Related Heel Pain Guides

• Plantar Fasciitis Complete Guide
• Calcaneal Stress Fracture Guide
• Baxter’s Neuropathy Guide
• Fat Pad Atrophy Guide
• Haglund’s Deformity Guide
• Sever’s Disease — Pediatric Heel Pain

Expert Heel Pain Treatment in Michigan

Heel pain has many possible causes beyond plantar fasciitis. Our podiatrists perform thorough evaluations to identify the exact source of your pain and provide targeted, effective treatment.

Learn About Our Heel Pain Treatment → | Book Your Appointment | Call (810) 206-1402

Clinical References

1. Thomas JL, Christensen JC, et al. “The diagnosis and treatment of heel pain: a clinical practice guideline.” Journal of Foot and Ankle Surgery. 2010;49(3 Suppl):S1-S19.
2. Yi TI, Lee GE, et al. “Differential diagnosis of heel pain.” Annals of Rehabilitation Medicine. 2011;35(4):507-513.
3. Tu P, Bytomski JR. “Diagnosis of heel pain.” American Family Physician. 2011;84(8):909-916.