Heel Pain: Causes and What Actually Fixes It

Before anything else, put a finger on the sore spot. It does more diagnostic work than any symptom list.

That's the shortcut. Here's what's behind each one.

Your plantar fascia is the thick band of tissue running from your heel bone to your toes. When it gets irritated, the pain sits underneath the heel.

It's the most common foot condition treated by health care providers ⁸, with a peak between 40 and 60 years of age ³. It accounts for roughly 15% of adult foot complaints needing professional care and about 8% of running injuries ⁸, and in around a third of people it turns up in both feet at once ⁴.

The giveaway is the morning pattern. Pain may be worse when you first get out of bed, then usually eases after a few minutes of walking ¹, and comes back after you've been sitting, or after a long day standing.

A note on the name, because you'll see both: the condition is also called plantar heel pain ⁹, since "-itis" implies an inflammation that isn't always the main story ⁴.

If this is the pattern you recognise, our plantar fasciitis page goes much deeper: what changes the load on that tissue, what the loading research shows, and what a program looks like week to week.

Move your finger to the back of the heel, where the Achilles tendon anchors onto the bone, and you're in different territory. Achilles tendinitis is one of the three most common causes of heel pain ¹, and the version that hurts right at the attachment point is called insertional, as opposed to the type that sits a few centimetres higher up in the tendon itself.

That distinction matters more than it sounds, because the insertional kind is harder to treat. Loading the tendon (progressive strength work, usually starting with eccentric exercise) is still the first-line approach. But the research is unusually blunt about its limits: insertional Achilles tendinopathy is typically treated with eccentric exercises "despite the absence of satisfactory and sustained results" ⁵. It's the right starting point. It isn't a guaranteed fix, and anyone promising you one isn't reading the same literature.

What about shockwave? We offer shockwave therapy, and we'd rather you heard this from us. A 2021 randomised trial put 119 people with insertional Achilles tendinopathy through eccentric exercise plus either real shockwave or a sham. At 24 weeks there was no difference between the groups on any outcome measure ⁵. The secondary results pulled in both directions: the shockwave group had a higher failure rate but a lower recurrence rate, which is another way of saying the picture isn't settled. For this specific problem, shockwave has not been shown to add anything to loading, and we won't present it as though it has.

More on the tendon itself, including the non-insertional version, on our Achilles tendinopathy page.

This is the one that causes the most unnecessary worry, so we'll be direct.

A heel spur is a bony growth on the heel bone. If an X-ray has found one, the natural assumption is that the pointy thing is what's stabbing you. It usually isn't. An estimated one in ten Australians have heel spurs with no symptoms whatsoever; the spur itself does not cause the pain, though pain may be associated with inflammation in the area ².

So a spur on a scan doesn't change the plan much. What's irritated, and why, is still the question to answer. We've written more on heel spurs separately.

Under your heel bone sits a specialised pad of fat, built to absorb load every time your foot lands. It can thin out or lose its shock-absorbing quality with age, high mileage, or repeated impact, and when it does, the pain is different in character. It tends to feel deep and bruised in the middle of the heel, not like the sharp pull of the fascia, and it's noticeably worse barefoot on hard surfaces.

In the clinical literature, fat pad atrophy is described as the second cause of heel pain after plantar fasciitis ⁷. Take that ordering as a clinical impression, not a population statistic: it comes from a nine-patient case series, not an epidemiological study. The same paper flags another one worth ruling out: entrapment of Baxter's nerve, a small nerve branch in the foot that can mimic fascia pain ⁷.

One cause is avoidable. Corticosteroid injections do relieve heel pain temporarily, but they may increase the risk of both plantar fascia rupture and fat pad atrophy ⁴. That's a real trade-off found in the literature, and it's a conversation for the doctor offering it; injections sit outside what physiotherapists prescribe or administer, so it's not something we'd be doing either way.

We don't have a dedicated page for fat pad problems yet. If this is what your heel sounds like, it's worth having someone put hands on it instead of reading further.

If you're the parent reading this, this is your section.

Sever's disease is the most common cause of heel pain in children aged eight to 16 ², and the reason it exists at all is growth. There's an active growth plate at the back of the heel bone, and in a growing child it's the weakest link in that chain. Running and jumping put repeated stress through it, and it gets sore ².

It's strongly tied to sport (soccer, Australian football and basketball come up repeatedly in the research ⁶), which is why it tends to show up mid-season, not out of nowhere. Boys between roughly eight and 13 are listed among the higher-risk groups ².

The reassuring part is that it responds to conservative treatment. A 2024 systematic review pulled together eight randomised studies of non-surgical management (insoles, therapeutic exercise, taping, foot orthoses) and concluded that conservative treatment is an effective option for relieving the symptoms ⁶. But that evidence base is small and uneven. Of those eight studies, only four were at low risk of bias, three were at high risk, and one raised some concern ⁶. It points clearly in one direction; it just isn't a large, settled body of work.

Practically, management usually means rest from the aggravating activity, ice, calf stretching and heel lifts ², along with load management, not a season written off. Our Sever's disease page covers it properly, and it's the kind of thing our paediatric physiotherapy team sees regularly.

One thing that helps every parent who asks: it's self-limiting. The growth plate closes, and when it does, this stops.

Some of the first-line management overlaps regardless of which cause you're dealing with. The standard starting list for heel pain includes ice, supportive footwear or orthoses, changing the activities that aggravate it, strengthening work for the foot and calf, managing body weight where that's a factor, and night splints or strapping ¹.

Two things to know before you start.

The timeline is longer than you want it to be. Non-operative treatment resolves pain completely in about 90% of people ⁴. Those are good odds, and the reason surgery is rarely the answer. But the same source puts the usual timeframe at three to six months ⁴. Most people quit at week four because nothing's changed yet. Week four isn't the verdict.

"Rest" isn't a plan on its own. Stopping what hurts settles things down; it doesn't build the tissue's capacity back up. What changes the outcome is the graded return afterwards, which is the part that's hard to get right alone, and the part physiotherapists and podiatrists exist for ¹. Physiotherapy's own professional body revised its clinical practice guideline for heel pain in 2023 ³, which is where the profession's current treatment framing comes from.