Causes of Heel Pain
Heel pain has multiple etiologies that can be systematically categorized by anatomic location: plantar fasciitis is the most common overall cause, while location-specific pain patterns help narrow the differential diagnosis to include traumatic, inflammatory, neurologic, and less commonly, systemic or neoplastic conditions 1, 2.
Common Causes by Anatomic Location
Plantar (Bottom) Heel Pain
- Plantar fasciitis - The single most common cause, characterized by medial plantar heel pain that is worst with first steps in the morning or after prolonged sitting 2, 3
- Calcaneal stress fractures - Progressive worsening pain after increased activity or change to harder walking surfaces 1, 2
- Nerve entrapment/neuroma - Pain accompanied by burning, tingling, or numbness 2
- Heel pad syndrome - Deep, bruise-like pain in the middle of the heel, particularly in older and obese patients 2, 3
- Plantar warts - Localized painful lesions 2
Posterior Heel Pain
- Achilles tendinopathy (tendinosis/tendinitis) - Insidious onset with chronic posterior heel pain and swelling, aggravated by activity and shoe pressure 1, 4
- Insertional Achilles tendonitis - Tenderness at the Achilles insertion with radiographic spurring or erosion 1
- Haglund's deformity with retrocalcaneal bursitis - Most common in women 20-30 years old, with posterolateral prominence and pain relieved when walking barefoot 1, 4
Medial Midfoot Heel Pain
- Tarsal tunnel syndrome - Compression of the posterior tibial nerve causing pain with prolonged weight bearing, accompanied by tingling, burning, or numbness 2, 3
Lateral Midfoot Heel Pain
- Sinus tarsi syndrome - Feeling of instability with increased activity or walking on uneven surfaces 2
Traumatic Causes
Acute calcaneal fractures are the most common osseous cause, typically from falls from height, presenting with diffuse rearfoot pain when intra-articular or focal pain when extra-articular 1. Diagnosis requires radiographic confirmation, with surgery indicated for most cases except minimally displaced fractures 1.
Calcaneal stress fractures occur from repetitive loading, with pain on lateral calcaneal wall compression just posterior to the subtalar joint facet. Bone scan may be needed when radiographs are initially negative 1.
Acute plantar fascia rupture can occur, though radiographs and bone scans may be negative 1.
Age-Specific Considerations
Calcaneal apophysitis (Sever disease) is the most common cause of heel pain in adolescents and children, responding well to palliative treatment 1, 2.
Neurologic Causes
Neurologic heel pain results from irritation or entrapment of nerves innervating the heel, or from more proximal nerve impingement syndromes causing referred pain or sensory loss 1. Subspecialist referral is indicated when neurologic etiology is suspected, with diagnostic workup including electromyography, nerve conduction studies, and MRI 1.
Rare but Important Causes
Systemic Disease
Arthritides can cause heel pain, particularly the seronegative spondyloarthropathies 1. Consider systemic illness when patients present with bilateral heel pain, pain in other joints, or known inflammatory arthritis 3. Other systemic conditions include rheumatoid arthritis, crystal deposition arthropathies, and diabetes mellitus 5.
Serious Pathology
Tumors (benign and malignant), infections (soft tissue and bone), and vascular compromise rarely cause heel pain but require proper diagnostic testing and urgent consultation when suspected 1. These should be considered when symptoms are prolonged, unexplained, or accompanied by constitutional symptoms 3.
Clinical Pitfalls
- Don't assume all heel pain is plantar fasciitis—the anatomic location of pain is critical for accurate diagnosis 2
- Calcaneal stress fractures may not be visible on initial radiographs; maintain high suspicion with appropriate history and consider bone scanning 1
- Avoid corticosteroid injections near the Achilles tendon insertion due to rupture risk 1
- Bilateral heel pain or pain in multiple joints should prompt evaluation for systemic disease rather than mechanical causes 3