Health

Heel Pain Causes: When Is It Serious (Not Just Plantar)?

John H

Health Enthusiastt

18 min read

Heel Pain Causes: When Is It Serious (Not Just Plantar Fasciitis)?

Heel pain is one of the most common complaints among adults, particularly those who are on their feet for extended periods, athletes, or individuals with certain medical conditions. While plantar fasciitis is the most widely known cause of heel pain, it's far from the only one. Many people assume all heel pain stems from overuse or strain of the plantar fascia, but overlooking other potential causes can delay proper diagnosis and treatment—especially when the underlying issue is serious.

In this comprehensive guide, we’ll explore the various causes of heel pain beyond plantar fasciitis, identify warning signs that suggest a more serious condition, and help you understand when to seek medical attention. By the end, you’ll have a clearer picture of what might be causing your heel pain and how to respond appropriately.

Understanding Heel Pain: Anatomy and Common Triggers

To understand heel pain, it’s essential to know the anatomy of the foot. The heel bone, or calcaneus, is the largest bone in the foot. It supports your body weight and absorbs the impact when you walk, run, or jump. Surrounding the heel are tendons, ligaments, fat pads, nerves, and blood vessels—all of which can be sources of pain.

Common triggers of heel pain include:

Overuse from running or standing for long hours
Sudden increase in physical activity
Wearing ill-fitting or unsupportive footwear
Obesity, which increases stress on the heel
Aging, which leads to tissue degeneration
Medical conditions such as arthritis or diabetes

While plantar fasciitis is responsible for about 80% of heel pain cases, it's crucial not to assume this is always the culprit. Let’s dive into the less common—but potentially serious—causes of heel pain.

Common Causes of Heel Pain Beyond Plantar Fasciitis

Achilles Tendinitis

The Achilles tendon connects the calf muscles to the heel bone. When this tendon becomes inflamed due to overuse or repetitive strain, it leads to Achilles tendinitis. Unlike plantar fasciitis, which typically causes pain under the heel, Achilles tendinitis pain is located at the back of the heel and may extend up the calf.

Symptoms include:

Stiffness and soreness in the back of the heel, especially in the morning
Swelling or thickening of the tendon
Pain that worsens with activity
Tenderness when pressing on the tendon

Left untreated, Achilles tendinitis can progress to tendinosis (chronic degeneration) or even a tendon rupture, which usually requires surgery. Athletes, particularly runners and jumpers, are at higher risk.

Heel Bursitis

Bursae are small, fluid-filled sacs that cushion bones, tendons, and muscles near joints. Inflammation of the bursa at the back of the heel—called retrocalcaneal bursitis—is often mistaken for Achilles tendinitis.

Causes include:

Frequent pressure from tight shoes or high heels
Overuse in sports like basketball or tennis
Repetitive heel impact such as in jumping or running

Signs of bursitis include:

Pain at the back of the heel, especially when walking or standing on tiptoes
Visible swelling and redness
Warmth in the affected area
Pain that improves with rest

Chronic bursitis may require corticosteroid injections or physical therapy. In rare cases, infection (septic bursitis) can occur, requiring antibiotics or drainage.

Stress Fractures

A stress fracture is a small crack in the bone caused by repetitive force or overuse. In the heel, stress fractures are less common than in other weight-bearing bones but can still occur—especially in military recruits, athletes, or individuals with osteoporosis.

Risk factors include:

Sudden increase in training intensity
Long-distance running or jumping sports
Low bone density
Proper footwear not being used

Symptoms of a heel stress fracture:

Dull, aching pain that worsens with activity and improves with rest
Swelling and tenderness around the heel
Pain that persists at night or at rest (a red flag)

Diagnosis often requires imaging such as an MRI or bone scan, as X-rays may not show early-stage fractures. Treatment includes rest, immobilization, and in some cases, crutches or a walking boot. Failure to treat can lead to full fractures or chronic pain.

Heel Spurs

Heel spurs are bony growths that develop on the underside or back of the heel bone. They often form in response to long-term tension from plantar fasciitis or Achilles tendinitis. However, many people have heel spurs without any symptoms.

When painful, heel spurs may cause:

Sharp pain with the first steps in the morning
Localized tenderness under or behind the heel
Worsening pain with prolonged standing

It’s important to note that heel spurs are a symptom, not a disease. Treating the underlying inflammation (plantar fasciitis or tendinitis) usually resolves pain. Surgery is rarely needed.

Sever’s Disease (Calcaneal Apophysitis)

Common in children and adolescents, Sever’s disease is inflammation of the growth plate in the heel. It’s not a true disease but a condition caused by repetitive stress during growth spurts—often affecting active kids between 8 and 14 years old.

