Plantar fasciitis: why the first steps hurt most
There is one movement almost everyone with this problem recognises. You wake up, swing your legs down, put your foot on the floor. And take it straight back off.
Then you walk to the bathroom on your toes. After a minute or two it eases. By breakfast it is nearly gone. Then you sit for an hour, stand up, and there it is again.
That pattern is not random. It is the clearest clue your body gives you, and it also explains why the two most common responses, rest and a new heel cushion, rarely fix anything. Both are aimed at the heel. The problem lives in the arch.
The old name points at the wrong thing
Plenty of people still call this a heel spur, and Sweden's national health service notes on its heel pain page that pain in the tissue under the heel used to go by exactly that name. The word survives in everyday speech, in search boxes, in conversations at work. It points at a bony outgrowth on the heel bone, which is not where the problem lives.
Just how weak that link is emerged from an Australian study published in 2008 in the Journal of Foot and Ankle Research. The researchers X-rayed the feet of 216 people aged 62 to 94. Of those, 119, or 55 per cent, had at least one plantar calcaneal spur. That is more than half of an older group, far more than the number reporting heel pain. The authors note themselves that the sample was not randomly selected but drawn from a retirement village and a university clinic, so the proportion does not transfer straight to the wider population. The direction is clear all the same.
Spurs were more common in people who were obese (odds ratio 7.9, interval 3.6 to 17.0), who reported osteoarthritis (2.6, interval 1.6 to 4.8) and who had current or previous heel pain (4.6, interval 2.3 to 9.4). So an association with heel pain does exist. What did not exist was any relationship between spurs and radiographic measures of foot posture, and that is the detail the authors settle on. Their conclusion is that the spur is probably a response to vertical compression of the heel rather than to the fascia pulling at its attachment.
Two practical consequences follow. An X-ray showing a spur does not establish that the spur is your source of pain. And none of the treatments that actually work are aimed at it.
Why it is specifically the first steps
A broad, strong sheet of tissue runs along the sole of your foot, from the heel bone forward to the base of the toes. How it works was described in 1954 by J. H. Hicks in the Journal of Anatomy, in a paper still cited every time anyone explains the arch.
Hicks called it the windlass mechanism. When the toes bend upwards, the fascia winds around the heads of the metatarsals the way a rope winds around a drum. The distance between its attachments shortens. The arch rises. The foot goes from soft and compliant to stiff and springy, at precisely the moment you push off.
It is an elegant piece of engineering. It also explains your mornings.
Overnight your foot rests with the toes straight or pointed. The fascia sits short, unloaded, not working. On the first step it takes your full body weight at the same instant your toes bend upwards, so full stretch and full load arrive together. After a few minutes of walking the tissue has worked through it and the pain fades. Sweden's national health service describes the same thing from the patient's side: it usually hurts most on the first steps in the morning and then eases once you have been walking for a while.
The same thing happens after a long meeting, a car journey or an evening on the sofa. It is not that sitting makes you worse. It is that every time the fascia rests, it starts again from short.
Is the pain in the right place?
The heel hosts several different problems that all feel like heel pain. Sorting them by location is the fastest way to know whether the rest of this page applies to you.
| Where it hurts | What it usually is | Typical sign |
|---|---|---|
| Under the heel or on the inside | The fascia under the foot | Worst on the first steps of the morning, eases within minutes |
| At the back of the heel | The Achilles insertion | Tender behind, sometimes swollen, the tendon feels stiff |
| A tender spot behind that swells | Bursitis | Sore to press, often after a knock or from tight shoes |
| A permanent lump at the back | Haglund's deformity | Long-standing irritation, often from shoes that pinch |
| Diffuse in and under the heel | The heel fat pad | Hurts on walking, more common with age, diabetes or excess weight |
The trial behind the strength protocol further down required tenderness on pressing the inside of the underside of the heel bone before anyone counted as a participant. That is the spot to look for with your thumb. Participants also had to have had symptoms for at least three months and a fascia measuring at least 4.0 mm thick on ultrasound.
That millimetre figure deserves a note, because it reads like a requirement. It was an entry criterion for a study, not a step you need to take. Diagnosis is usually made by looking at the foot and feeling it.
