Heel Pain

By Peter Charles, Sports Podiatrist — Shoes Feet Gear, 148 Boundary Rd Bardon

Heel pain refers to pain at the back half of the foot — underneath the heel, at the back of the heel, or towards the top of the heel bone. It is one of the most common presentations we see in our Brisbane podiatry clinic, and one of the most frequently misdiagnosed.

The heel is a large, solid bone designed to absorb the full impact of your body weight with every step. Whether walking or running, substantial load is driven through the heel at ground contact — making it strong by necessity, but also highly vulnerable once injured. Because load through the heel never stops, heel pain can be challenging to treat if the right diagnosis isn't made early.

Common causes of heel pain we treat:

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Why So Many Structures Get Injured

The heel is the attachment point for many of the body's most important load-bearing structures. Strong tendons from the lower leg connect onto the heel to drive you forward. A large ligament runs underneath the arch and anchors into the heel bone. Nerves wrap underneath and around the heel. A growth plate sits at the back of the heel in children. Each of these structures has a critical role — and each can be independently injured, often producing pain in the same location.

Heel pain affects everyone: recreational adults, elite athletes, school-age children, and the elderly. Each group brings different contributing factors, different loading patterns, and different treatment priorities.

Structures of the Heel That Can Be Injured

Heel Bone (Calcaneus)

The heel bone itself can fracture with high-energy impact — landing from a height or a fall. These are usually obvious, with severe pain and inability to weight-bear, and are typically managed in emergency. However, small stress fractures are frequently missed. Young athletes and competitive active people can develop stress reactions in the heel bone from repetitive load. We also see calcaneal stress injuries in people with compromised bone health — osteopenia, coeliac disease, low vitamin D, or other conditions affecting bone density.

Achilles Tendon (Insertional)

The Achilles tendon connects the calf muscles to the back of the heel bone. It is the primary driver of walking, running, and jumping. The fibres that attach directly onto the heel bone are commonly injured, producing pain at the back of the heel — particularly when pushing off hard or walking on the balls of the feet.

Plantar Fascia

The plantar fascia is a large, strong ligament running underneath the arch and joining into the bottom of the heel bone. When cumulative stress exceeds what the fascia can handle, it becomes injured — producing pain directly underneath the heel when standing. This is the most common heel pain diagnosis we see. It must be managed with specific strategies to allow the ligament to repair and strengthen, because it is under load with every single step.

Sever's Disease (Calcaneal Apophysitis)

Children between approximately 9 and 13 years of age have an active growth plate at the back of the heel bone. During this period, the growth plate is attempting to fuse into one solid bone, making it vulnerable to the pull of the Achilles tendon and the impact of sport. This is often confused with Achilles tendinitis but is a distinct condition, present only in this age group. Learn more about heel pain in children.

Nerve Compression Under the Heel

Small nerves wrap underneath the heel to provide sensation to the sole of the foot and supply small intrinsic muscles. When these nerves are compressed — by body weight pressing down through the hard heel bone, hard surfaces, or rigid footwear — they produce intense, often unpredictable pain. This condition is frequently misdiagnosed as plantar fasciitis. The pain pattern is typically more sporadic: good days and bad days depending on surface hardness and footwear.

Adventitial Bursitis (Fat Pad Syndrome)

The soft tissue pad underneath the heel skin is prone to shear forces. Rather than true fat pad atrophy, what we more commonly see is adventitial bursitis — an inflammatory response to the shearing forces under the skin. This is seen in sports with high stop-start demands, downhill running, and hard surface training. It can be tricky to diagnose but is often straightforward to treat once correctly identified.

Why Accurate Diagnosis Is Critical

All of these conditions can produce pain in the same location — directly underneath or around the heel. But the treatments are completely different, and in some cases, the wrong treatment will make the wrong condition significantly worse.

Consider two common examples. Nerve compression under the heel responds well to soft cushioning — a simple foam insole or soft thongs may provide immediate relief. Plantar fasciitis requires arch support and load reduction — wearing unsupportive footwear will aggravate it significantly. The same logic applies to activity modification: nerve compression or adventitial bursitis typically requires no reduction in training, while more significant calcaneal stress injuries may require several weeks of substantial unloading, sometimes including immobilisation in an air cast or boot.

Treatment costs also vary enormously — from a $10 piece of foam for nerve cushioning to a $750 custom 3D-printed orthotic for plantar fasciitis. An accurate diagnosis from an experienced clinician ensures you're investing in the right solution from the start.

How We Diagnose Heel Pain

We begin with a very detailed clinical history — because the pattern of pain is often the most diagnostic tool available. Plantar fasciitis produces classic first-step-after-rest pain, as the fascia cools and contracts during periods of non-weight-bearing. Nerve compression produces more sporadic, on-off pain that varies with surface and footwear. A calcaneal stress reaction produces a dull, continuous, unrelenting ache that doesn't vary much day to day. Insertional Achilles pain is typically provoked by push-off and hard effort.

Not all structures are visible on imaging. Nerves will not show on MRI. Small stress reactions may not show on X-ray. Our clinical assessment uses a systematic range of tests to identify which structures are involved and confirm the most likely diagnosis — so that treatment is targeted from the first appointment.

When to Seek Help

Mild heel pain after wearing inappropriate footwear for a day, or after a big weekend on your feet, is common and often resolves quickly with supportive shoes and rest. However, if heel pain is not settling within a few days, or is affecting your walking, work or sport, it is worth having it assessed early.

Early, mild heel pain is typically treated quickly with less invasive and less costly interventions, with minimal disruption to sport and activity. Left untreated, the large structures of the heel continue to be loaded with every step — and injuries that could have been resolved in two weeks can become chronic problems lasting months or years.

Seek assessment promptly if:

  • Pain has not improved within 48 hours of onset
  • Pain is present first thing in the morning or after rest
  • Pain is affecting your ability to walk, train, or work
  • You are a child or teenager with heel pain during sport
  • Pain is bilateral (both heels)

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Frequently Asked Questions — Heel Pain

What causes heel pain?

Heel pain is caused by injury to one or more of the structures that attach to or surround the heel bone — most commonly the plantar fascia, Achilles tendon, heel bone itself, or small nerves underneath the heel. The cause varies significantly between individuals and age groups.

Is heel pain serious?

It depends on the diagnosis. Some heel pain resolves quickly with simple measures. Others — such as calcaneal stress fractures or chronic plantar fasciitis — require structured treatment over weeks to months. Early assessment is the best way to determine severity and avoid prolonged recovery.

How long does heel pain take to heal?

This varies by diagnosis. Nerve compression may resolve in days with the right footwear. Plantar fasciitis typically takes 6–12 weeks with appropriate treatment. More significant calcaneal stress injuries may require several weeks of substantial unloading, sometimes including immobilisation in an air cast or boot. Early diagnosis significantly shortens recovery time.

Do I need orthotics for heel pain?

Not always. Orthotics are highly effective for plantar fasciitis and some Achilles presentations, but are not the primary treatment for nerve compression or adventitial bursitis. The right treatment depends entirely on the diagnosis.

Can children get heel pain?

Yes. Sever's disease (calcaneal apophysitis) is very common in children aged 9–13 during growth spurts and periods of high sporting activity. It is distinct from adult heel pain and requires age-appropriate management. See our page on heel pain in children.

Should I keep training with heel pain?

It depends on the diagnosis. Some conditions allow continued training with load modification. Others — particularly stress reactions — require a significant reduction in impact activity. Training through the wrong diagnosis can significantly delay recovery.