Heel Pain That Is Not Plantar Fasciitis: Nerve Entrapment, Fat Pad, or Stress Fracture?

Most people with sore heels are told they have plantar fasciitis. That is often true—but not always. When heel pain lingers, keeps you off your feet, or simply does not match the classic “first-step in the morning” story, the culprit may be different: nerve entrapment (inside or just beyond the ankle), heel fat pad syndrome, or a calcaneal stress fracture. Getting that distinction right matters, because the treatments diverge.^[2]

Below, you will find a clear, patient-friendly map to the most common non–plantar fasciitis causes of heel pain—how each feels, what to do first, and which tests confirm the diagnosis.

Go straight to urgent care or the emergency department if heel pain is accompanied by any of the following:

• Fever, feeling very unwell, or a hot, red heel (possible infection)
• Inability to bear weight after a fall or high-energy injury (possible fracture)
• New numbness, burning, or weakness in the foot that is rapidly worsening (possible significant nerve compression)

If none of these are present, a methodical approach at home and with your clinician will usually identify the right cause and treatment.

Plantar fasciitis usually causes sharp, medial plantar heel pain that is worst with the first steps after rest (morning, after sitting) and eases as the tissue warms up. Symptoms often flare again after long activity. Stretching the plantar fascia and short-term foot orthoses help many people, but when your story does not fit this pattern, look beyond the fascia.^[3]

What it is:

Baxter nerve entrapment involves compression of the first branch of the lateral plantar nerve, often where it courses near the inner heel. It can account for a significant fraction of chronic medial heel pain, yet it is frequently misdiagnosed as plantar fasciitis. Patients often describe burning, tingling, or electric pain that builds with weight-bearing through the day, rather than the classic first-step pain.^[4]

Tarsal tunnel syndrome is tibial nerve compression inside the fibro-osseous tunnel behind the inner ankle. Symptoms include numbness, tingling, and burning under the foot and into the toes, sometimes worse after prolonged standing or at night. A clinician may elicit symptoms by pressing over the tunnel (a compression or Tinel-style test) and may use nerve conduction studies when needed.^[2]

Medial calcaneal nerve entrapment specifically affects sensation to the posterior-medial heel and can be the sole cause of chronic plantar heel pain in a subset of patients; it often coexists with other local problems.^[5]

Clues that point to nerve pain rather than fascia pain:

• Burning or tingling quality; numb spots on the heel or sole
• Pain that worsens as the day goes on with standing, rather than only on first steps
• Focal tenderness just anterior to the heel bone on the inner side (Baxter), or behind the medial ankle (tarsal tunnel)
• Reproduction of symptoms with tarsal tunnel compression or with foot positions that tension the entrapped branch; sometimes pain with passive eversion or abduction of the foot in Baxter nerve entrapment^[6]

What confirms it:

Diagnosis rests on history and examination; when uncertainty remains, clinicians may add nerve conduction studies, diagnostic local anesthetic injections, or targeted ultrasound. For tarsal tunnel syndrome, abnormally slow nerve conduction across the tibial nerve predicts poor response to conservative care and may push management toward decompression if symptoms persist.^[2]

What it is:

The heel fat pad is a multi-chamber cushion that protects the calcaneus. With age, repetitive impact, lean body mass loss, or systemic factors, this pad can lose thickness and spring. The classic symptom is deep, central heel pain that feels like a bruise, worse on hard floors or when walking barefoot. Unlike plantar fasciitis, pain is typically centered rather than on the inner border of the heel, and first-step pain is not mandatory.^[7]

Clues that point to heel fat pad syndrome:

• “Stepping on a stone” or deep, central ache in the middle of the heel
• Worsens with concrete or tile, improves in cushioned shoes or with heel cups
• May follow repetitive impact activities or significant weight change (down or up)
• On exam, pressing directly under the calcaneal tuberosity reproduces the familiar bruise-like pain

What confirms it:

Diagnosis is clinical. Some clinicians use ultrasound to measure heel pad thickness or assess for focal tears; treatment focuses on load management and cushioning.^[7]

What it is:

