Heel pain causes can range from common overload problems such as plantar fasciitis and Achilles tendinopathy through to stress fractures, nerve irritation, arthritis, and children’s growth-related heel pain. For a broader overview, visit our heel pain guide.

The best starting point is the exact location and behaviour of your pain. Pain under the heel often points towards plantar heel pain. Pain at the back of the heel may involve the Achilles tendon, heel bone insertion, or a nearby bursa. Sometimes the source can also come from the foot, ankle, lower leg, or a nearby nerve.

What are the most common heel pain causes?

The most common heel pain causes include plantar fasciitis, heel spur irritation, Achilles tendinopathy, retrocalcaneal bursitis, Sever’s disease in children, stress fractures, and, less often, nerve irritation or inflammatory joint conditions. The likely cause usually depends on where the pain sits, what loads aggravate it, and whether you also notice swelling, stiffness, numbness, limping, or pain at rest.

Quick guide: where is your heel pain?

Heel pain location gives useful clues. It does not confirm a diagnosis on its own, but it helps narrow the most likely structures involved.

Common heel pain patterns

Heel pain becomes easier to sort through when you match the pain pattern to the likely structure involved. Pain with the first few steps in the morning often points towards plantar heel pain. Pain at the back of the heel during running, calf raises, or stairs may point more towards the Achilles tendon or the bursa near the heel bone.

Which heel pain cause matches your symptoms?

The sections below outline common heel pain causes. They are not a substitute for diagnosis, but they can help you decide whether your symptoms sound like a plantar fascia, Achilles tendon, bursa, nerve, bone stress, or children’s growth-related problem.

Plantar Fasciitis

Plantar fasciitis is one of the most common causes of pain under the heel. It often causes sharp pain with the first few steps in the morning or after sitting. Calf tightness, prolonged standing, walking volume changes, running load, and footwear changes can all contribute.

Heel Spur

Heel spurs are bony growths that may appear alongside plantar heel pain. However, a spur on imaging is not always the true pain source. Many people improve when treatment focuses on the irritated soft tissues, foot strength, load management, and footwear support rather than the X-ray finding alone.

Achilles Tendinopathy

Achilles tendinopathy often causes pain at the back of the heel or just above it. Symptoms usually build with running, jumping, hills, or repeated calf raises. Morning stiffness and soreness after activity are common.

Retrocalcaneal Bursitis

Retrocalcaneal bursitis causes irritation between the Achilles tendon and the heel bone. People often notice swelling, tenderness near the back of the heel, or pain where shoes rub. This can overlap with insertional Achilles problems.

Sever’s Disease

Sever’s disease is a common cause of heel pain in active children, especially during growth spurts. Running and jumping sports often aggravate it. Children may limp, complain after training, or feel pain when rising onto tiptoes.

Foot Stress Fracture or Bone Irritation

A foot stress fracture can also cause heel or foot pain, especially if pain is severe, progressive, or linked with a sudden rise in training load. Broader stress fracture patterns often behave differently from routine soft tissue overload and deserve earlier assessment if walking becomes difficult.

Nerve-Related Causes

Nerve irritation can mimic heel pain. Tarsal tunnel syndrome, a pinched nerve, or even sciatica may cause burning, tingling, numbness, or pain that does not behave like a typical plantar fascia or Achilles problem.

Inflammatory or Arthritic Causes

Less commonly, heel pain can relate to inflammatory or arthritic conditions such as rheumatoid arthritis, psoriatic arthritis, or broader ankle arthritis presentations. These cases often need a wider assessment, especially if symptoms are persistent, bilateral, or linked with other joint complaints.

Why does heel pain location matter?

The location of your heel pain helps narrow the likely cause. Pain under the heel often points towards plantar heel pain or a heel spur. Pain at the back of the heel may fit Achilles tendinopathy, insertional irritation, or retrocalcaneal bursitis. Medial or lateral heel pain may suggest tendon overload, nerve irritation, or foot mechanics issues. You may also find our foot pain and ankle pain pages helpful if your symptoms spread beyond the heel.

How is the cause of heel pain assessed?

A physiotherapist usually checks your pain location, walking pattern, calf strength, ankle movement, foot posture, footwear, and recent load changes. They may also test tenderness under the heel, the Achilles insertion, the heel bone, or the inside ankle region if nerve symptoms are present.

When should heel pain be checked?

You should get heel pain checked if it keeps returning, limits walking, affects work or sport, or does not improve after a short period of sensible load reduction. Earlier assessment is also important if you have marked swelling, bruising, numbness, a limp, pain at rest, or difficulty weight-bearing.

For an external evidence-based overview of plantar heel pain management, the JOSPT guideline provides a useful summary of current best practice: Heel Pain - Plantar Fasciitis: Revision 2023.

