Understanding Heel Pain: Get the right diagnosis
Heel pain is a common complaint among amateur athletes – runners, hikers, weekend warriors, you name it. Most people immediately think plantar fasciitis is to blame, and often it is. But did you know heel pain can have several different causes?(10) In fact, “plantar heel pain” is an umbrella term covering not only plantar fasciitis but also issues like fat pad syndrome, heel spurs, nerve irritation, or even a stress fracture of the heel bone. In clinic we often see people incorrectly diagnosed, and thus not following the best management strategy for their true condition.
Understanding what's really causing your heel to hurt is the first step toward getting back to pain-free sport.
In this blog, we’ll break down the common causes of heel pain (1)(beyond just plantar fasciitis), and our next blog will cover effective treatment options backed by the latest research (including a 2023 review from the Journal of Orthopaedic & Sports Physical Therapy). As a specialist sports physiotherapist, I’ll also share some personal insights and real-world examples to help you understand how to manage heel pain and get back on your feet. Let’s dive in!
Common Causes of Heel Pain in Sport
Heel pain can stem from multiple issues, and it’s important not to jump to conclusions. While plantar fasciitis is the most frequent culprit, accounting for roughly 15% of all foot-related injuries in adults, and especially common in runners (5), we need to consider other possibilities.
Here are some common causes of heel pain, and how they differ:
Plantarfasciitis
The classic cause of pain under the heel. It involves irritation of the plantar fascia – a thick band of tissue under your foot. Pain is typically felt at the inside/bottom of the heel (near the medial calcaneal tubercle) and is often worst with the first steps in the morning or after sitting for a while (2). It may ease as you warm up, then come back after long periods of standing or activity. Plantar fasciitis is common in runners and people who stand a lot, and often develops gradually after a change in activity or an increase in training volume or intensity (5).
Heel Fat Pad Syndrome
Beneath your heel bone lies a cushion of fat that absorbs shock. Over time or with hard impact, this fat pad can wear down or get bruised. Fat pad syndrome causes a deep, aching pain right in the center of the heel (where your heel strikes the ground). Unlike plantar fasciitis, which hurts with first steps in the morning, fat pad pain tends to hurt with prolonged standing or walking on hard surfaces and feels like you’re walking on a bruise. It can happen from repeated jumping, running on concrete, or even walking barefoot on hard floors (6,7)
Heel Spur (Haglund Deformity)
Heel spurs are bony growths that sometimes develop at the heel bone where the plantar fascia attaches. Despite their scary image on X-rays, heel spurs themselves are often not the true source of pain. Many people have heel spurs without any pain. However, a heel spur often co-exists with plantar fasciitis. In the past, chronic plantar fasciitis was nicknamed “heel spur syndrome” (1,2).
The spur isn’t usually treated directly; we focus on the fascia irritation instead (2).
Baxters Nerve Entrapment (Nerve Irritation in the Heel)
A small nerve runs along the bottom/inner side of the heel (the first branch of the lateral plantar nerve, commonly called Baxter’s nerve). If this nerve becomes pinched or irritated, it can cause heel pain that mimics plantar fasciitis(9). In fact, research suggests up to 20% of chronic heel pain cases are due to Baxter’s nerve entrapment (8)
Calcaneal Stress Fracture (Heel Fracture)
The calcaneus is your heel bone. High-impact activities (like distance running, basketball, or soldiers marching long distances) can cause a hairline stress fracture in that bone (10). This causes sharp, deep heel pain that usually worsens with activity and improves with rest – almost the opposite pattern of plantar fasciitis. Unlike plantar fasciitis, a stress fracture often causes constant aching even when not weight-bearing, and pressing on the sides of the heel may be very tender. Sudden increase in training volume or intensity is a red flag for a possible stress fracture. If you suspect this, it’s important to get it evaluated promptly.
