Where your heel hurts is one of the best clues to what is causing the pain. Pain under the heel is most often plantar fasciitis. Pain at the back of the heel is most often Achilles tendonitis (also called Achilles tendinopathy). The two conditions are both common, can feel similar at first, and are sometimes confused, but they affect different structures and are managed differently.
This guide explains how to tell them apart by location, timing and triggers, what else can cause heel pain, and when it is worth seeing a specialist.
Medically reviewed by Dr Abdul Rahman Alvi, Consultant Vascular & Interventional Radiologist (MBBS, MRCS, FRCR, Dual CCT UK), Dubai.
| Where it hurts | Most likely cause |
|---|---|
| Underneath the heel, towards the inner side, sometimes spreading into the arch | Plantar fasciitis |
| Back of the heel or just above it, along the thick cord above the heel | Achilles tendonitis |
| Where the Achilles tendon attaches to the heel bone, sometimes with a bony bump | Insertional Achilles tendinopathy or Haglund’s deformity |
| Centre of the heel pad, worse on hard floors or barefoot | Heel fat-pad pain |
| Whole heel, worse with activity and painful when the sides of the heel are squeezed | Possible heel (calcaneal) stress fracture |
| Burning, tingling or numbness on the inside of the heel or sole | Nerve-related heel pain |
Use this as a guide only. More than one problem can be present at the same time, and an examination is the only reliable way to confirm the cause.
Pain under the heel: plantar fasciitis
The plantar fascia is a thick band of tissue that runs along the sole of the foot, from the heel bone to the base of the toes. It supports the arch every time you stand, walk or run. When it is repeatedly overloaded, the point where it attaches to the heel bone can become painful and thickened. This is plantar fasciitis, the most common cause of pain under the heel in adults.
Where plantar fasciitis pain is felt
- Underneath the heel, usually towards the inner (big-toe) side
- Sometimes spreading forward into the arch of the foot
- A tender spot you can often press with a thumb on the underside of the heel
Typical signs
- First-step pain: sharp pain with the first few steps out of bed in the morning, or after sitting for a while
- Pain that eases after a few minutes of walking, then returns after long periods of standing or walking
- Worse on hard floors, barefoot, or in flat, unsupportive shoes
Common risk factors
- Long hours standing, especially on hard surfaces
- A sudden increase in walking, running or exercise
- Tight calf muscles or a tight Achilles tendon
- Flat feet or high arches
- Weight gain
- Worn-out or unsupportive footwear
Many people are told they have a “heel spur”. Heel spurs are often seen on X-rays, including in people with no pain, and are not usually the cause of the pain itself. Treatment focuses on the plantar fascia, not the spur.
If pain under your heel has lasted several months despite stretching, footwear changes and physiotherapy, see our page on plantar fasciitis treatment in Dubai.
Pain at the back of the heel: Achilles tendonitis
The Achilles tendon is the thick cord at the back of the ankle that connects the calf muscles to the heel bone. It takes a large load with every step, jump and climb. When the tendon is overloaded over time, it can become painful, stiff and thickened. Doctors now usually call this Achilles tendinopathy, because the problem is mainly wear in the tendon rather than simple inflammation.
Where Achilles tendonitis pain is felt
There are two main types, and the location tells them apart:
- Mid-portion Achilles tendinopathy: pain and sometimes a thickened, tender area a few centimetres above the heel, in the cord itself
- Insertional Achilles tendinopathy: pain right where the tendon attaches to the back of the heel bone, sometimes with a bony bump that rubs on shoes
Typical signs
- Stiffness and pain at the back of the heel in the morning, often easing as the tendon warms up
- Pain when walking uphill, climbing stairs, running or rising onto tiptoe
- Tenderness when the tendon is squeezed between finger and thumb
- Visible swelling or thickening of the tendon in longer-standing cases
Common risk factors
- A sudden increase in running, sport or hill walking
- Tight calf muscles
- Age over 30 to 40, when tendons become less elastic
- Footwear that presses on the back of the heel
- Some medicines, including certain antibiotics (fluoroquinolones)
When it is urgent: a sudden snap or a feeling of being kicked in the back of the ankle, followed by difficulty pushing off or standing on tiptoe, may mean the Achilles tendon has ruptured. This needs same-day medical assessment.
