Heel Pain After Pickleball: Achilles Tendonitis vs Plantar Fasciitis
- sarangndesai
- 24 hours ago
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Heel Pain After Pickleball: Achilles Tendonitis vs Plantar Fasciitis
By Sarang Desai, DO — Fellowship-Trained Orthopedic Foot and Ankle Surgeon
Sports Medicine | McKinney and Flower Mound, Texas
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Here's the simplest way I explain heel pain to pickleball players in clinic: the location of your pain usually tells you which problem you have. Pain at the back of the heel where the cord attaches is almost always Achilles tendonitis (tendinopathy). Pain on the bottom of the heel — especially those brutal first steps out of bed in the morning — is almost always plantar fasciitis. Both are overuse injuries, both are extremely common in the start-stop, push-off world of pickleball, and both respond very well to the right treatment.[1][2] The trick is telling them apart and not chasing the wrong plan.
This guide walks you through how to tell the difference, what actually works for each, and when heel pain is a sign of something more serious that needs a specialist.
For related reading: Achilles Tendinitis: Causes, Symptoms, Treatment and Recovery · Plantar Fasciitis: Causes, Symptoms, Treatment · The Most Common Pickleball Foot and Ankle Injuries
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WHY PICKLEBALL CAUSES HEEL PAIN
Pickleball loads the heel complex hard. Every push-off, lunge to the kitchen, and quick backpedal loads both the Achilles tendon (which powers push-off) and the plantar fascia (which supports your arch on landing). Two things make players especially vulnerable:
- The demographic. Both conditions peak in the 45-to-64 age range — exactly the pickleball crowd. Plantar fasciitis is most common in patients aged 45 to 64, and it accounts for over 1 million patient visits a year in the US.[3]
- The risk-factor overlap. Reduced ankle flexibility (limited dorsiflexion), higher body mass index, and a rapid ramp-up in activity drive both problems — and these are common in players who go from the couch to five sessions a week. In recreational pickleball players, overuse injuries slightly outnumber traumatic ones, and greater weekly playing hours independently raise injury risk.[3][1][4]
Interesting anatomical point I share with patients: the Achilles tendon and the plantar fascia are mechanically linked across the heel bone. When the calf and Achilles get tight, tension transmits to the plantar fascia — which is why some players end up with both, and why calf stretching helps both.[5]
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THE KEY DIFFERENCE: LOCATION AND TIMING
Feature | Achilles Tendonitis | Plantar Fasciitis |
Where it hurts | Back of the heel / along the cord (2–6 cm above the heel, or right at the insertion) | Bottom of the heel, toward the inner (medial) side |
Classic symptom | Aching/stiff cord, worst starting activity; pain with push-off | Sharp, stabbing pain with the first steps in the morning or after sitting |
What makes it worse | Pushing off, going up on toes, passive dorsiflexion (foot pulled up) | Prolonged standing; worse at end of day; first steps after rest |
Tender spot | Along the Achilles tendon; sometimes a thickened nodule | Medial calcaneal tuberosity (inner bottom of heel bone) |
Provocation test | Pain/weakness with single-leg heel raise | Windlass test — pain when the big toe is pulled upward |
References |
The "first steps in the morning" clue is the single most useful distinguishing symptom. Sharp pain on the bottom of the heel that's worst with your first steps of the day, then eases as you warm up, is plantar fasciitis until proven otherwise.[2][11] A stiff, achy back-of-the-heel that hurts when you push off or rise onto your toes is Achilles tendinopathy.[1]
To make the anatomy-based approach concrete, here is the diagnostic algorithm foot and ankle physicians use, which sorts heel pain by location — inferior (bottom), posterior (back), and midfoot — from the American Academy of Family Physicians heel pain review:
Figure 2 Algorithm for determining the etiology of heel pain. Adapted with permission from Tu P, Bytomski JR. Diagnosis of heel pain. Am Fam Physician. 2011; 84 (8):911.
