Causes of Heel Pain and Treatment Options

Everything you need to know about pain in the heel

Plantar fasciitis, Achilles tendonitis, Haglund’s syndrome, and a range of conditions affecting the actual heel bone and/or structures near it are all possible causes of pain in the back of the heel.

Heel pain can be throbbing, stabbing, burning, or aching depending on the underlying cause and its severity. It can come from behind or beneath the heel.

When walking, heel pain may be most pronounced first thing in the morning but may improve after walking for a while. Excess walking or standing, however, can make the pain worse.

heel pain causes
Illustration by Alexandra Gordon, Verywell

Heel pain treatment usually involves rest, pain medications as needed, immobilizing the heel, and physical therapy exercises. In some cases, surgery may be necessary.

This article explores the common and uncommon causes of heel pain, as well as what can be done to diagnose and treat this all-too-common symptom.

Common Causes of Heel Pain

Heel pain is usually caused by any injury or infection to the heel bone or surrounding structures and tissues. It can also be caused by the nerves that service the ankle or foot.

The heel bone (calcaneus) lies at the back of the foot beneath the ankle. Along with surrounding tissues and a small bone called the talus, the heel bone works to provide balance and side-to-side movement of the back of the foot.

The two most common causes of heel pain involve the connective tissues that link the heel to the base of the foot or bottom of the calf muscle. The conditions are called plantar fasciitis and Achilles tendonitis.

Plantar Fasciitis

Plantar fasciitis refers to the inflammation of the band of tissue that forms the arch of the foot and connects your heel bone to the base of your toes.

Plantar fasciitis causes stabbing or throbbing heel pain. It is felt on the bottom of the heel and occurs when you place weight on the heel after rest. For example, you may feel plantar fasciitis pain when taking your first step in the morning or standing up after prolonged sitting.

If plantar fasciitis persists for a long time, a bony protrusion called a heel spur may form where the fascia connects to your heel bone.

In rare cases, the plantar fascia may rupture (tear). The pain of a rupture is severe, sharp, and sudden, and there may be swelling and bruising present as well.

Achilles Tendonitis

Achilles tendonitis refers to inflammation of the Achilles tendon. This is the large, cord-like tendon that attaches the back of your heel bone to the calf muscle.

Achilles tendonitis causes tightening or burning heel pain at the part of the tendon that is slightly above the heel bone. Mild swelling around the tendon and morning stiffness in the heel and calf are also common.

Achilles tendonitis is usually due to overuse, such as running too much, or not warming up your calf muscles before exercise. Wearing poor-fitting shoes or having arthritis may also lead to Achilles tendonitis.

In rare cases, the Achilles tendon may rupture. This typically occurs during vigorous physical activity when the foot pivots suddenly, such as with basketball or tennis. Besides severe heel pain, some people report hearing a “popping” or “snapping” sound when the tendon tears.

Recap

The two most common causes of heel pain are plantar fasciitis (inflammation of the band of tissue that connects the heel to the base of the toes) and Achilles tendonitis (inflammation of the Achilles tendon).

Uncommon Causes of Heel Pain

Other less common causes of heel pain must also be considered, even if you’ve experienced this discomfort and gotten one of the above diagnoses before.

Tarsal Tunnel Syndrome

Tarsal tunnel syndrome is a nerve condition in which a large nerve in the back of the foot becomes pinched.

Tarsal tunnel pain, described as aching or burning, may be felt as heel pain but is more common in the bottom of the foot and near the toes.

Similar to carpal tunnel syndrome in the hand, tarsal tunnel syndrome can cause numbness and tingling with pain that worsens at night.

Stress Fractures 

Stress fractures of the foot and heel commonly occur in athletes or long-distance runners who increase their running mileage over a short period of time. Repeated stress on the heel bone eventually leads to a break.

A stress fracture causes significant heel pain that intensifies with activity and improves with rest. In addition to pain, swelling may be present, along with tenderness felt in the area of the bone break.

Heel Pad Bruise

A heel pad bruise causes sharp pain over the bottom of the heel.

It may occur after trauma, such as landing after a high fall or stepping on a stone, or excessive weight-bearing exercises.

Fat Pad Atrophy

In older adults, the cushioning fat of the heel pad may break down (atrophy).

Like plantar fasciitis, the pain of fat pad atrophy is absent in the morning, but worsens with activity during the day.

Heel pad syndrome is a similar condition in which the thinning of the fat pad is caused by repetitive trauma, such as the consistent pounding of the foot in marathon runners or pressure placed on the foot due to obesity. This causes a deep, aching pain in the middle of the heel that worsens with weight-bearing activities.

Haglund’s Syndrome

Haglund’s syndrome, also referred to as “pump bump,” occurs when a bony prominence forms at the back of the heel. This typically occurs in wearers of rigid or poorly fitted shoes.

