Chronic heel pain is not a single diagnosis. It is a symptom that can arise from several different conditions, and in many patients more than one problem may be present at the same time. Understanding the underlying cause is one of the most important steps in developing an effective treatment plan. Assuming that every patient has plantar fasciitis can result in delayed recovery if another condition is responsible for the pain.
The most common cause of persistent pain beneath the heel is plantar fasciosis. In chronic cases, the plantar fascia often demonstrates degenerative change rather than ongoing inflammation. Patients typically describe pain during the first few steps in the morning, discomfort after prolonged standing or walking, and tenderness where the plantar fascia attaches to the heel bone.
Another important cause of chronic heel pain is Baxter's nerve entrapment. This small nerve runs close to the inside of the heel and can become irritated or compressed. Symptoms may closely resemble plantar fasciitis, but patients sometimes report burning discomfort, aching that persists after activity, or pain that has failed to improve despite otherwise appropriate treatment.
Heel fat pad syndrome is another common condition, particularly in older adults or people who spend long hours standing on hard surfaces. Rather than pain at the attachment of the plantar fascia, discomfort is often felt directly beneath the centre of the heel and may worsen when walking barefoot on hard floors.
Calcaneal bone marrow oedema represents irritation within the heel bone itself and may be identified on MRI. It can occur following repetitive loading, stress injury or alongside chronic plantar fascia disorders. Patients often describe deep aching pain that is difficult to localise.
Less common causes include stress fractures of the calcaneus, inflammatory arthritis, plantar fascia tears, nerve disorders, Achilles tendon pathology and pain referred from the lower back. While these conditions are less frequent, they should be considered when symptoms do not follow the typical pattern or fail to respond to appropriate treatment.