Symptoms include:

Pain in one or both heels, especially after sports
Limping or walking on tiptoes to avoid heel pressure
Swelling or redness

The condition is self-limiting and resolves once the growth plate closes. However, rest, stretching, and supportive footwear are essential to manage discomfort and prevent long-term issues.

Tarsal Tunnel Syndrome

Similar to carpal tunnel syndrome in the wrist, tarsal tunnel syndrome occurs when the posterior tibial nerve is compressed as it passes through a narrow space inside the ankle. This can cause heel pain, tingling, or numbness.

Symptoms include:

Burning or shooting pain in the heel, arch, or sole
Numbness or tingling that may radiate
Pain that worsens at night or with prolonged standing
A sensation of electric shocks in the foot

Causes include flat feet, ankle swelling, or systemic diseases like diabetes. Early diagnosis is critical, as chronic nerve compression can lead to permanent nerve damage.

Referred Pain from the Spine

Surprisingly, some heel pain originates not in the foot but in the lower back. Sciatica or lumbar radiculopathy—caused by a herniated disc or spinal stenosis—can send pain down the sciatic nerve, affecting the heel.

Signs of referred heel pain from the spine:

Heel pain accompanied by lower back pain
Pain radiating from the buttock down the leg
Weakness or numbness in the leg or foot
Pain that worsens with sitting or bending

Imaging such as an MRI of the spine may be needed. Physical therapy, medications, or in severe cases, surgery may be required.

Infections and Abscesses

Though rare, infections can cause serious heel pain. Diabetics or individuals with compromised immune systems are at higher risk. A heel abscess may form from a puncture wound, untreated ingrown toenail, or spread of infection from nearby tissue.

Symptoms of infection:

Severe, throbbing pain
Redness, warmth, and swelling
Pus or drainage
Fever or chills

Infections in the heel require urgent treatment with antibiotics or surgical drainage. Delay can lead to bone infection (osteomyelitis) or sepsis.

Osteomyelitis (Bone Infection)

Osteomyelitis is a serious infection of the bone, including the heel. It can occur after trauma, surgery, or spread from another infected area via the bloodstream.

Signs include:

Deep, persistent heel pain
Swelling and redness
Fever and malaise
Wound drainage if there’s a skin break

Diagnosis is confirmed with blood tests, imaging, and sometimes bone biopsy. Treatment involves long-term intravenous antibiotics and possibly surgery to remove infected tissue.

Tumors and Cysts

Benign or malignant tumors in or around the heel are rare but possible. A bone cyst, lipoma, or even a rare form of bone cancer (like chondrosarcoma) can present as heel pain.

Warning signs include:

Unexplained, progressive pain not linked to injury
Noticeable lump or mass
Night pain that wakes you up
Weight loss or fatigue (systemic signs)

Imaging (X-ray, MRI) and biopsy are essential for diagnosis. Early detection improves outcomes, especially with malignant tumors.

Rheumatologic Conditions (Arthritis)

Autoimmune conditions such as rheumatoid arthritis, psoriatic arthritis, or ankylosing spondylitis can affect the heel. These cause inflammation in the joints and entheses (where tendons attach to bone).

Heel involvement in arthritis may present as:

Morning stiffness lasting more than 30 minutes
Pain in multiple joints
Swelling and warmth in the heel
Skin changes (e.g., psoriasis)

Reactive arthritis, often triggered by infections, can also cause heel pain. Blood tests and imaging help confirm the diagnosis. Treatment includes anti-inflammatory medications and disease-modifying agents.

Nerve Entrapment and Neuropathy

Peripheral neuropathy, often due to diabetes, vitamin deficiencies, or alcohol use, can cause burning, tingling, or numbness in the feet—including the heel. Unlike mechanical causes, neuropathic pain is often bilateral and worse at night.

Symptoms include:

Burning or electric-like pain
Lack of sensation or hypersensitivity
Balance issues due to sensory loss

Managing the underlying cause (e.g., blood sugar control) is key. Medications like gabapentin or pregabalin may help control symptoms.

When Is Heel Pain Serious? Red Flags to Watch For

While most heel pain resolves with conservative treatment, certain signs indicate a serious underlying condition. Don’t ignore these red flags:

Pain at night or at rest: Mechanical pain usually improves with rest. Persistent pain, especially if it wakes you up, may suggest infection, tumor, or nerve issues.
Swelling, redness, and warmth: These are signs of inflammation or infection. Seek care if they don’t improve in a few days.
Systemic symptoms: Fever, chills, fatigue, or unexplained weight loss may point to infection or autoimmune disease.
History of trauma: A recent fall, jump, or puncture wound increases the risk of fracture or infection.
Neurological symptoms: Numbness, tingling, or weakness may indicate nerve compression or neuropathy.
No improvement with rest or home care: If pain persists beyond 2–4 weeks despite stretching, icing, and proper footwear, see a doctor.