The pain is felt at the back of the heel and can cause limping, as well as swelling, warmth, and redness.

As the soft tissue surrounding the bony bump gets irritated, bursitis may develop. Bursitis, the inflammation of a fluid-filled sac between joints called the bursa, can cause pain in different parts of the heel:

  • Retrocalcaneal bursitis causes deep pain where the Achilles tendon attaches to the back of the heel bone.
  • Calcaneal bursitis causes pain on the top and side of the Achilles tendon.

Sinus Tarsi Syndrome

The sinus tarsi, referred to as “the eye of the foot,” is the space on the outside of the foot between the ankle and heel bone. This space, while small, contains several ligaments along with fatty tissue, tendons, nerves, and blood vessels.

Sinus tarsi syndrome is usually the result of a traumatic injury to this structure, which causes ongoing pain in the anterior (front) lateral (side) parts of the ankle.

This type of heel pain tends to be greatest with weight-bearing activities. There may also be a sensation of ankle looseness and difficulty walking on uneven surfaces.

Rare Causes of Heel Pain

Other rare causes of heel pain include:

  • Piezogenic papules: Painful bumps caused when fat bulges (herniates) from the heel capsule, often due to connective tissue diseases like Ehlers-Danlos syndrome
  • Heel bone infection: A form of osteomyelitis, or bone inflammation, that can cause constant heel pain and even fever
  • Heel bone tumor: A typically non-cancerous) growth on the heel bone that can cause deep, boring pain that worsens at night

Recap

Less common causes of heel pain include tarsal tunnel syndrome, stress fracture, heel pad bruises or atrophy, Haglund's syndrome (with or without bursitis), and sinus tarsi syndrome.

When to See a Healthcare Provider

If you are unsure of the cause of your symptoms, or if you do not know the specific treatment recommendations for your condition, seek a medical evaluation.

Here are some definite signs that you should be seen by a healthcare provider:

  • Inability to walk comfortably on the affected side
  • Heel pain that occurs at night or while resting
  • Heel pain that persists beyond a few days
  • Swelling or discoloration of the back of the foot
  • Signs of an infection, including fever, redness, and warmth
  • Any other unusual symptoms

Diagnosis

Most heel conditions can be diagnosed with just a medical history and physical examination. In certain cases, though, additional tests like imaging studies and/or blood tests are warranted.

Medical History

A detailed medical history is often the most important part of diagnosing heel pain. It's best to come prepared to your healthcare provider's appointment with answers to these basic questions:

  • Where is your pain located?
  • When did your pain start?
  • What does your pain feel like?
  • Does your pain occur when you place weight on it?
  • Is the pain worse at different times of day or night?
  • Do you recall doing anything that might have injured the foot?
  • Are there any other symptoms?

Physical Examination

During your physical exam, your doctor will inspect and press on (palpate) various areas of your foot, including your heel, ankle, calf, and lower leg. By doing this, they can check for areas of tenderness, swelling, bruising, rash, or deformity.

The doctor will likely evaluate your gait, or pattern of walking, including the position and angle of your foot, ankle, and heel. They may also move your foot and ankle to see if that elicits pain.

Blood Tests

While blood tests are not commonly ordered for the diagnosis of heel pain, your healthcare provider may order one or more laboratory studies if they suspect or want to rule out a particular condition.

A C-reactive protein (CRP) test is the most commonly ordered type of blood test to rule out an infection.

Imaging Studies

An X-ray of the heel may be ordered to diagnose certain conditions like a stress fracture of the heel, Haglund’s syndrome, a heel spur, or a bone tumor.

Less commonly, other imaging tests are used. For instance, magnetic resonance imaging (MRI) may be used to diagnose a soft-tissue injury or an infection.

Differential Diagnoses

While it is reasonable to think that heel pain must stem from your heel, this is not always the case. Sometimes the pain is referred to the heel, meaning that it is being caused by an issue in another part of the body.

Nerve Disorders

Irritation of a nerve in the lower back (radiculopathy) may cause pain of the calf muscle that moves down into the heel.

In addition, nerve damage caused by diabetes or alcohol abuse (peripheral neuropathy) can cause "electrical" foot pain as well as a high-stepping gait. This is when you walk on your tiptoes to avoid foot pain.

Skin Problems

Skin problems, like cellulitis (a bacterial skin infection), plantar warts, diabetic ulcers, and fungal foot infections (like athlete’s foot) can cause discomfort in the heel or sole of the foot.

Systemic Diseases

Whole-body inflammatory diseases like sarcoidosis, rheumatoid arthritis, or reactive arthritis can cause heel pain. Other symptoms like fever, rash, and joint pain may be present.

Recap

The diagnosis of heel pain involves a physical exam and a review of your medical history. Imaging studies such as an X-ray are common. Blood tests can help detect an infection or inflammatory condition, as well as rule out suspected causes.