A stress fracture is a small crack resulting from repetitive overload, not a single traumatic event. In the heel bone (calcaneus), the story is often gradual onset after a recent jump in walking or running volume, a new job with long hours on concrete, or a change of shoes. The hallmark exam finding is a positive calcaneal squeeze test—pain when the clinician compresses the heel from both sides. Early radiographs can be normal; confirmation may require a bone scan or magnetic resonance imaging or computed tomography scan. Activity reduction and protected weight-bearing are the backbone of treatment.^[3]

Clues that point to calcaneal stress fracture:

• Diffuse heel pain that builds with impact (walking, running), often unilateral
• Pain on medial–lateral squeeze of the heel (very suggestive)
• Minimal morning warm-up phenomenon compared with plantar fasciitis
• Possible swelling or warmth early on; normal x-ray does not rule it out

What confirms it:

When the story and squeeze test suggest a stress fracture, clinicians often begin with plain radiographs but rely on magnetic resonance imaging or computed tomography scan if the x-ray is negative and suspicion remains. Recent reviews reinforce this pathway and describe typical healing timelines with load modification.^[8]

• Burning, tingling, or numb patches under the heel or arch, worse at day’s end → think nerve entrapment (Baxter nerve or tarsal tunnel), not plantar fasciitis.^[4]
• Deep, central, bruise-like ache that hates hard floors and barefoot walking → think heel fat pad syndrome.^[7]
• Impact-related pain with a positive calcaneal squeeze test → think calcaneal stress fracture, especially after a training spike or new weight-bearing job.^[3]

These are pointers, not diagnoses. If you are unsure—or if pain is severe or worsening—seek an evaluation.

1. History and focused examination

   They will map location (medial border, central heel, posterior heel), timing (first steps vs. later in the day), quality (burning vs. bruise), and triggers (hard floors, long standing, running). Expect specific palpation points (plantar fascia origin, central heel, inner ankle), a calcaneal squeeze test, and in suspected nerve cases, a tarsal tunnel compression maneuver.^[1]

2. Decide whether imaging is needed

   • Suspected calcaneal stress fracture: start with x-ray; if negative but suspicion is high, proceed to magnetic resonance imaging or bone scan or computed tomography scan to confirm.^[1]

   • Suspected nerve entrapment: imaging is not always necessary. Nerve conduction studies, ultrasound, or magnetic resonance imaging may be used when the diagnosis is unclear or to plan procedures. Slowed conduction across the tibial nerve supports a tarsal tunnel diagnosis and predicts poorer response to conservative care.^[2]

   • Suspected heel fat pad syndrome: generally a clinical diagnosis; ultrasound can document thinner or damaged pad when needed.^[3]

3. Rule out mimics and associations

   Some people have overlapping problems (for example, plantar fasciitis plus Baxter nerve irritation). Others have posterior heel issues (Achilles or retrocalcaneal bursitis) or systemic conditions. A good exam keeps the focus on the true pain generator.^[2]

Start with conservative care that reduces nerve irritation:

• Unload hotspots: supportive footwear with a soft, forgiving insole, avoid tight medial counters or straps that compress the inner heel and tarsal tunnel.
• Nerve-friendly positioning and mobility: a skilled therapist can teach gentle tibial nerve gliding and adjust hindfoot alignment that narrows the tunnel.
• Targeted strength: improve foot intrinsics and hip mechanics (especially external rotators) to reduce strain on the medial foot.

Escalation when needed:

• Image-guided local anesthetic and corticosteroid into the tarsal tunnel or near the Baxter nerve region can help in select cases, especially where a space-occupying lesion is suspected; this is also useful diagnostically. If a mass or ganglion compresses the nerve, decompression tends to have good outcomes. Surgery is considered when well-documented nerve compression does not respond to a proper trial of non-operative care.^[2]

Clinical nuance: Baxter nerve pain often worsens through the day with standing—unlike plantar fasciitis—so pay attention to that daily rhythm when tailoring treatment.^[4]

Core strategy: cushion and calm the heel while you keep moving.

• Footwear upgrade: a cushioned heel with some rocker and a mild heel-to-toe drop can reduce impact.
• Heel cups or “donut” pads: many patients describe immediate relief from silicone heel cups that cradle the pad and centralize pressure.
• Surface swap: avoid barefoot on hard floors; add anti-fatigue mats in work areas.
• Short-course pain relief: ice after long standing; consider nonsteroidal anti-inflammatory drugs if safe for you.

