Heel Pain: What’s Really Going On Under Your Foot?
- Xavier Grech - Osteopath at Prom Health
- 2 days ago
- 3 min read
Heel pain is one of the most common foot complaints seen in clinical practice. Population studies suggest it affects approximately 3–4% of adults, rising to close to 1 in 10 people over the age of 50, with a slightly higher prevalence in women¹. While heel pain can feel like a simple problem, it often reflects complex changes in the tissues beneath the foot.
To understand heel pain, it helps to look at the anatomy. The heel bone, known as the calcaneus, forms the foundation of the rear foot. Pain at the bottom of the heel most commonly involves two key structures: the heel fat pad and/or the plantar fascia.
The heel fat pad is a specialised layer of fat and connective tissue that sits directly under the calcaneus. Its primary role is shock absorption, helping to manage forces that can reach two to three times body weight with each step during walking². With ageing, this fat pad can thin and lose elasticity, reducing its ability to cushion impact. In younger people, repetitive loading, high training volumes, or frequent barefoot walking can overload the fat pad, leading to pain. Dysfunction of the fat pad is referred to as heel fat pad syndrome. This pain is typically mechanical in nature rather than due to true inflammation. Management often focuses on reducing load and using cushioned heel cups (around 15 mm thick), which can provide immediate symptom relief by restoring shock absorption.
The other major contributor to heel pain is the plantar fascia. It is a thick, strong band of connective tissue running from the calcaneus toward the toes. It acts like a spring, supporting the arch and helping propel the body forward during walking and running. Pain related to this structure is often labelled “plantar fasciitis,” but this term can be misleading. While the term itis implies inflammation, most long-standing cases involve tissue degeneration rather than active inflammation³. For this reason, the term plantar fasciopathy is more accurate.
The plantar fascia has a relatively poor blood supply and is difficult to rest, as standing and walking are unavoidable. Recovery can therefore be slow, often taking two to six months. Management involves a careful balance: reducing excessive daily irritation (such as prolonged standing or large increases in walking volume) while progressively loading the tissue through structured strengthening exercises, particularly calf strengthening. While walking itself isn’t harmful, excessive repetitive loading can continually irritate healing tissue, much like scratching a scab, whereas heavier, less frequent loading can provide a more effective stimulus for repair.
A hallmark feature of plantar fasciopathy is sharp pain with the first steps in the morning. Overnight, the tissue shortens as it heals and suddenly stretching it in the morning under full body weight can be very painful. Gentle foot massage before standing and wearing supportive footwear immediately on rising can significantly reduce morning pain.
Evidence-based treatments continue to evolve. A recent systematic review and meta-analysis supports extracorporeal shockwave therapy as an effective option for reducing pain and improving function in plantar fasciopathy⁴. Photobiomodulation (laser therapy) has also demonstrated improvements in pain and disability, particularly when used alongside other interventions rather than as a stand-alone treatment⁵. Alongside exercise prescription and footwear modification we utilise these treatment options at Prom Health generally with good results.
Sudden increases in activity are a common trigger. Importantly, heel spurs seen on imaging often do not correlate with pain and are frequently incidental findings. Hormonal factors may also influence heel pain. Reduced oestrogen during perimenopause and menopause is associated with stiffer, less compliant connective tissues, while pregnancy-related hormones such as relaxin increase tissue laxity, altering foot mechanics⁷. These hormonal changes may affect tissue resilience, sensitivity, and recovery and may be significant contributing factors to the onset of dysfunction.
Finally, not all heel pain is mechanical. Irritation of nerves, particularly branches of the tibial or inferior calcaneal nerve, can mimic plantar fascia or fat pad pain and must be carefully assessed. Pain at the back of the heel, on the other hand, often involves the Achilles tendon or nearby bursae, a topic worthy of its own discussion.
If you have or know someone with ongoing heel pain, feel free to contact us at Prom Health.
References
Riel H et al. Prevalence and incidence of heel pain. J Foot Ankle Res. 2019.
Wearing SC et al. Heel fat pad biomechanics. Clin Biomech. 2009.
Lemont H et al. Plantar fasciosis vs fasciitis. J Am Podiatr Med Assoc. 2003.
Lou J et al. Shockwave therapy for plantar fasciopathy. Foot Ankle Surg. 2024.
Alfredo PP et al. Photobiomodulation in plantar fasciopathy. Lasers Med Sci. 2023.
Franceschi F et al. PRP injections for plantar fasciopathy. Sports Med Arthrosc Rev. 2014.
Abate M et al. Hormonal influences on tendons. Muscles Ligaments Tendons J. 2013.