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INSERTIONAL vs. NON-INSERTIONAL ACHILLES TENDONITIS
One important nuance with Achilles pain: where along the tendon it hurts changes the treatment.
- Midportion (non-insertional): pain 2–6 cm above the heel bone. This is the classic type that responds best to eccentric loading.[3]
- Insertional: pain right where the tendon meets the heel bone, sometimes with a bony bump (Haglund deformity) and retrocalcaneal bursitis. This type is more sensitive to full stretching and needs a modified exercise program.[12][5]
This distinction matters because aggressive full-range eccentric drops off a step can aggravate insertional disease. I cover this in depth here: Insertional vs. Midportion Achilles Tendinopathy.
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HOW EACH IS DIAGNOSED
- Achilles tendonitis: tenderness and sometimes thickening along the tendon, pain with push-off, and pain when the foot is passively pulled upward.[1]
- Plantar fasciitis: tenderness at the inner bottom of the heel, reproduced by the Windlass test (extending the big toe), and often reduced ankle dorsiflexion.[3][1]
Imaging is not needed at first. In fact, only about 2% of imaged heels in patients with atraumatic heel pain show findings that change initial treatment.[3] Ultrasound can confirm the diagnosis when it's unclear — a plantar fascia thickness of 4 mm or more supports plantar fasciitis, and ultrasound shows Achilles thickening.[1] MRI is reserved for cases that don't improve, or when a tear, stress fracture, or nerve entrapment is suspected.[3][1]
Don't forget the mimics. Not all heel pain is tendonitis or fasciitis. A calcaneal stress fracture causes progressively worsening pain after ramping up activity or switching to a harder court — a real risk in pickleball. Nerve entrapment (including the first branch of the lateral plantar nerve, which mimics plantar fasciitis in up to 20% of plantar heel pain) causes burning, tingling, or numbness.[1][2] These are exactly the "won't get better" cases where a specialist evaluation pays off.
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TREATING PLANTAR FASCIITIS
The good news: about 80% of patients improve within 12 months, and first-line care is simple and effective.[11] What works best:[1][11][3]
- Plantar fascia and calf stretching — the cornerstone. Home stretching works as well as formal physical therapy in trials.
- Arch support / orthotics — prefabricated (off-the-shelf) orthotics are as good as costly custom ones for most people, and soft orthotics are more cost-effective for milder symptoms.
- Ice massage (rolling the arch on a frozen bottle) and activity modification.
- NSAIDs for short-term pain relief.
- Night splints for those with persistent morning pain.
- Second-line (if not improving): extracorporeal shockwave therapy (ESWT), corticosteroid injection, or PRP — though evidence for these is mixed.[1][3]
- For truly stubborn cases: ultrasound-guided partial fasciotomy can help recalcitrant plantar fasciitis.[1]
A realistic expectation I set: while most improve, plantar fasciitis can linger — up to 44% of patients report some symptoms years later — so consistency with stretching matters.[3] More detail here: Plantar Fasciitis: Causes, Symptoms, Treatment.
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TREATING ACHILLES TENDONITIS
For Achilles tendinopathy, the evidence is clear and consistent: loading exercise beats everything else, and it beats rest or a "wait-and-see" approach.[13][14] Cornerstones:[3][13]
- Eccentric (or heavy-slow-resistance) calf strengthening — the best-evidenced treatment. A typical protocol is heel-lowering drops off a step, 3 sets of 15, twice daily, done over about 12 weeks. You can keep training if pain stays in the 2–5 out of 10 range.
- Relative rest / load management — cut back volume, don't stop entirely.
- ESWT — a reasonable option, especially for those who can't tolerate loading exercises.
- Night splints or a brace — similar functional benefit to eccentric training for people who can't do the exercises.