For pain at the back of the heel that has not settled with rest, calf strengthening and physiotherapy, see our page on Achilles tendonitis treatment in Dubai.
Other causes of heel pain
Not every painful heel is plantar fasciitis or Achilles tendonitis. Other causes include:
- Heel fat-pad pain: the cushioning pad under the heel thins or is bruised. Pain sits in the centre of the heel and is worse on hard floors and barefoot, but there is usually no first-step morning pain.
- Calcaneal stress fracture: a small crack in the heel bone, more common in runners and people who have suddenly increased walking. Pain builds with activity and the heel hurts when squeezed from both sides.
- Retrocalcaneal bursitis and Haglund’s deformity: inflammation of a small fluid sac, often with a bony bump at the back of the heel that rubs against shoes.
- Nerve-related heel pain: irritation of nerves on the inner side of the heel (such as in tarsal tunnel syndrome) can cause burning, tingling or numbness rather than an ache.
- Arthritis and inflammatory conditions: some forms of arthritis affect where tendons and ligaments attach to the heel, often in both feet.
- Sever’s disease in children: heel pain in active children aged about 8 to 14, caused by irritation of the heel’s growth plate.
Because these conditions are treated differently, persistent heel pain should be properly assessed rather than assumed to be plantar fasciitis.
Plantar fasciitis vs Achilles tendonitis at a glance
| Plantar fasciitis | Achilles tendonitis | |
|---|---|---|
| Pain location | Under the heel, inner side, may spread to the arch | Back of the heel or a few cm above it |
| Worst time | First steps in the morning or after rest | Morning stiffness; during and after activity |
| Common triggers | Long standing, hard floors, barefoot walking | Running, hills, stairs, jumping |
| Tender spot | Underside of the heel | The tendon cord, or where it meets the heel |
| Swelling | Usually not visible | Thickening of the tendon may be visible |
| First-line treatment | Calf and plantar fascia stretching, supportive footwear or insoles, load management | Progressive calf and tendon loading exercises, load management, heel raise in shoes |
When to see a specialist
Most heel pain improves with the right self-care over weeks to months. Book an assessment if:
- Heel pain has lasted more than 6 to 8 weeks despite rest, stretching and footwear changes
- Pain is getting worse or is stopping you from working, exercising or walking comfortably
- You are not sure which condition you have, or both areas hurt
- Physiotherapy or injections have not given lasting relief
- You have diabetes or poor circulation in your feet
Seek urgent care for a sudden snap at the back of the ankle, heel pain after a fall or injury, a hot, red and swollen heel, fever, or new numbness or weakness in the foot.
How heel pain is diagnosed and treated
Diagnosis usually starts with your history and a hands-on examination: where it hurts, when it hurts, and which movements bring it on. Ultrasound can show thickening of the plantar fascia or changes in the Achilles tendon. MRI or X-ray is used when a stress fracture, bone problem or another cause needs to be ruled out.
Treatment is step by step:
- Self-care and load management: reduce the activities that flare the pain without stopping movement altogether.
- Stretching and strengthening: calf and plantar fascia stretches for plantar fasciitis; a structured tendon-loading programme for Achilles tendinopathy. These are the most important treatments for both conditions.
- Footwear and insoles: cushioned, supportive shoes; heel cups or orthotics; a small heel raise for Achilles pain.
- Physiotherapy: a supervised programme, sometimes with shockwave therapy.
- Advanced options for persistent cases: when pain continues for months despite the steps above, a specialist may discuss other options. For selected patients with chronic, treatment-resistant pain, this can include minimally invasive, image-guided procedures such as embolization, which targets the abnormal small blood vessels that develop around long-standing tendon and fascia problems. This is an emerging option, not a first-line treatment, and suitability depends on a full assessment.
Dr Abdul Rahman Alvi assesses patients with persistent heel pain at his clinic in Dubai Healthcare City. If your heel pain has not improved with the steps above, book a consultation on WhatsApp.
Frequently asked questions
This article is for general information and does not replace a medical consultation. Heel pain has several causes, and the right treatment depends on an examination.