Heel Pain - A Comprehensive Clinical Overview

Epidemiology

About 10% of people will experience an episode of plantar heel pain at some point in their lives. More than 2 million patients are treated for plantar fasciitis every year in the United States alone. It is more common in rheumatology patients and in active individuals.

Rheumatology, 2-Volume Set (Elsevier 2022), p. 756

Differential Diagnosis of Heel Pain

Heel pain has multiple causes, broadly divided by anatomical location:

Plantar (Under the Heel)

Condition	Key Features
Plantar fasciitis (plantar fasciopathy)	Most common cause; worst pain in morning first steps
Heel pad atrophy	Degeneration of elastic adipose tissue; worse with aging
Calcaneal stress fracture	Athletes; diffuse heel pain with activity
Plantar calcaneal bursitis	Localized swelling under the heel
Entrapment of Baxter's nerve (1st branch of lateral plantar nerve)	Neurogenic pain, lateral heel tenderness
Tarsal tunnel syndrome	Burning/tingling along medial heel and sole
Plantar heel spur	Osseous exostosis; often a result of chronic plantar fasciitis
Soft tissue abscess	Consider in diabetic/neuropathic patients

Posterior (Behind the Heel)

Condition	Key Features
Achilles tendinopathy / enthesitis	Common in seronegative arthropathies (AS, PsA, ReA)
Retrocalcaneal bursitis	Deep to Achilles; associated with RA and inflammatory disease
Achilles bursa (superficial)	Mechanical irritation from footwear
Haglund's deformity/exostosis	Dorsal calcaneal prominence; bursal inflammation
Insertional Achilles tendinopathy	Posterior heel spur at tendon insertion

Systemic / Other

Rheumatoid arthritis, ankylosing spondylitis, Reiter syndrome - especially if bilateral heel pain
Calcaneal apophysitis (Sever's disease) - children/adolescents during growth spurts
Campbell's Operative Orthopaedics 15th Ed 2026, p. 4902; THIEME Atlas of Anatomy

Plantar Fasciitis - The Most Common Cause

Risk Factors

Obesity
Pes planus (flat foot) or pes cavus (high arch)
Limited ankle dorsiflexion
Prolonged standing or walking on hard surfaces
Inappropriate footwear
Runners (especially with change to harder surface or increased mileage)

Mechanism - Windlass Effect

The plantar fascia originates from the anteromedial calcaneal tuberosity and inserts into the metatarsophalangeal joint plantar plates. When toes dorsiflex, the fascia tightens around the metatarsal heads (windlass mechanism), elevating the longitudinal arch and placing maximum traction at the calcaneal origin - the point of peak tenderness.

Classic Presentation

Morning pain: severe pain with the very first steps on arising (or after periods of inactivity)
Pain lessens initially with walking, then worsens with continued activity
Pain worse on walking barefoot or going up stairs
Tenderness on palpation over the inferior heel at the plantar fascia calcaneal attachment

Imaging

Ultrasound (below): Shows thickening of the fascia at the calcaneal insertion and diffuse hypoechogenicity (edema). The arrows indicate marked fascial thickening at the calcaneus (C), with more normal structure distally (arrowheads).

Ultrasound of plantar fascia showing marked thickening at calcaneus

Ultrasound showing plantar fasciitis - marked thickening of fascia (arrows) at the calcaneus (C), normal structure distally (arrowheads). From Rheumatology, 2-Volume Set, p. 756.

Plain X-ray: May show a heel spur (calcaneal enthesophyte) - of little diagnostic significance on its own
MRI: Sensitive but usually not needed to establish the diagnosis

Management

Conservative (First-Line) - >80% resolve within 12 months

Activity modification: Reduce or eliminate inciting activities
Stretching: Plantar fascia and calf stretching exercises
Ice, heat, massage
Footwear modification: Supportive shoes with cushioning
Orthoses: Medial arch support (contoured foot orthoses)
Taping: "Low-Dye" taping has evidence of efficacy
Night splints: Keep ankle in neutral position to prevent contracture
Weight loss: Helpful in overweight patients
NSAIDs: Short course for those without contraindications

Injections

Corticosteroid injection: Evidence for short-term benefit, but painful and long-term benefits unclear; small risk of plantar fascia rupture with repeated injections
PRP (platelet-rich plasma): Emerging evidence, particularly for tendinopathy (recent meta-analysis, 2025)

Extracorporeal Shock Wave Therapy (ESWT)

Evidence supports use for chronic/recalcitrant cases
A recent 2024 systematic review and meta-analysis (PMID 38738305) comparing ESWT to corticosteroid injections found ESWT is effective for pain, plantar fascia thickness, and foot function, with more durable benefits than corticosteroids

Surgery

Plantar fasciotomy: Reserved for patients who have failed at least 6-12 months of conservative treatment
Gastrocnemius recession is an option in patients with associated gastrocnemius tightness

Posterior Heel / Bursitis Treatment

Physical therapy + NSAIDs for mechanical bursitis
Footwear modification to offload the posterior heel
Corticosteroid injection for inflammatory bursitis (RA-associated)
Harrison's Principles of Internal Medicine 22E, p. 3019; Rheumatology 2-Volume Set, p. 756

Red Flags - When to Investigate Further

Bilateral heel pain - rule out seronegative spondyloarthropathy (ankylosing spondylitis, psoriatic arthritis, reactive arthritis)
Heel pain in a diabetic or immunocompromised patient - rule out deep soft-tissue abscess
Night pain or rest pain - consider neoplasm or systemic disease
Failure to improve with conservative treatment at 6-12 weeks - consider imaging (MRI, bone scan)

Sources: Harrison's Principles of Internal Medicine 22E; Rheumatology 2-Volume Set (Elsevier 2022); Campbell's Operative Orthopaedics 15th Ed 2026; THIEME Atlas of Anatomy

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