Physio · 5 minute read

The first few steps of the morning are the worst part of the day, then it eases off. That pattern has a name, it gets busier every spring, and it responds to almost the opposite of what most people do about it.

It usually starts as a bruised feeling under the heel that you notice getting out of bed. The first three or four steps to the bathroom are sharp, then it warms up and you mostly forget about it.

Until you stand up after a long meeting, or get out of the car after school pick-up, and there it is again.

If that’s you, you’re in good company. Plantar heel pain (you may know it as plantar fasciitis) is the most common cause of heel pain we see in clinic. It’s most common between 40 and 60, and it has a season. September is the start of it.

What’s going on under your heel

Running from your heel bone to the base of your toes is a thick band of connective tissue called the plantar fascia. It holds up the arch of your foot and works like a spring, storing energy as your foot flattens on each step and giving it back as you push off.

Where it attaches to the heel bone, it takes a lot of load. When that load rises faster than the tissue can adapt to, the attachment gets irritated, a little thickened and a lot more sensitive.

It’s not really an inflammation, despite the name. Under the microscope it looks like a tendon that’s been asked for more than it was ready for, which is why researchers now call it plantar fasciopathy rather than fasciitis.

Why mornings are the worst

Overnight your foot rests pointed slightly downward, so the fascia sits in a shortened position for seven or eight hours and stiffens. Your first step out of bed stretches it suddenly, under your full bodyweight, before it’s had any warning.

A few minutes of walking and it’s warmed up and lengthened, and the pain settles. The same thing happens after any long stretch of sitting.

That pattern, sharp on the first steps and easing with movement, is the tell. It’s what we listen for when someone describes their heel, and it’s the main reason most people don’t need a scan. A heel spur on an X-ray is common, sits in plenty of feet that don’t hurt at all, and isn’t the cause of the pain.

Why it starts in spring

Almost every heel we see in September has a story that begins with a change. A new walking route with a hill in it. A return to running after a quiet winter. A weekend on your feet at netball or the football. A holiday spent walking all day in sandals.

The things that make a heel more likely to complain are fairly consistent:

• A sudden increase in walking or running
• A lot of standing on hard floors
• Tight calves, or an ankle that doesn’t bend far
• Carrying a bit more weight than the foot is used to
• Flat, unsupportive shoes, or bare feet on floorboards

None of those is a character flaw. They’re load arriving faster than the tissue could keep up with.

What actually helps

Rest is the instinct, and rest on its own is the thing that keeps this going for a year. A large proportion of people still have symptoms two years after diagnosis, and in our experience they’re usually the ones who waited for it to go away, then went back to the same load and got the same result.

Here’s what the evidence supports instead.

1. 1Trim the spike, keep the walkingFind the change that set it off and pull that back for a few weeks. Not to zero, just back to something the heel copes with. Everyday walking is fine and usually helpful.
2. 2Strengthen it, slowlyThe part most people skip, and the part with the best evidence. Stand on a step with a rolled towel under your toes so they’re pulled up. Rise onto the ball of the foot over three seconds, hold for two, lower over three. Three sets of twelve, every second day, adding load over the weeks (a backpack with a few books does the job). Slowly is the word that matters. Rushed heel raises flare it up.
3. 3Stretch before the first stepStretching alone won’t fix it, but for morning stiffness it helps. Before you get out of bed, pull your toes back toward your shin and hold for thirty seconds, a few times. Then a calf stretch against the wall once you’re up.
4. 4Change the shoes for a whileFor a few weeks, wear supportive shoes with a small heel, even around the house. Leave the flat sandals and the bare feet on floorboards. A gel heel cup can take the edge off. This is a splint while the tissue settles, not forever.
5. 5Taping and orthotics, short termA physio can tape the arch in a way that offloads the heel and often gives immediate relief. That buys comfort while the strengthening does the real work. Injections give short-term relief in some cases but carry their own risks, and they’re not the right first move.

With a plan like that, most heels are noticeably better within six to eight weeks and keep improving over the following months. The strengthening is what makes it stay better.

The work itself is fairly low-drama. An assessment looks at how your calf, ankle and foot are working together, what changed in your load, and what you’re wearing on your feet. From there the plan is built for what your body needs, and you keep walking while it heals.