Related heel, foot, and ankle conditions

• Heel Pain
• Plantar Fasciitis
• Heel Spur
• Achilles Tendinopathy
• Retrocalcaneal Bursitis
• Sever’s Disease
• Tarsal Tunnel Syndrome
• Foot Stress Fracture
• Foot Pain
• Ankle Pain

Heel Pain Causes: FAQs

What is the most common cause of heel pain?

The most common cause of heel pain is often plantar fasciitis, especially when pain sits under the heel and is worse with the first few steps after rest. However, pain at the back of the heel may fit Achilles tendinopathy or retrocalcaneal bursitis instead, so the pain pattern still matters.

Can a heel spur cause pain on its own?

A heel spur can be linked with pain, but it is not always the true source of symptoms. Many people have a heel spur on imaging without pain. In practice, the surrounding soft tissues, load tolerance, calf tightness, and foot mechanics often matter more than the spur itself.

Why does my heel hurt more in the morning?

Morning heel pain is commonly linked with plantar heel pain, including plantar fasciitis. The tissues can feel stiff after rest, so the first few steps become sharp or tender. This pattern is less typical of nerve pain and can help separate plantar heel pain from some other heel problems.

What causes heel pain in children?

In active children, one of the most common causes is Sever’s disease, also called calcaneal apophysitis. It tends to appear during growth spurts and with running or jumping sports. Children may complain after training, limp, or feel pain when the heel is squeezed or loaded.

Can heel pain come from a nerve?

Yes. Heel pain can sometimes come from a nerve rather than the heel tissues themselves. Tarsal tunnel syndrome, a pinched nerve, or referred pain from sciatica may cause burning, tingling, numbness, or symptoms that do not behave like typical plantar fascia or Achilles pain.

Can shoes or training changes trigger heel pain?

Yes. A sudden change in shoes, walking volume, running load, hills, court sport, or standing time can trigger heel pain. This does not mean the shoe is always the only cause. It means the heel tissues may not have adapted to the new load yet.

When should I worry about heel pain?

You should take heel pain more seriously if it causes a marked limp, swelling, bruising, numbness, pain at rest, or difficulty weight-bearing. Pain that keeps returning or worsens despite rest also deserves a proper assessment, particularly when a stress fracture or tendon rupture needs to be ruled out.

What to do next

If your heel pain is not settling, the main priority is to identify which structure is overloaded and why. The location of the pain, the activities that aggravate it, and the way it behaves after rest all help guide the right diagnosis and treatment plan.

A physiotherapist can assess your heel, foot, ankle, calf strength, walking pattern, training load, and footwear factors. Early advice may help you avoid a longer cycle of recurring heel pain and repeated activity setbacks.

References

1. Koc TA Jr, Bise CG, Neville C, et al. Heel Pain - Plantar Fasciitis: Revision 2023. J Orthop Sports Phys Ther. 2023;53(12):CPG1-CPG39. doi:10.2519/jospt.2023.0303.
2. Morrissey D, Cotchett M, Said JH, et al. Management of plantar heel pain: a best practice guide informed by a systematic review, expert clinical reasoning and patient values. Br J Sports Med. 2021;55(19):1106-1118. doi:10.1136/bjsports-2019-101970.
3. Chen J, Ahn J, Mullen S, et al. Management of Insertional Achilles Tendinopathy. Orthop Clin North Am. 2022;53(2):221-232. doi:10.1016/j.ocl.2021.11.002.
4. Kothari EA, Marshall C, Young TP. A Review of Pediatric Heel Pain. Cureus. 2023;15(2):e34937. doi:10.7759/cureus.34937.
5. Tu P, Bytomski JR. Diagnosis of Heel Pain. Am Fam Physician. 2011;84(8):909-916.

Most heel pain comes from plantar fasciitis, not heel spurs. Heel spurs and plantar fasciitis are related, but they are not the same condition. If you are comparing these two problems, it also helps to consider other causes of heel pain, as symptoms can overlap.

In practice, many people with plantar heel pain do not need imaging straight away. Your physiotherapist can assess your symptoms, foot loading, calf flexibility, tenderness, and walking mechanics to guide diagnosis. Imaging may help if symptoms are unclear, severe, linked to trauma, or not improving as expected.

What is the difference between heel spurs and plantar fasciitis?

The main difference is that a heel spur is a bony growth, while plantar fasciitis is irritation or overload of the plantar fascia. Heel spurs may appear on X-ray without causing pain, whereas plantar fasciitis more often matches the classic first-step heel pain pattern.

Key differences at a glance

• Heel spurs are usually identified on X-ray.
• Plantar fasciitis is often diagnosed from symptoms and assessment.
• Both conditions can occur together.
• Many people have a heel spur without pain.
• First-step pain strongly suggests plantar fascia irritation.

Heel Spurs vs Plantar Fasciitis: Quick Comparison

What are heel spurs?

Heel spurs, also called calcaneal spurs, are bony growths that form near the underside of the heel bone. They typically develop over time where the plantar fascia and surrounding tissues attach to the calcaneus.

