Heel pain is caused by many different conditions.  The most common type of heel pain occurs on the bottom of the heel and is caused by inflammation in a ligament called the plantar fascia.  The pain in this condition is located on the middle bottom of the heel or along the back of the arch where it meets the heel, and is usually present in most people upon first arising in the morning or after arising from a seated position.  Plantar fasciitis, as it is called, is seen in those with flat feet and in those with high arches.  Flat feet, which are usually the cause of this condition, allow for chronic stretching and tearing of the fascia where it attaches to the heel bone.  The foot does not have to be severely flat for this to occur, as moderate flattening can cause damage also.  High arches, another common cause, allow for abnormal shock to be transmitted to the heel with every step.  Direct injuries or traumatic tearing of the tissue (either miniscule, partial, or complete), though less common, can also cause inflammation to the plantar fascia.  Though possibly self-healing over a long period of time, this condition can last for many years when no treatment is given, and can make activity nearly impossible. For treatment, a combination therapy of inflammation reduction with anti-inflammatory medications, steroid injections, icing and stretching is necessary, along with arch support through prescription shoe inserts (orthotics) to stabilize and support a flat foot or provide shock absorption to a high arched foot.  Only rarely is surgery required.

Inflammation control will reduce the pain, and help heal the injury as long as it has not reached a chronic stage of scarring and ongoing inflammation called fasciosis.  This is seen in fasciitis cases that do not get treated for a long while.  The use of a steroid injection (cortisone-like medication, not a bodybuilding steroid) seems to have the most immediate impact on patients, although the reduction in inflammation can take up to a week to occur after the injection and up to three injections may be needed, best split two weeks apart.  Anti-inflammatory medications, like strong prescription versions of ibuprofen,  also help reduce the body's overall state of inflammation, reducing pain further.  Finally, icing of the arch and heel to decrease more inflammation will be necessary, as well as stretching of the arch and calf to make the bottom of the foot more limber, reducing damage to the fascia.

Pain behind the heel can usually be caused by inflammation of the Achilles tendon (tendonitis), as well as inflammation due to extra bone growth in the heel bone (Haglund's deformity and heel spurs).  Achilles tendonitis is quite common, and activity only worsens the condition.  It develops for a wide variety of reasons. These include chronic stretching of the tendon from unbalanced motion, violent injuries forcing the foot upward, and blunt pressure on the back of the heel itself as when someone steps on another's heel.  When combined with a spur or enlargement of the back of the heel bone, even simple shoe use can be painful as the heel rubs against the back of the shoe.  The pain can feel dull, sharp and knife-like, throbbing, aching, or all of the above.  This pain usually goes down with rest and inactivity, and resumes with simple motion at the ankle or full activity.

Treatment centers around stretching of the Achilles tendon, along with icing, anti-inflammatory medication, ankle bracing, and physical therapy.  A tight Achilles tendon makes recovery incredibly difficult, and stretching becomes the most important aspect of this treatment course.  Icing and anti-inflammatory medication relieve the inflamed tissue around and in the tendon, and bracing prevents excessive tendon pulling.  This will all help to reduce pain and improve mobility, as well as foster full healing.  When needed, physical therapy accomplishes numerous goals, including eventual inflammation reduction, improved flexibility, and better tendon strength.  Immobilization in a walking cast, or with a non-weight bearing cast with crutches may be necessary in severe cases.  Unfortunately, many people ignore their pain until it is very advanced.  Untreated Achilles tendonitis can lead to tendon degeneration and even rupture.  This requires surgical repair in many cases.  When the bone spur or bone enlargement is causing most of the pain, and the treatment outlined above is not helping, surgery is needed to remove the excess bone to relieve pressure off the Achilles tendon.  This procedure requires the most surgical recovery time and needs nearly 3 months rehabilitation prior to returning to activity.