Heel pain: causes and common conditions beyond plantar fasciitis

Not all heel pain is plantar fasciitis.

Understanding the spectrum of heel pain conditions helps pharmacists deliver targeted advice, recommend appropriate products, and identify red flags requiring referral.

Common causes of heel pain: how to tell them apart?

Condition	Where is the pain?	Typical features	“Clue” that helps you spot it
Mid-portion Achilles tendinopathy	Tendon, above the heel	Worse with load; stiffness	Tender, thickened tendon; pain with heel raises
Insertional Achilles tendinopathy ± retrocalcaneal bursitis	Back of the heel (insertion)	Worse with shoes or uphill walking	Shoe counter irritation; insertion tenderness
Heel fat pad syndrome	Central plantar heel	Worse on hard floors or barefoot	Deep “bruised” heel pain; less morning first-step pain
Calcaneal stress fracture	Heel bone (often focal)	Progressive pain; may occur at rest or night	Recent load increase; focal bony tenderness
Tarsal tunnel / nerve entrapment	Medial heel → sole	Burning or tingling; worse with standing	Neuropathic pain (tingling, numbness)
Inflammatory enthesitis (SpA)	Achilles or plantar insertions	Morning stiffness; often bilateral	Back pain, psoriasis, inflammatory bowel disease, uveitis

Heel pain may have mechanical, neurological, or inflammatory causes. For pharmacists, pain location, timing, and associated symptoms offer a practical framework to guide advice and referral ¹.

Posterior heel pain: Achilles-related disorders

Achilles tendinopathy is a common cause of posterior heel pain, particularly in running or jumping sports and in middle-aged adults after a recent increase or change in physical activity. Pain is typically localized to the tendon (mid-portion) or its insertion on the calcaneus, worsens with activity, and may be accompanied by morning stiffness ^2-4.

Insertional Achilles tendinopathy may be worsened by shoe pressure and may coexist with adjacent conditions such as retrocalcaneal bursitis or a Haglund-type prominence. From a pharmacy perspective, relevant advice includes avoiding compressive footwear, temporarily reducing provocative activities, and encouraging referral for exercise-based rehabilitation when symptoms persist ^{2, 4, 5}.

Central plantar heel pain: heel fat pad syndrome

Heel fat pad syndrome (HFPS) is increasingly recognized as a distinct cause of plantar heel pain and may be overlooked when all plantar pain is assumed to be plantar fasciopathy. Patients often describe deep, bruise-like pain in the centre of the heel, often worsened by prolonged standing, barefoot walking, or hard surfaces ^{6, 7}.

Management is primarily mechanical offloading, including cushioned footwear, heel cups, viscoelastic inserts, and activity modification ⁶.

Calcaneal stress fracture

A calcaneal stress fracture should be considered when heel pain develops after a recent increase in load, such as starting a job with prolonged standing, increasing training volume, or changing to harder walking or running surfaces. Pain may initially occur with activity but can progress to persistent pain, including pain at rest or at night. These injuries are often difficult to diagnose clinically and require medical referral for imaging and appropriate offloading ^{8, 9}.

Neuropathic heel pain: tarsal tunnel and calcaneal nerve entrapment

Neuropathic heel pain should be suspected when patients report burning, tingling, numbness, or shooting pain, sometimes radiating into the sole. Tarsal tunnel syndrome, caused by compression of the tibial nerve, is a recognized cause. Diagnosis is primarily clinical and may be supported by imaging in specialist care ^10-12.

Inflammatory and systemic causes: spondyloarthritis (enthesitis)

Heel pain may reflect enthesitis, defined as inflammation at tendon or ligament insertions.

In spondyloarthritis (SpA), enthesitis is a common manifestation, and heel pain is a typical presentation. SpA should be considered in the presence of bilateral heel pain, prolonged morning stiffness, inflammatory back pain, or associated conditions such as psoriasis, uveitis, or inflammatory bowel disease ^{13, 14}.

!! When heel pain is reported together with one of these conditions, an underlying inflammatory cause should be kept in mind, and referral is appropriate.

WHEN TO REFER: RED FLAGS IN HEEL PAIN

Urgency	Red flag	Why it matters
🔴 Immediate	Inability to bear weight, severe pain after trauma	Possible fracture or tendon rupture
🔴 Immediate	Sudden posterior heel pain with a “snap”	Suspected Achilles rupture
🔴 Immediate	Redness, warmth, swelling ± fever	Possible infection
🟠 Prompt	Pain at rest or night pain	Possible stress fracture
🟠 Prompt	Localized bony heel tenderness	Possible stress fracture
🟠 Prompt	Burning pain, tingling, numbness	Nerve entrapment or neuropathy
🟠 Prompt	Bilateral heel pain with prolonged morning stiffness	Possible inflammatory disease
🟡 Refer if persistent	No improvement after 6–12 weeks of self-care	Alternative diagnosis
🟡 Lower threshold	Diabetes, neuropathy, vascular disease	Higher risk of complications

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