- What doesn't help much: oral NSAIDs and topical diclofenac showed no significant benefit over placebo for the tendinopathy itself, and well-controlled studies show PRP has no significant benefit for Achilles tendinopathy. I'm honest with patients about these.[3][13]
One key caution: be careful with fluoroquinolone antibiotics and corticosteroid injections directly into the Achilles — both raise the risk of tendon rupture. I generally avoid injecting steroid into the Achilles itself. More detail here: Achilles Tendinitis: Causes, Symptoms, Treatment · Best Exercises for Achilles Tendon Pain · Can Achilles Tendinitis Heal Without Surgery?.
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THE OVERLAP: WHEN YOU HAVE BOTH
Because the Achilles and plantar fascia are biomechanically linked across the heel bone, a tight calf and Achilles increase tension on the plantar fascia — so it's common to have both at once.[5] The upside: calf stretching and heel-cord flexibility work help both problems simultaneously. If your calf is tight, addressing it is one of the highest-yield things you can do regardless of which diagnosis dominates.
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RETURN TO PICKLEBALL AND OTHER SPORTS
Neither condition usually requires stopping pickleball entirely — the goal is load management, not total rest. General guidance I give:
- Keep playing within a pain limit of 2–5/10 for Achilles tendinopathy while doing your loading program.[13]
- Reduce volume and frequency temporarily — cut sessions per week and total court time until symptoms settle.
- Warm up and stretch the calf before play, and ice afterward.
- Progress gradually — the rapid ramp-up is what caused it; don't repeat the pattern on return.
For crossover athletes: runners should rebuild mileage slowly (plantar fasciitis affects roughly 6–8% of runners); tennis, padel, and basketball players face the same push-off and landing loads and should recondition the calf and arch before returning to explosive play.[1][15]
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COMMON MISTAKES I SEE
- Treating the wrong diagnosis. Doing plantar-fascia-only care for back-of-heel Achilles pain (or vice versa) wastes months. Location tells you which is which.
- Complete rest. Rest alone doesn't rebuild a tendon or fascia — loading and stretching do.[13]
- Steroid injection into the Achilles. This raises rupture risk and is generally avoided.
- Ignoring a "stress fracture" pattern. Heel pain that steadily worsens even at rest after an activity spike needs imaging, not more stretching.[1]
- Chasing PRP first. For both conditions, injections are second-line at best, and PRP has weak evidence.[3][13]
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WHEN TO SEE A FOOT & ANKLE SPECIALIST
Get evaluated if you have:
- Heel pain that isn't improving after 6–8 weeks of stretching, activity modification, and appropriate footwear
- Burning, tingling, or numbness in the heel (possible nerve entrapment)
- Pain that progressively worsens even at rest after an activity spike (possible calcaneal stress fracture)
- A sudden pop at the back of the ankle with weak push-off (possible Achilles rupture — see Can You Walk on a Torn Achilles Tendon?)
- A desire for a clear diagnosis and a plan to return to pickleball safely
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THE BOTTOM LINE
Location is your first clue: back-of-the-heel pain is Achilles tendonitis; bottom-of-the-heel pain with painful first morning steps is plantar fasciitis. Both are common overuse injuries in pickleball players in the 45–64 age range, both are clinical diagnoses that rarely need early imaging, and both respond to the same foundation —[1][2] calf stretching, load management, and a progressive exercise program. Achilles tendinopathy is treated primarily with eccentric loading; plantar fasciitis with stretching and arch support. When heel pain won't improve, involves burning or numbness, or steadily worsens at rest, see a foot and ankle specialist to rule out the more serious mimics and get back on the court.
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RELATED READING
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ABOUT THE AUTHOR
Dr. Sarang Desai is a fellowship-trained orthopedic foot and ankle surgeon with particular expertise in sports medicine. With over 15 years of experience, Dr. Desai serves as a professional sports team physician and treats the full spectrum of foot and ankle conditions. He is a published researcher, an orthopedic implant inventor, a national lecturer, and a former University of Texas All-American athlete.