Achilles Tendinopathy (Insertional Achilles Pain)
Not all heel pain is under the foot. Pain at the back of the heel, where the Achilles tendon attaches, is usually an Achilles tendinopathy or bursitis rather than plantar fasciitis (11). This pain is located higher up (at the back of the calcaneus) and tends to worsen with running, jumping, or climbing stairs. It’s important to distinguish this from plantar heel pain because the treatment approach may differ. (If your pain is more in the rear heel/Achilles area, you might be dealing with an Achilles issue rather than the plantar fascia.)
As a sports physio, I’ve seen many athletes come in convinced they have plantar fasciitis because their heel hurts – only to find out it was something else. For example, one runner I worked with had persistent heel pain that didn’t follow the typical morning pain pattern of plantar fasciitis. After a thorough exam, I suspected a stress fracture, and sure enough, an MRI confirmed a small crack in her heel bone. In her case, the treatment involved rest and wearing a immobilisation boot, not the usual plantar fasciitis treatment.
The takeaway: If your heel pain isn’t following the classic signs, consider the other causes. Getting the right diagnosis is crucial.
Getting the Right Diagnosis
Properly diagnosing the cause of your heel pain is the key to fixing it. Each condition above might require a slightly different management strategy. A skilled clinician (physiotherapist or sports doctor) will typically:
- Take a detailed history: We ask about how and when your pain started, what makes it better or worse, your training routine, footwear, and any changes in activity. Certain clues (like morning pain, or pain with activity, recent increase in running mileage, etc.) help us narrow down the cause.
- Examine the foot and ankle: This includes checking the exact location of the pain (bottom of heel vs back of heel vs inner heel), feeling for tenderness (for instance, point tenderness at the plantar fascia attachment vs diffuse heel pad tenderness vs along the Achilles). We also assess flexibility (tight calves can predispose to plantar fasciitis), foot posture, and strength. Special tests may be done, such as a squeeze test on the heel (pain might indicate stress fracture) or a Tinel’s sign (tapping on a nerve path to see if it tingles, which might suggest a nerve entrapment).
- Consider imaging if needed: In stubborn or confusing cases, imaging may be ordered. An X-ray can show a heel spur or rule out an obvious fracture. Diagnostic ultrasound or MRI can help identify plantar fascia thickening, tears, or a stress fracture. Occasionally, an ultrasound with a Doppler might show increased blood flow indicative of plantar fasciitis, or it can identify nerve entrapment. For suspected Baxter’s nerve entrapment, sometimes a diagnostic injection by a doctor can confirm it (numbing the nerve gives pain relief).
"Getting a clear diagnosis matters because it guides the treatment plan. If you’re an athlete dealing with heel pain and you’re not 100% sure of the cause, it’s wise to get assessed by a professional. A comprehensive assessment can save you money and weeks of trying the wrong treatments."
Need Accurate Diagnosis?
Our sports physio team utilizes:
- ✓ Expert Diagnosis
- ✓ Running gait analysis
- ✓ Medical imaging and specialist referral network
Don't guess - evidence-based diagnosis saves recovery time!
References
- Koc et al (2023). Heel Pain - Plantar Fasciitis: Revision 2023. J Orthop Sports Phys Ther.
- Morrissey D et al. (2021). Management of plantar heel pain. Br J Sports Med.
- Hill et al. (2008). Prevalence and correlates of foot pain in a population-based study: the North West Adelaide health study.
- Thomas et al. (2019). Plantar heel pain in middle-aged and older adults: population prevalence, associations with health status and lifestyle factors, and frequency of healthcare use.
- Hunt K et al. (2009). Heel pain in the athlete. Sports Health.
- Chang AH et al. (2022). Heel Fat Pad Syndrome. J Foot Ankle Res.
- Balius R et al. (2021). Heel fat pad syndrome beyond acute plantar fascitis.
- Moroni et al. (2019). Clinical-anatomic mapping of the tarsal tunnel with regard to Baxter's neuropathy in recalcitrant heel pain syndrome: part I.
- Kaur et al. (2024). Plantar Fasciitis with Chronic Baxter's Neuropathy Causing Hindfoot Pain - A Case Report.
- Tu P. (2018). Heel Pain: Diagnosis and Management. Am Fam Physician.
- Malliaras P. (2022). Physiotherapy management of Achilles tendinopathy.