Heel Pain Treatment

Treatment depends entirely on the root cause of your heel pain. If you are unsure of your diagnosis or how severe your condition is, be sure to seek medical advice before beginning any treatment plan.

Rest

For more acute causes of heel pain, such as a heel bruise, avoiding the precipitating activity may be all you need to feel better. For example, take a few days off from jogging or prolonged standing/walking.

Elevating the leg also helps.

Ice Application

For most sources of heel pain, applying an ice pack over the heel for 20-minute intervals up to four times daily can help diminish swelling and soothe your pain. Be sure to place a thin towel between the ice pack and the skin of your heel.

Taping

Taping the foot with sports tape or hypoallergenic tape is useful for certain heel diagnoses like plantar fasciitis, heel pad bruise, and heel pad syndrome.

For plantar fasciitis, your healthcare provider may recommend a taping technique involving four strips of tape that get applied around the foot and heel. The tape should not be applied too tightly and can stay in place for one week.

Immobilization

Many acute Achilles tendon ruptures are treated by placing the limb in a cast with the toes pointed down.

Other injuries may only require a removable orthopedic boot, which helps stabilize the ankle and limit movement of the foot.

Exercise and Physical Therapy

Exercises and stretches are designed to relax the tissues that surround the heel bone. Some simple exercises, performed in the morning and evening, often help patients feel better quickly.

For Achilles tendonitis, your healthcare provider may refer you to a physical therapist who uses a specialized exercise program called the Alfredson protocol, which focuses on strengthening the Achilles tendon with eccentric exercises. With these, the tendon is contracted as the supporting muscles are stretched.

Footwear Modification

Depending on the cause of your heel pain, your healthcare provider may recommended various foot supports.

For plantar fasciitis, they may suggest you wear a splint at night to keep your foot straight. Wearing sturdy, comfortable shoes with a good arch and heel support can also help.

Heel wedges or shoe orthotics may be recommended for the treatment of Achilles tendonitis.

For Haglund’s syndrome, your healthcare provider may recommend having the heel height of your shoes altered.

Pain Medications

Nonsteroidal anti-inflammatory medications (NSAIDs) are commonly used to relieve pain caused by plantar fasciitis, Achilles tendonitis, Haglund’s syndrome, heel pad problems, and sinus tarsi syndrome.

For severe heel pain, like that caused by a heel fracture, opioid drugs may be prescribed for a short period of time.

Sometimes, cortisone—a steroid that reduces inflammation—may be injected into the heel to temporarily ease the pain.

Surgery

For most causes of heel pain, surgery is generally only recommended if all other conservative options have failed to provide relief for six to 12 months.

In people with plantar fasciitis, a plantar fascia release may be used to surgically detach the plantar fascia from the heel bone. Another procedure, called a gastrocnemius resection, surgically lengthens the calf muscle to relieve plantar fasciitis pain.

Recap

The treatment of heel pain varies by the underlying cause. It may involve rest, ice application, taping, immobilization, footwear modification, pain medications, and physical therapy. Surgery may be considered if all other options have failed after six to 12 months.

Prevention

Whether you have had heel pain in the past or not, there are things you can do to avoid injuring your heel or supporting structures.

These include:

  • Maintain a healthy body weight: Excess body weight places increased stress on the lower extremities, including the heel.
  • Wear the right footwear: Wearing appropriate, properly fitting footwear with adequate support and cushioning is critical for the prevention of many types of heel pain.
  • Warm-up before activities: This is especially true if you are engaging in vigorous sports or long-distance running.
  • Listen to your body: Pain is never normal. If there is heel pain you cannot explain, back off a little and see if it improves. If it recurs or gets worse, see a healthcare provider.

Summary

There are many causes of heel pain, some of which involve the heel itself and others of which involve supporting structures, such as the ankle.

The two most common causes are Achilles tendonitis and plantar fasciitis, but there are numerous others that can directly affect the heel or cause referred pain—when inflammation or injury in another part of the body causes pain in the heel.

The diagnosis of heel pain typically involves a physical exam, a review of your medical history, and, if needed, an imaging study like an X-ray. Treatment options include rest, ice application, taping, immobilization, pain medications, footwear modification, physical therapy, and surgery.

A Word From Verywell

Some causes of heel pain are more serious than others. Regardless, your doctor can help you figure out what’s causing the pain and design a treatment plan specific to your situation. The upside is that most solutions are fairly simple—rest, ice packs, and footwear modifications—and extremely effective if used correctly.

Always follow your doctor's instructions even if you start to feel better. Stopping short or returning to normal activity too quickly can end up causing serious injury.

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Additional Reading

By Jonathan Cluett, MD
Jonathan Cluett, MD, is board-certified in orthopedic surgery. He served as assistant team physician to Chivas USA (Major League Soccer) and the United States men's and women's national soccer teams.