A heel spur may look significant on an X-ray, but it does not always cause pain. In many cases, the primary issue is irritation of the surrounding soft tissue, particularly the plantar fascia.

What is plantar fasciitis?

Plantar fasciitis involves irritation of the thick band of tissue that runs from the heel to the toes and supports your arch. Many cases behave more like a load-related tissue irritation than a simple inflammatory condition.

This condition is one of the most common causes of plantar heel pain and often develops when activity levels exceed what the tissue can tolerate.

How do symptoms differ between heel spurs and plantar fasciitis?

Plantar fasciitis usually follows a recognisable pain pattern, whereas a heel spur may cause no symptoms. Sharp pain with your first steps in the morning or after rest is far more typical of plantar fasciitis.

Common signs include:

• pain under the heel when getting out of bed
• pain after sitting and then standing
• soreness under the heel or arch after prolonged standing or walking
• pain that eases with movement but returns later

By contrast, a heel spur is often an incidental finding on imaging.

How do you diagnose heel spurs and plantar fasciitis?

Heel spurs are usually confirmed with X-ray. Plantar fasciitis is often diagnosed clinically, although ultrasound or MRI may assist when symptoms are unclear or persistent.

Your physiotherapist may assess tenderness, first-step pain, calf flexibility, foot posture, and walking patterns. Other causes such as Achilles tendinopathy or broader foot pain may also be considered.

For a broader overview, Healthdirect provides helpful information on plantar fasciitis.

Can you have heel spurs and plantar fasciitis at the same time?

Yes. These conditions often occur together, particularly with long-term plantar heel overload. However, the pain usually comes from the surrounding soft tissues rather than the spur itself.

How can physiotherapy help plantar heel pain?

Physiotherapy aims to reduce irritation, improve load tolerance, and guide a gradual return to normal activity. A treatment plan may include education, footwear advice, taping, strength work, plantar fascia loading, and pacing strategies.

• calf stretching and strengthening
• plantar fascia loading exercises
• foot muscle strengthening
• taping and support strategies
• footwear advice

Supports such as heel cups or orthotics may assist as part of a broader management plan.

When should you seek help for heel pain?

You should seek help if your heel pain is worsening, not improving after several weeks, changing your walking pattern, or limiting work, exercise, or sleep.

A clear diagnosis helps guide the right treatment plan. You can also explore our heel pain FAQs for more information.

Heel Spurs vs Plantar Fasciitis FAQs

Are heel spurs always painful?

No. Many people have heel spurs on X-ray without heel pain. A heel spur may sit near the plantar fascia attachment, but pain often comes from the surrounding soft tissue rather than the spur itself. This is why symptoms and physical assessment matter more than the X-ray image alone.

Is first-step pain more likely to be plantar fasciitis?

Yes. Sharp heel pain with your first steps in the morning, or after sitting, is more typical of plantar fasciitis than a heel spur alone. The pain may ease as you move, then return after long periods of standing, walking or running.

Do I need an X-ray for plantar fasciitis?

Not always. Many cases of plantar fasciitis can be assessed clinically by reviewing your pain pattern, heel tenderness, calf flexibility, foot posture and walking mechanics. Imaging may help if symptoms are unusual, severe, linked to trauma, or not improving as expected.

Can orthotics or heel cups help plantar heel pain?

Orthotics, heel cups or footwear changes may help some people reduce strain and improve comfort. They usually work best as part of a broader plan that also considers calf strength, plantar fascia loading, walking volume, work demands and gradual return to activity.

Can a heel spur go away?

The bony spur usually remains, but symptoms can still improve. Treatment generally focuses on reducing soft tissue irritation, improving load tolerance and addressing contributing factors. Many people feel better even though the spur remains visible on imaging.

When should I book a physiotherapy assessment for heel pain?

Book an assessment if heel pain is worsening, lasting more than a few weeks, changing how you walk, or limiting work, exercise or sleep. A physiotherapist can help identify whether the pain pattern fits plantar fasciitis, heel spur irritation, Achilles tendinopathy or another heel pain source.

References

1. Drake C, Whittaker GA, Kaminski MR, et al. Medical imaging for plantar heel pain: a systematic review and meta-analysis. J Foot Ankle Res. 2022;15(1):4. doi:10.1186/s13047-021-00507-2
2. Koc TA Jr, Bise CG, Neville C, et al. Heel Pain - Plantar Fasciitis: Revision 2023. J Orthop Sports Phys Ther. 2023;53(12):CPG1-CPG39. doi:10.2519/jospt.2023.0303
3. Johal KS, Milner SA. Plantar fasciitis and the calcaneal spur: fact or fiction?. Foot Ankle Surg. 2012;18(1):39-41. doi:10.1016/j.fas.2011.03.003
4. Kirkpatrick J, Yassaie O, Mirjalili SA. The plantar calcaneal spur: a review of anatomy, histology, etiology and key associations. J Anat. 2017;230(6):743-751. doi:10.1111/joa.12607