Heel Pain

Heel pain may be described as pain, stabbing, tenderness, or aching felt in the back or underside of the foot. This complaint is often related to overuse, soft-tissue strain, or biomechanical loading; however, details such as the exact location of the pain, its relation to the first steps in the morning, a history of injury, and associated swelling are central to evaluation. ^[1][2]

How does heel pain feel?

Heel pain does not feel the same for everyone. Some people describe pain on the plantar surface, especially beneath the heel, as "like stepping on a knife," whereas others feel more pulling and stiffness at the back of the heel near the Achilles tendon. Pain that is most noticeable with the first steps, increases after standing up from sitting, or worsens after running or climbing stairs may suggest involvement of different tissue structures. For that reason, rather than simply saying "my heel hurts," it is clinically more useful to describe whether the pain is underneath or behind the heel and under what circumstances it worsens. ^[1][3][4]

MedlinePlus notes that heel pain is often due to overuse, but it may also result from injury. Inadequate shoe support, repetitive loading on hard surfaces, calf or Achilles tightness, and striking the heel forcefully can all contribute. This point matters when taking the history, because in some cases the key lies precisely in a recent change in footwear, exercise intensity, or walking surface. ^[1][2]

What causes heel pain?

One of the common causes of heel pain is strain involving the plantar fascia region. In plantar fasciitis, pain and stiffness beneath the heel may be prominent; the complaint is often more noticeable with the first steps in the morning or after standing up following rest. MedlinePlus states that plantar fasciitis pain may be felt under the heel and may worsen with walking, running, or climbing stairs. This pattern is especially notable in office workers, people who stand for long periods, and runners. ^[3][4]

Pain at the back of the heel may arise from the Achilles tendon and surrounding structures. In Achilles tendinitis or heel bursitis, the pain is felt more at the back of the heel, where the shoe contacts the area, or along the tendon. Stiffness, swelling, or worsening after activity may accompany it. MedlinePlus materials emphasize that both Achilles overuse and inflammation of the bursa at the back of the heel can produce similar symptoms. That is why it is important to distinguish whether the pain is located under the heel or along the posterior surface. ^[1][5][6]

Heel pain may also sometimes be related to injury after a direct blow, fall, or strain. Soft-tissue bruising, irritation around bone, or tissue damage caused by sudden movement can produce marked tenderness. Excess body weight, prolonged standing, poor shoe choice, and a rapid increase in sports load may all contribute to persistence of symptoms. Therefore, heel pain is not explained by a single diagnosis alone; in many cases it requires combined consideration of mechanical loading, tissue adaptation, and daily use patterns. ^[1][2][3]

Which situations require more careful evaluation?

In heel pain, inability to bear weight after sudden trauma, marked swelling, bruising, deformity, or major difficulty walking warrants closer assessment. Similarly, severe pain that continues even at rest, night pain, redness and increased warmth, or fever may be important from the standpoint of infection or inflammation. In people with diabetes, peripheral vascular disease, or neuropathy, foot symptoms should be evaluated at a lower threshold because pain alone may not accurately reflect tissue stress. ^[1][2][6]

Pain that persists for weeks, localizes intensely to one point, or is accompanied by symptoms spreading to other parts of the foot also increases clinical importance. If heel pain is accompanied by numbness, burning, or electric shock-like sensations in the sole, nerve entrapment and not only mechanical causes should be considered. Heel pain in children may also be interpreted differently from that in adults; growth-related loading problems and sport-related causes carry greater weight. Correct interpretation is difficult unless age, activity level, and associated symptoms are considered together. ^[2][3][4]

Why does the exact location of pain provide a clue?

In heel pain, whether the pain is centered underneath, along the inner aspect, at the posterior surface, or laterally may help narrow the possibilities. Pain with the first steps on the underside of the foot more strongly suggests loading of plantar structures, whereas pain and swelling where the back of the shoe contacts the heel may point toward the Achilles region or the bursa. Focal bony tenderness or pain that begins suddenly after trauma requires a different evaluation. For that reason, anatomic localization may be even more informative than duration. ^[1][4][6]

How is heel pain evaluated?

Evaluation includes asking whether the pain is underneath or behind the heel, whether it worsens with the first steps in the morning, whether there has been a change in shoes or exercise, and whether trauma occurred. On examination, the tenderness point, gait pattern, calf-Achilles tightness, and swelling are assessed. When necessary, imaging may be requested to evaluate for fracture, bony prominence, or another cause, but imaging is not mandatory in every case of heel pain. The most important step is correctly identifying the location and pattern of the complaint. ^[1][2][4]

Heel pain is often mechanical in nature; however, individualized evaluation is important if it is prolonged, begins after trauma, or is associated with inability to bear weight. In particular, how the pain changes in the morning, after exercise, and with shoe contact are among the key details that guide the clinician. ^[1][3][5]