Heel pain is one of the commonest reasons people end up in a foot and ankle clinic — and one of the most misunderstood. Most of it is not caused by anything sinister, most of it gets better, and much of the early treatment is something you can start yourself. This page explains the three causes I see far more often than any others — I call them the "Big Three" — how to tell them apart, what genuinely helps at home, and when it is time to seek specialist help.
Start with where it hurts
The single most useful clue in heel pain is location. Pain under the heel, pain at the back of the heel where the Achilles tendon attaches, and pain a few centimetres above the heel in the tendon itself point to three different diagnoses — and they are treated differently. Between them, these three account for the great majority of heel pain I see.
1. Plantar fasciitis — pain under the heel
The plantar fascia is a strong band of tissue running from the underside of the heel bone towards the toes, supporting the arch. When it becomes irritated at its attachment to the heel, the result is plantar fasciitis.
The classic story: sharp pain under the heel with the first steps of the morning or after sitting for a while, easing as you get moving, then often aching again after a long day on your feet. It is more common in people who spend long periods standing, after an increase in activity, and with a tight calf muscle.
The good news is that most plantar fasciitis settles without surgery — but it is slow, and it tests patience. Improvement is usually measured over months, not weeks.
2. Insertional Achilles tendinopathy — pain at the back of the heel
The Achilles tendon anchors the calf muscles to the back of the heel bone. When the problem is at the attachment point itself, pain and often a tender bony prominence develop at the back of the heel. Stiff first thing in the morning, aggravated by walking uphill and by firm shoe backs rubbing against the area.
This pattern matters because some of the standard advice for the third condition below — particularly stretching regimes performed over the edge of a step — can actually aggravate insertional problems. Getting the diagnosis right changes the treatment.
3. Non-insertional Achilles tendinopathy — pain above the heel
When the painful area is in the main body of the tendon, typically two to six centimetres above the heel bone, this is non-insertional (or mid-portion) Achilles tendinopathy. There is often a tender, thickened segment of tendon you can pinch between finger and thumb. It is common in runners and in people who have recently increased their activity, but it also occurs in people who are not sporty at all.
Despite the old name "tendonitis", this is usually not an inflammatory condition — it is a problem of tendon structure and load. That is why the mainstay of treatment is a graded loading programme that strengthens the tendon, rather than simply resting it.
What genuinely helps at home
- Calf stretching. A tight calf increases load on both the plantar fascia and the Achilles. Regular, gentle calf stretches — done consistently for weeks, not days — are the foundation for all of the Big Three.
- Footwear. A cushioned, slightly raised heel and supportive sole offload the painful area. Avoid flat, unsupportive shoes and walking barefoot on hard floors while symptoms settle. For insertional Achilles pain, avoid rigid shoe backs that press on the tender spot.
- Heel cushions and insoles. For plantar fasciitis, a silicone heel cup or an off-the-shelf arch-support insole helps many people. Expensive custom orthotics are rarely needed as a first step.
- Activity modification — not rest. Complete rest rarely cures these conditions. Reduce the aggravating activity to a tolerable level and build back gradually. For Achilles problems, structured strengthening exercises — ideally guided by a physiotherapist — are the mainstay of treatment and have strong supporting evidence.
- Simple pain relief. Short courses of simple analgesia can make the exercise programme tolerable. If you take regular medication or have other conditions, check with a pharmacist or your GP first.
- Body weight. An honest one: load matters, and weight loss measurably reduces the load on the heel with every step. It is not easy, but it helps.
The other honest message is about time. Most heel pain of this kind improves over six to twelve months even without specialist treatment. The home measures above are about making that journey shorter and more comfortable.
A word of caution about injections
Steroid injections have a limited role in selected cases of plantar fasciitis, but they are not a quick fix and carry risks — including rupture of the plantar fascia and thinning of the heel's natural fat pad. Around the Achilles tendon, steroid injections risk tendon rupture and are generally avoided. If someone offers you an injection as a first-line treatment for heel pain, it is reasonable to ask careful questions.
When it is not the Big Three
A minority of heel pain has another cause: a stress fracture of the heel bone, nerve entrapment, thinning of the heel's fat pad, a partial tear of the plantar fascia, or — particularly if both heels are affected in a younger person — an inflammatory condition. These need a different approach, which is one reason a proper assessment matters when pain is not behaving as expected.
When to seek specialist help
- Pain that has not improved after several months of consistent home treatment
- Pain at night or at rest, or symptoms in both heels
- A sudden "pop" with immediate weakness — a possible tendon or fascia rupture, which needs prompt assessment
- You cannot put weight on the heel
- Numbness, tingling or burning alongside the pain
- You have diabetes, an inflammatory condition, or take long-term steroids
Specialist treatment starts with confirming the diagnosis — examination, sometimes imaging — and then matching treatment to it, from structured physiotherapy and shockwave therapy through to surgery, which is only rarely needed for heel pain and only after non-surgical options have been properly exhausted.
Next steps
If heel pain is limiting your walking, work or sport and you would like a clear diagnosis and an honest plan — which will usually not involve surgery — you can book a consultation at my clinic in Southampton. Self-pay and insured patients are welcome.
This article is general information and does not replace an individual consultation. Independent patient information is available from the British Orthopaedic Foot and Ankle Society (BOFAS) at bofas.org.uk.