Heel Pain: Why It Isn't Always Plantar Fasciitis

Start with where it hurts

• Bottom of the heel, inner side. Plantar fasciitis, or sometimes an irritated nerve (Baxter's neuropathy).
• Bottom of the heel, in the middle. Deep and bruise-like: heel fat pad syndrome.
• The whole heel, hurts when squeezed from both sides. A possible bone stress injury.
• Back of the heel. Insertional Achilles tendinopathy, or Sever's disease in a growing child.
• Behind the inner ankle bone, with burning or tingling into the sole. Tarsal tunnel syndrome.

Plantar heel pain is an umbrella term that covers several different problems.^1,6 The clinic figures above came from one hospital and did not routinely look for bone stress or nerve problems, so those were probably under-counted.⁵

1. Plantar fasciitis

Load-related change where the plantar fascia attaches to the inner heel bone. Despite the “-itis”, it is largely not an inflammatory problem. The classic sign is pain with the first steps in the morning or after sitting, which eases after a few minutes of walking and returns after long periods of standing.¹

What tends to help: progressive strengthening of the calf and foot. In one trial, high-load heel raises with a towel under the toes did better than stretching alone at three months.² Manual therapy, stretching and foot orthoses are also supported by the 2023 clinical guideline.¹ Orthoses reduced pain in the medium term, and off-the-shelf orthoses performed no differently from custom ones.³

2. Heel fat pad syndrome

Thinning or loss of elasticity in the cushion under the heel bone. Pain is in the centre of the heel, deep and bruise-like, and worse barefoot on hard floors or with long periods of standing.^4,5

What tends to help: cushioned heel cups, supportive footwear and avoiding bare feet on hard surfaces. These are the usual recommendations, but a 2022 review found almost no good-quality trials testing them.⁴

3. Calcaneal bone stress injury

The heel bone not keeping up with repeated loading, often after a jump in training or a change of surface. Pain is spread across the heel, gets worse with activity rather than warming up, and squeezing both sides of the heel hurts. Hopping on that leg is painful.⁷

This one matters: X-rays are often normal early on, and MRI is more sensitive. If this sounds like you, stop impact activity and see your doctor, who can arrange imaging. Recovery usually involves a period of offloading and a gradual return to impact, plus looking at what caused it, such as training load and overall energy intake and bone health.⁷

4 and 5. Nerve entrapment: Baxter's neuropathy and tarsal tunnel syndrome

A small nerve near the inner heel can become irritated (Baxter's neuropathy), causing burning pain on the inner heel that often builds through the day rather than being worst first thing. Compression of the tibial nerve behind the inner ankle bone (tarsal tunnel syndrome) causes tingling, burning or numbness spreading into the sole, often worse at night.⁶

What tends to help: footwear changes, orthoses, nerve-gliding exercises and offloading the area. A doctor may use a diagnostic nerve block, an injection of local anaesthetic, to confirm which nerve is involved. The research behind these approaches is limited.⁶

6. Insertional Achilles tendinopathy

Pain and sometimes swelling at the back of the heel where the Achilles tendon attaches, not underneath. It is often stiff in the morning and aggravated by uphill running, deep squats and stiff shoe backs.

What tends to help: progressive calf strengthening done on flat ground rather than letting the heel drop off a step, because dropping into that position compresses the sore spot.⁸ A small heel lift and shoes that do not press on the back of the heel can also help. Expect months rather than weeks.

7. Sever's disease (in children)

Irritation of the growth plate at the back of the heel in active children, usually aged about 8 to 15. Pain is worse during and after sport and is often in both heels. It settles once the growth plate closes.

What tends to help: reducing activity to a comfortable level rather than complete rest, heel raises or off-the-shelf inserts, calf flexibility work and a footwear review. A systematic review found heel lifts and orthoses appeared to ease pain, but the studies had significant design problems.⁹

8. Inflammatory enthesitis

Sometimes heel pain is the first sign of an inflammatory condition such as spondyloarthritis, psoriatic arthritis or reactive arthritis.¹⁰ Clues include:

• Pain in both heels in a younger adult with no clear training cause
• Long morning stiffness, night pain, and pain that improves with movement rather than rest
• Inflammatory back pain, swollen fingers or toes, eye inflammation, psoriasis, bowel disease or a recent infection
• No improvement despite well-run care over an appropriate time

Any of these is a reason to see your family doctor, who can arrange tests and refer you to a rheumatologist if needed.

Take-home

• Work out where and when it hurts before choosing a treatment.
• Most heel pain responds to well-applied conservative care.
• If heel pain has not improved after about six weeks of doing the right things for plantar fasciitis, it may be something else. Get it examined.

Sources

1. Koc TA, Bise CG, Neville C, Carreira D, Martin RL, McDonough CM. Heel pain – plantar fasciitis: revision 2023. J Orthop Sports Phys Ther 2023;53(12):CPG1-CPG39. Clinical practice guideline. Link
2. Rathleff MS, Mølgaard CM, Fredberg U, et al. High-load strength training improves outcome in patients with plantar fasciitis: a randomized controlled trial with 12-month follow-up. Scand J Med Sci Sports 2015;25(3):e292-e300. Randomised controlled trial. Link
3. Whittaker GA, Munteanu SE, Menz HB, et al. Foot orthoses for plantar heel pain: a systematic review and meta-analysis. Br J Sports Med 2018;52(5):322-328. Systematic review and meta-analysis. Link
4. Chang AH, Rasmussen SZ, Jensen AE, Sørensen T, Rathleff MS. What do we actually know about a common cause of plantar heel pain? A scoping review of heel fat pad syndrome. J Foot Ankle Res 2022;15(1):60. Scoping review. Link
5. Yi TI, Lee GE, Seo IS, et al. Clinical characteristics of the causes of plantar heel pain. Ann Rehabil Med 2011;35(4):507-513. Retrospective clinic review. Link
6. Alshami AM, Souvlis T, Coppieters MW. A review of plantar heel pain of neural origin: differential diagnosis and management. Man Ther 2008;13(2):103-111. Narrative review.
7. Warden SJ, Davis IS, Fredericson M. Management and prevention of bone stress injuries in long-distance runners. J Orthop Sports Phys Ther 2014;44(10):749-765. Narrative review. Link
8. Jonsson P, Alfredson H, Sunding K, Fahlström M, Cook J. New regimen for eccentric calf-muscle training in patients with chronic insertional Achilles tendinopathy. Br J Sports Med 2008;42(9):746-749. Pilot study. Link
9. James AM, Williams CM, Haines TP. Effectiveness of interventions in reducing pain and maintaining physical activity in children and adolescents with calcaneal apophysitis (Sever's disease): a systematic review. J Foot Ankle Res 2013;6:16. Systematic review. Link
10. López-Medina C, et al. Achilles enthesitis on physical examination leads to worse outcomes after 2 years of follow up in patients with ankylosing spondylitis from REGISPONSER-AS registry. Arthritis Res Ther 2023;25:8. Registry cohort study. Link

This article is general education. It does not replace advice from a clinician who has examined you.