When it lingers: a podiatry or sports-med consult can explore custom padding, taping to corral the pad, or—rarely—injectable options in carefully selected cases. The essential theme remains force management, not aggressive stretching of the plantar fascia.^[7]

Immediate priorities:

• Relative rest and load reduction: consider crutches or a boot if walking is painful.
• Pain control: nonsteroidal anti-inflammatory drugs can help in the short term, but follow your clinician’s guidance.
• Imaging to confirm if the squeeze test and history are convincing but x-rays are normal.^[3]

Healing timeline and return:

Many calcaneal stress fractures heal with four to six weeks of reduced weight-bearing and then a graded return to activity, though individual timelines vary depending on location and severity. Persistent pain or high-risk patterns may prompt more protective management. Recent case literature underscores that early x-rays may be falsely negative, so do not push through escalating symptoms if your story fits.^[3]

1) Circle the pain spot on your heel.

• Inner border with burning/tingling → consider nerve entrapment.
• Dead center, bruise-like → consider heel fat pad syndrome.
• Diffuse heel ache that spikes with impact → consider stress fracture.^[4][7]

2) Notice the daily rhythm.

• Worst on first steps → more like plantar fasciitis.
• Builds during the day with standing → more like nerve entrapment.
• Worsens with impact and hurts on heel squeeze → more like stress fracture.^[4]

3) Make two smart changes for one week:

• Switch to cushioned footwear (and a silicone heel cup if central pain).
• Trim standing time on hard floors; replace a run with low-impact cardio.

4) Reassess after seven to ten days.

• Improving → continue the plan and begin graded activity.
• No better or worse → book a visit; ask specifically about Baxter nerve, tarsal tunnel, heel fat pad syndrome, and calcaneal stress fracture so your exam targets the right culprits.

Yes. Chronic mechanical stress can irritate both the plantar fascia and nearby nerve branches. Baxter nerve entrapment is particularly under-recognized and can coexist with fascia trouble; asking about burning, tingling, and day-end worsening helps surface the nerve component.^[4]

There is no single definitive test. Clinicians combine the history, a tarsal tunnel compression or tapping test, nerve conduction studies, and sometimes imaging to look for a mass or bony spur. Conservative care works for many; surgery is reserved for persistent, well-documented compression.^[2]

With a stress fracture, the calcaneal squeeze test (pain when the heel is compressed side-to-side) is often positive, and pain behaves more like impact-driven bone pain than first-step fascia pain. If suspicion is high and x-rays are negative, magnetic resonance imaging or bone scan can confirm.^[3]

Usually no. It is a clinical diagnosis; the fastest relief often comes from cushioning and load changes. Imaging is reserved for atypical features or poor response.^[7]

• Match load to capacity: increase running or walking volume by no more than ten percent per week, and rotate shoes before they are flat and firm.
• Respect surfaces: long days on concrete deserve forgiving footwear and mats where you stand.
• Strengthen the hips and foot intrinsics: better control up the chain reduces local overuse in the heel and medial arch.
• Address alignment and fit: shoes that pinch the inner heel or collapse the arch can agitate both the plantar fascia and nearby nerves.

If your heel pain does not behave like classic plantar fasciitis, consider three common alternatives:

• Nerve entrapment (Baxter nerve or tarsal tunnel): more burning/tingling, often worse as the day goes on, sometimes with numb patches; confirmed with focused exam and, when needed, nerve studies or diagnostic injection.^[4]
• Heel fat pad syndrome: deep, central bruise-like pain that hates hard floors and barefoot; respond with cushioning and load management.^[7]
• Calcaneal stress fracture: impact-related pain with a positive heel squeeze; early x-rays may be normal, so ask about magnetic resonance imaging if symptoms fit. Treat with load reduction and a graded return.^[3]

Getting the right diagnosis saves months of frustration—and gets you back on your feet sooner.

References:

This article is educational and does not replace personalized medical care. If your symptoms are severe, new, or uncertain, please seek professional evaluation.