In short
Most heel pain is plantar fasciitis, hurts under the arch, affects one foot and settles with stretching and better shoes. Pain at the back of the heel, in both feet, or alongside stiffness elsewhere may be enthesitis and needs a different assessment.
Heel pain that is worst on the first few steps out of bed, eases as you walk and bites again after a long day standing is almost always plantar fasciitis. It is common, it is mechanical, and it usually settles.
A smaller group of people have something else. Their pain sits at the back of the heel rather than under it, affects both feet, refuses to improve with insoles, and arrives alongside a stiff back or a swollen toe. That pattern is enthesitis, inflammation at the point where a tendon or ligament anchors into bone, and it can be the first visible sign of an inflammatory joint disease.
This article sets out how to tell the two apart, which features should make you stop buying insoles and get assessed, and when heel pain needs urgent attention rather than patience.
Where heel pain actually comes from
The heel bone is a busy anchor point. The plantar fascia, a thick band supporting the arch, attaches to the underside of it. The Achilles tendon, the strongest tendon in the body, attaches to the back of it. A small fluid sac sits between the two, and a pad of fat cushions the whole thing when you land.
Any of these can be the source. The NHS lists sharp pain between the arch and the heel that is worse when you start walking and better when resting as typical of plantar fasciitis, pain at the back of the heel extending into the ankle and calf as typical of Achilles tendonitis, and redness with a dull ache as typical of bursitis.
It also lists a fourth possibility that matters more than the others: sudden sharp pain with swelling and a popping or snapping sound at the moment of injury, which suggests a broken heel bone or a ruptured Achilles tendon and should never be self-treated.
What plantar fasciitis usually looks like
The story is remarkably consistent. The first steps in the morning are agony, the pain fades over a few minutes of walking, and it returns after standing at a kitchen counter or walking through a market. It is usually one foot. It is worse barefoot on a hard floor, which in most Indian homes means marble or granite.
Mechanical heel pain tends to follow a change: a new job on your feet, a sudden increase in walking, a weight gain, flat chappals replacing supportive shoes, or a long trip in unfamiliar footwear.
A word about the spur. Many people are told an X-ray shows a heel spur and conclude that the spur is the problem. Spurs are commonly found in people with no symptoms at all, and they are better understood as a sign that the fascia has been pulling on the bone than as the cause of the pain. Removing your attention from the spur usually improves treatment, because the treatment that works is aimed at the fascia and the calf, not at the bone.
Enthesitis: inflammation where tendon meets bone
An enthesis is the junction where a tendon or ligament fixes into bone. In several inflammatory diseases the immune system targets those junctions specifically, and the NHS defines enthesitis as painful inflammation where a bone is joined to a tendon or a ligament.
The same page names the common sites, and they are worth knowing because they cluster: at the top of the shin bone, behind the heel at the Achilles tendon, under the heel, and where the ribs join the breastbone. If your heel hurts and so does the front of your knee and the middle of your chest, that is not four separate injuries.
The pattern is the same in psoriatic disease. NIAMS lists tenderness in entheses, with the back of the heel and the sole of the foot as commonly affected spots, among the symptoms of psoriatic arthritis. In ankylosing spondylitis and related forms of axial spondyloarthritis, a painful heel is sometimes the symptom that appears years before anyone looks at the spine.
The first-step pattern, and what it does not prove
Both problems hurt on the first steps of the day, so that feature alone settles nothing. The differences are in what happens next and in where exactly it hurts.
Plantar fasciitis. Pain under the heel, at a single tender point you can find with a thumb. It eases within a few minutes of walking. One foot, usually. No visible swelling. No stiffness anywhere else.
Enthesitis. Pain often at the back, where the Achilles meets the bone, sometimes with a visible thickening you can compare against the other side. It takes much longer than a few minutes to loosen. Both heels may be involved, either together or in turn. It frequently comes with more than thirty minutes of stiffness in the back or other joints on waking.
Either way. Night pain that wakes you, swelling you can see, and failure to improve at all over several weeks of sensible self-care all argue against a simple mechanical strain.
Clues that the heel is part of something larger
The evidence that decides this question is usually somewhere other than the foot. Go through the past few years of your own history for the following:
- Low back or buttock pain that wakes you in the second half of the night and eases as you move
- Psoriasis anywhere, including only on the scalp, or nails with pitting, ridges or lifting
- A whole finger or toe that once swelled up like a sausage rather than at one knuckle
- A red, painful, light-sensitive eye that needed treatment from an eye specialist
- Gut or urinary infection in the weeks before the heel started, which can trigger reactive arthritis
- A parent or sibling with spondylitis, psoriasis or inflammatory bowel disease
NICE is explicit about what should happen next. It advises referring people with enthesitis that has no apparent mechanical cause to a rheumatologist for a spondyloarthritis assessment if it is [persistent, or in multiple sites, or accompanied by features such as back pain, uveitis, psoriasis or a first-degree relative with spondyloarthritis](https://www.nice.org.uk/guidance/ng65/chapter/Recommendations).
Achilles trouble at the back of the heel
Pain at the back deserves its own thought, because the Achilles tendon is both a common site of mechanical overload and a favourite target of inflammation.
Mechanical Achilles problems usually build after a change in activity, hurt most at the start of exercise, and are tender a few centimetres above the bone rather than right at the insertion. Inflammatory disease tends to strike at the insertion itself, where the tendon enters bone, and is often worse in the morning than during exercise.