Offices in McKinney and Flower Mound, Texas, serving Plano, Frisco, Denton, Lewisville, Southlake, Dallas, Fort Worth, Arlington, and the greater Dallas–Fort Worth metroplex.
📞 (972) 547-0047 🌐 theachillesdoc.com 📍 McKinney, TX | Flower Mound, TX
This article is for educational purposes only and does not constitute personal medical advice. Always consult a qualified physician about your individual situation.
References
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Diagnosis of Heel Pain. Tu P, Bytomski JR. American Family Physician. 2011;84(8):909-16.
Common Painful Foot and Ankle Conditions. Cooper MT. JAMA. 2023;330(23):2285-2294. doi:10.1001/jama.2023.23906.
Prevalence and Associated Factors of Pickleball-Related Injuries Among Korean Recreational Players: A Multi-Tournament Cross-Sectional Study. Lee KJ, Jeong B, Nam SH, et al. Frontiers in Public Health. 2026;14:1898734. doi:10.3389/fpubh.2026.1898734.
A Radiographic Study of Biomechanical Relationship between the Achilles Tendon and Plantar Fascia. Zhu G, Wang Z, Yuan C, et al. BioMed Research International. 2020;2020:5319640. doi:10.1155/2020/5319640.
Emerging Patterns of Foot and Ankle Injuries in Pickleball Players: A Short Report. Kingston K, Parker EB, Higgins A, Smith JT. Foot & Ankle International. 2024;45(11):1266-1269. doi:10.1177/10711007241271215.
Clinical Risk Factors for Achilles Tendinopathy: A Systematic Review. van der Vlist AC, Breda SJ, Oei EHG, Verhaar JAN, de Vos RJ. British Journal of Sports Medicine. 2019;53(21):1352-1361. doi:10.1136/bjsports-2018-099991.
Achilles Tendinopathy: Current Concepts about the Basic Science and Clinical Treatments. Li HY, Hua YH. BioMed Research International. 2016;2016:6492597. doi:10.1155/2016/6492597.
Epidemiology of A chilles tendon ruptures: Increasing incidence over a 33‐year period. Lantto I, Heikkinen J, Flinkkilä T, Ohtonen P, Leppilahti J. Scandinavian Journal of Medicine & Science in Sports. 2015;25(1):e133-8. doi:10.1111/sms.12253.
Epidemiology of Musculoskeletal Injuries in Tennis Players: Risk Factors. Minghelli B, Cadete J. The Journal of Sports Medicine and Physical Fitness. 2019;59(12):2045-2052. doi:10.23736/S0022-4707.19.09842-6.
Plantar Fasciitis. Trojian T, Tucker AK. American Family Physician. 2019;99(12):744-750.
The Heel Complex: Anatomy, Imaging, Pathologic Conditions, and Treatment. Flores DV, Goes PK, Damer A, Huang BK. Radiographics : A Review Publication of the Radiological Society of North America, Inc. 2024;44(4):e230163. doi:10.1148/rg.230163.
Dilemma in the Treatment of Sports Injuries in Athletes: Tendon Overuse, Muscle Strain, and Tendon Rupture. Kjær M, Petersen J, Dünweber MR, et al. Scandinavian Journal of Medicine & Science in Sports. 2025;35(2):e70026. doi:10.1111/sms.70026.
Clinical management of tendinopathy: A systematic review of systematic reviews evaluating the effectiveness of tendinopathy treatments. Irby A, Gutierrez J, Chamberlin C, Thomas SJ, Rosen AB. Scandinavian Journal of Medicine & Science in Sports. 2020;30(10):1810-1826. doi:10.1111/sms.13734.
Heel Pain-Plantar Fasciitis: Revision 2014. Martin RL, Davenport TE, Reischl SF, et al. The Journal of Orthopaedic and Sports Physical Therapy. 2014;44(11):A1-33. doi:10.2519/jospt.2014.0303.
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