Heel Pain Causes: Complete Guide | Podiatrist Howell MI

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That stabbing pain in your heel when you take your first steps in the morning — or the ache that builds after a long day on your feet — is one of the most common reasons patients visit our clinic. Heel pain affects millions of Americans each year, yet it’s consistently undertreated because people assume it’s just something they have to live with.

The reality is that most heel pain has a specific, identifiable cause — and each cause has a specific, effective treatment. Getting the diagnosis right is the difference between resolving heel pain in weeks versus suffering for months or years. Dr. Tom Biernacki, DPM explains the full spectrum of heel pain causes and how we approach diagnosis at Balance Foot & Ankle.

Most Common Causes of Heel Pain

Heel pain is a symptom, not a diagnosis. The location, timing, and character of your pain are the most important diagnostic clues — which is why a thorough history and physical examination is essential before any treatment is started.

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1. Plantar Fasciitis

By far the most common cause of heel pain, plantar fasciitis involves inflammation and microtearing of the plantar fascia — the thick band of connective tissue running from the calcaneus (heel bone) to the base of the toes. Classic presentation: sharp pain at the medial (inner) aspect of the heel, worst with the first steps after rest (post-static dyskinesia), easing after 10–15 minutes of walking, but returning after prolonged standing or activity. Pain is reproduced by palpating the medial calcaneal tubercle (the bony bump at the base of the heel).

2. Achilles Tendinitis

Achilles tendinitis causes pain at the back of the heel, not underneath it — an important distinguishing feature. Insertional Achilles tendinitis affects the point where the tendon attaches to the heel bone (often with a bony prominence — Haglund’s deformity). Midportion tendinitis causes pain 2–6cm above the insertion. Morning stiffness and pain with activity that warms up and then returns worse after stopping are typical. Squeezing the tendon reproduces pain, as does the arc sign (moving tenderness with ankle motion).

3. Heel Spurs

A heel spur is a bony calcium deposit on the calcaneus, most commonly at the plantar fascia insertion. Critically: heel spurs themselves are not always the cause of pain. They’re present on X-ray in 15% of pain-free adults and in 50% of plantar fasciitis patients. The spur is often a result of chronic plantar fascial tension, not the primary cause of symptoms. Treating “the spur” is a common misdirection — treating the fascia is what resolves the pain.

4. Stress Fracture of the Calcaneus

A calcaneal stress fracture presents as diffuse heel pain that worsens progressively with activity and doesn’t respond to typical plantar fasciitis treatment. The squeeze test — compressing the heel from both sides simultaneously — is positive (painful) and helps differentiate stress fracture from plantar fasciitis. Risk factors include rapid increases in training load, osteoporosis, and female athletes (female athlete triad). Diagnosis requires MRI, as stress fractures are often invisible on initial X-ray.

5. Tarsal Tunnel Syndrome

Tarsal tunnel syndrome is compression of the posterior tibial nerve as it passes through the tarsal tunnel (a channel behind the medial ankle). It causes burning, tingling, or electric pain radiating from the inside of the heel into the arch and toes — symptoms that often worsen at night. Tinel’s sign (tapping over the tarsal tunnel reproduces shooting pain) is positive. This is the foot’s equivalent of carpal tunnel syndrome and requires nerve decompression if conservative care fails.

6. Subcalcaneal Bursitis

Subcalcaneal bursitis is inflammation of the bursa (fluid-filled sac) beneath the heel bone. It’s associated with fat pad atrophy and direct heel impact — common in older adults and those on hard floors. The pain is directly under the center of the heel rather than the medial aspect, distinguishing it from plantar fasciitis on examination.

7. Seronegative Spondyloarthropathy

Inflammatory arthritis conditions — including ankylosing spondylitis, reactive arthritis, and psoriatic arthritis — can cause enthesitis (inflammation at ligament/tendon insertion points), presenting as heel pain that mimics plantar fasciitis but is often bilateral, worse at rest, and associated with morning stiffness lasting more than an hour. Any patient with bilateral heel pain, systemic symptoms, or no mechanical cause should be screened for inflammatory arthropathy.

How Heel Pain Is Diagnosed

At Balance Foot & Ankle, we diagnose heel pain through a structured process: a detailed history covering onset, activity level, footwear, and symptom pattern; physical examination including palpation mapping, range-of-motion testing, and provocative maneuvers; and diagnostic imaging as indicated. X-rays identify heel spurs, fractures, and arthritis. Ultrasound assesses plantar fascia thickness in real-time and confirms fasciitis or bursitis. MRI is used when stress fracture, nerve compression, or soft tissue pathology isn’t clear on ultrasound.

Heel Pain Treatment

Treatment depends entirely on the correct diagnosis. For plantar fasciitis: stretching (plantar fascia and Achilles), supportive footwear, custom orthotics, NSAIDs, night splints, and cortisone or PRP injections for recalcitrant cases. For Achilles tendinopathy: eccentric heel drop protocol (Alfredson program), load management, and shockwave therapy. For stress fractures: activity modification and protected weight-bearing. For tarsal tunnel: nerve gliding, orthotics, and surgical decompression if needed.

Frequently Asked Questions

Why is heel pain worse in the morning?

During sleep, the plantar fascia shortens slightly as the foot rests in a plantarflexed position. The first steps of the day stretch this contracted tissue suddenly, tearing micro-adhesions that formed overnight — creating the characteristic “post-static dyskinesia” of plantar fasciitis. This is why night splints (which hold the foot in dorsiflexion while sleeping) significantly reduce morning pain.

Does walking make heel pain worse?

In plantar fasciitis, pain often improves after the first few minutes of walking but returns after prolonged activity. Complete rest is not recommended — maintaining low-impact movement helps prevent stiffness. Avoiding barefoot walking on hard surfaces (tile, hardwood) is one of the most impactful immediate changes patients can make.

Sources

1. Goff JD, Crawford R. Diagnosis and treatment of plantar fasciitis. Am Fam Physician. 2011;84(6):676-682.
2. Buchbinder R. Plantar fasciitis. N Engl J Med. 2004;350(21):2159-66.
3. Draghi F, et al. Imaging of plantar fascia disorders. Insights Imaging. 2017;8(1):69-78.
4. Maffulli N, et al. Achilles tendinopathy: aetiology and management. J R Soc Med. 2004;97(10):472-476.
5. American Academy of Orthopaedic Surgeons: Plantar Fasciitis and Bone Spurs — OrthoInfo