Two safety points. A sudden snap or pop at the back of the ankle, followed by an inability to push off or stand on tiptoe, suggests a ruptured tendon and needs assessment the same day. Separately, some medicines, including the fluoroquinolone group of antibiotics, have been linked with Achilles tendon problems. If you develop tendon pain while taking an antibiotic, tell the prescribing doctor promptly rather than stopping anything on your own.
Steroid injections are generally avoided around the Achilles tendon because of the risk of rupture, which is one reason the cause needs to be established before anyone reaches for a needle.
What ultrasound and MRI of the foot add
An X-ray is mostly useful for excluding a fracture and for showing bony changes at the insertion. It cannot show inflammation.
Ultrasound is the workhorse. It measures the thickness of the plantar fascia and the Achilles insertion, and the Doppler setting shows increased blood flow where tissue is actively inflamed. It is quick, involves no radiation, and can be done while you describe where it hurts.
MRI is reserved for harder cases. It can show fluid and swelling within the heel bone itself at the point of tendon attachment, which is a strong pointer towards inflammatory disease rather than overload.
Blood tests help least. CRP and ESR are often entirely normal in someone with genuine enthesitis, and a positive HLA-B27 result raises probability without proving anything. Tests support the clinical picture here. They do not replace it, and they are read alongside a full assessment for inflammatory joint disease.
Treatment aimed at the cause, not just the sole
Mechanical heel problems respond to mechanical treatment. The NHS advises resting and raising the heel, ice, wide comfortable shoes with a low heel and soft sole, soft insoles or heel pads, gentle regular stretching and losing weight if you are overweight, while avoiding long periods standing barefoot and avoiding high or pointed shoes. Calf and fascia stretching done consistently over months does more than anything bought off a shelf.
Inflammatory enthesitis needs the underlying disease treated. Anti-inflammatory medicines usually help the symptom, and where a spondyloarthritis is confirmed the aim shifts to controlling the disease itself so that entheses across the body settle rather than treating one foot at a time. A local injection is occasionally used around the plantar fascia in resistant cases, and the article on what a joint injection involves explains how that is done and when it is not appropriate.
Orthotics, physiotherapy and load management remain useful in both groups. They simply are not sufficient on their own when the driver is immune rather than mechanical.
When to stop treating it yourself
The NHS advice on heel pain is to see a doctor if the pain is severe or stopping you doing normal activities, if it is getting worse or keeps coming back, if it has not improved after treating it at home for two weeks, if you have tingling or loss of sensation in the foot, or if you have diabetes, because foot problems carry more risk in diabetes.
Add three rheumatology triggers to that list. Both heels affected. More than thirty minutes of stiffness in the morning in the back or other joints. Any of the skin, eye, gut or family clues listed above.
Urgent, same day. A heel that is hot, red, very swollen and painful, particularly with fever or shivering, needs immediate assessment because infection and crystal arthritis both present this way and both need prompt treatment. Gout can strike the ankle and heel, not only the big toe. So does a suspected broken heel bone after a fall from height, which should be assessed rather than strapped up at home.
What to take to a foot assessment
Bring the shoes you actually wear most days, including the ones you wear at home. They tell an examiner more than a description ever will, and the wear pattern on the sole is genuine evidence.
Write down when the heel pain started, whether it began after a change in activity or out of nowhere, whether it is under or behind the heel, how many minutes it takes to loosen in the morning, and whether both feet have ever been involved. Add the skin, nail, eye, back and bowel history, and any relatives with these conditions.
Carry previous X-ray films and ultrasound reports in date order, and a full list of medicines and supplements including anything bought without a prescription. If you are not sure whether your symptoms warrant a specialist opinion, the guide on when to see a rheumatologist sets out the thresholds. Do not stop a prescribed medicine before your appointment, and speak to your rheumatologist before changing anything you are already taking.
Common questions
How do I know if my heel pain is plantar fasciitis or something inflammatory?
Location and company. Plantar fasciitis hurts under the heel at one tender point, affects one foot, and eases within minutes of walking. Inflammatory enthesitis often hurts at the back, can affect both heels, takes much longer to loosen, and usually arrives with stiffness in the back or other joints.
Does a heel spur on my X-ray mean I need surgery?
Almost never. Spurs are commonly found in people with no heel symptoms at all, and they are usually a consequence of long-standing pull on the bone rather than the cause of pain. Treatment is directed at the fascia, the calf and footwear. Surgery is a last resort in a small minority.
Can heel pain be the first sign of arthritis?
Yes. Inflammation at tendon attachment points can appear years before spinal or joint symptoms become obvious, particularly in psoriatic arthritis and axial spondyloarthritis. A heel that will not settle, especially in a young adult with back stiffness or psoriasis, is worth a rheumatology assessment.
How long should I try insoles and stretches before seeing a doctor?
The NHS suggests seeing a doctor if home treatment has not helped after two weeks, or sooner if the pain is severe or stopping normal activities. For a mechanical problem, meaningful improvement should be visible within a few weeks. No improvement at all after six weeks needs a proper assessment.
Sources
- NHS - Heel pain: causes and self-care www.nhs.uk
- NHS - Ankylosing spondylitis: symptoms and enthesitis www.nhs.uk
- NIAMS - Psoriatic arthritis: symptoms and causes www.niams.nih.gov
- NICE NG65 - Spondyloarthritis: referral for enthesitis www.nice.org.uk
This article is general information and does not replace a consultation.