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Pain under the heel that is worst on the first steps of the morning, or after sitting for a while, and eases as you walk. It comes from the plantar fascia, the thick band that runs under the foot from the heel to the toes. It is very common, and most people are better within a year without an operation.
Heel pain has several causes, and plantar fasciitis is the most common. Where exactly the heel hurts, and when, usually tells them apart — and the last of these is the one not to miss.
| Under the heel plantar fasciitis | Back of the heel the Achilles | Centre of the heel pad fat pad pain | Whole heel, squeezed stress fracture | |
|---|---|---|---|---|
| Where it hurts | The inner front of the heel, underneath | Where the tendon meets the back of the heel | The middle of the heel's cushion | Both sides of the heel when squeezed |
| When it is worst | First steps of the day, and after sitting | At the start of activity | Walking barefoot on hard floors | Worse the more you walk or run |
| What it feels like | Sharp, then easing as you walk | Stiff and sore at the back | A deep, bruised ache | A deep ache, even at rest |
| Who tends to get it | People who stand a lot, runners, and after weight gain | Runners, people with tight calves | Older adults, whose heel pad has thinned | Runners after a jump in training |
| How soon to be seen | Within a few weeks | Within a few weeks | Within a few weeks | Within a week — stop running |
A heel that hurts more with every run, and aches when squeezed from both sides, may have a stress fracture. It needs rest from running and an X-ray or scan, not stretching. Burning or tingling in the heel points to an irritated nerve rather than the fascia. Call the clinic and come in.
The plantar fascia runs from the underside of the heel bone to the base of the toes, like a bowstring holding up the arch. Every step stretches it, and it takes a large share of your weight as you push off.
What a picture cannot show is why it hurts. The name suggests inflammation, but a painful plantar fascia is mostly one that has been overloaded faster than it could recover, and has changed in structure where it joins the heel. It tightens overnight, so the first steps of the morning stretch it suddenly — which is why they hurt most.
It also explains heel spurs. A spur is a small bony outgrowth where tissue pulls on the heel bone, and it is found in many people who have no pain. It is usually a sign of long-term pull, not the cause of the pain, which is why removing a spur is rarely the answer.
Most people improve with simple measures kept up over weeks to months. It is slow rather than stubborn: the fascia recovers as the load on it comes down and the muscles around it get stronger.
Stretch the calf and the underside of the foot every day, and especially before the first steps of the morning. A few minutes before getting out of bed takes the sting out of those first steps.
Wear cushioned, supportive shoes, avoid going barefoot on hard floors, and consider a heel cup or insole. Strengthening exercises for the foot and calf help too. Cutting back on long spells of standing, and weight loss where it applies, reduce the load. A night splint helps some people with severe morning pain.
For pain that has lasted months despite the above, shockwave therapy is offered here, and this is one of the conditions where its evidence is strongest. It works alongside the stretching and footwear, not instead of them.
A steroid injection can ease the pain for a while, but repeated injections can weaken the fascia and risk it tearing, so they are used sparingly. Plantar fasciitis surgery is rarely needed, and kept for pain that persists after many months of proper treatment.
Plantar fasciitis here is seen by Dr Jeffrey Tan Gek Meng, a Senior Consultant Orthopaedic Surgeon whose subspecialty is foot and ankle, and who names plantar fasciitis among the sports injuries of the foot and ankle he treats. He is a Fellow of the Royal College of Surgeons of Edinburgh, completed his subspecialty fellowship in foot and ankle surgery at Toronto Western Hospital, and consults in English, Mandarin, Malay, Hokkien and Hainanese.
The plantar fascia tightens while you sleep, and your first steps stretch it suddenly. It loosens as you walk, which is why the pain eases, and returns after you have been sitting for a while.
Usually not. Heel spurs are common in people who have no heel pain at all, and many people with plantar fasciitis have none. A spur is a sign of long-term pull on the heel bone rather than the source of the pain.
Keep moving, but reduce what aggravates it, such as long spells of standing or running on hard ground. Complete rest is rarely needed, except for a stress fracture.
A cushioned heel cup or a supportive insole helps many people, especially combined with stretching and better shoes. Custom-made insoles are not always needed; a good off-the-shelf one is often enough to start with.
Most people improve over several months, and the large majority are better within a year. Keeping up the stretches and footwear changes, even once it eases, makes it less likely to come back.
No. Bring any foot X-rays or scan reports, and be ready to say when in the day the heel hurts most.
Foot pain · Achilles injuries · Shockwave therapy · Ankle pain
Be ready to say when in the day the heel hurts most. That one detail tells us a great deal about the cause.