The stretch you do before the first step
If you take one thing from this page, take this. It comes from a research group in Rochester, New York, who wanted to test an idea: that a stretch aimed at the fascia itself would beat an ordinary calf stretch, because the calf stretch reaches the wrong tissue.
They randomised 101 people who had had pain under the heel for at least ten months to either a plantar fascia stretch or an Achilles tendon stretch. Eighty-two of them came back for the eight-week assessment, and there the fascia group was better on both first-step pain and function. The results were published in the Journal of Bone and Joint Surgery in 2003.
Here is how it goes:
- Sit down. Cross the painful leg over the other one.
- Take hold of the base of your toes with the hand on the same side as the painful foot.
- Pull the toes back towards your shin until you feel a stretch in the arch, not in the calf.
- Put the fingers of your other hand against the arch and feel the fascia go tight. If you cannot feel it, the grip is wrong.
- Hold for 10 seconds. Repeat 10 times. Three times a day.
The decisive part is when you do it. The study protocol placed the first round before the first steps of the morning and after long periods of sitting. It is the exact mechanism that causes the morning pain, run in reverse: you wind the fascia up by hand before your body weight does it for you.
The two-year follow-up came in 2006. Of the 82 who had completed the original trial, 66 responded. Among them, 92 per cent reported total satisfaction or satisfaction with minor reservations, 94 per cent reported a decrease in pain and 77 per cent reported no limitation in their recreational activities. The difference between the two original groups had gone, which has a simple explanation: after the first eight weeks, every participant was taught the plantar fascia stretch.
The stretch also holds up in the broadest review yet done. In 2021 an international group published a review in the British Journal of Sports Medicine covering 51 randomised trials and 4,351 participants. For first-step pain in the short term, the plantar fascia stretch was the single strongest intervention in the whole body of evidence, with a standardised effect size of 1.21 (interval 0.78 to 1.63).
The towel under the toes
The next step is to stop treating the fascia as something to be spared and start treating it as tissue that gets stronger when it is loaded. The only question is how you load a structure that sits under your foot.
The answer came from a Danish research group in Aalborg, and it is the neatest application of Hicks's mechanism anywhere. You do a heel raise on a step with a rolled towel under your toes. The towel forces the toes up, the windlass winds the fascia tight, and the calf load that would otherwise stop at the Achilles carries on into the fascia.
In the trial, 48 people with ultrasound-verified symptoms were randomised to either a daily plantar fascia stretch or this strength programme every second day. Everyone received gel heel inserts and the same written information. The heel raise was performed like this:
| Element | How it was done |
|---|---|
| Tempo | 3 seconds up, 2-second pause at the top, 3 seconds down |
| Frequency | Every second day for three months |
| Weeks 1 to 2 | 3 sets at the load you can lift 12 times |
| From week 3 | 4 sets at the load you can lift 10 times, a backpack of books for resistance |
| From week 5 | 5 sets at the load you can lift 8 times, keep adding books |
If you cannot manage a single-leg heel raise, start on two legs. The towel should be thick enough that your toes are bent maximally upwards at the top of the raise, because that is where the entire point of the exercise lies.
After three months the strength group scored 29 points lower on the scale measuring foot function (interval 6 to 52). That is four times the smallest change considered meaningful on that scale, which is 7 points. The results were published in 2015 in the Scandinavian Journal of Medicine and Science in Sports.
Here is the honest part, which rarely travels with the study when it gets quoted. At 1, 6 and 12 months there was no difference between the groups. The strength training bought a faster route to the same destination, not a better destination. Forty-eight participants is also a small sample, which you can see in how wide the interval around those 29 points is.
Read it as an offer rather than a requirement. The stretch is the foundation. If you want a faster way back, add the heel raise every second day. How much it is allowed to hurt during the exercise follows the same rule that applies to tendons generally, which is the pain-monitoring model we go through in the guide to Achilles tendinopathy.
Where the studies disagree
The 2021 review landed on a stepped approach. The core for everyone is three things: taping, stretching and individualised education about footwear and load. If that is not working, shockwave therapy is added at around four weeks. If symptoms persist to week 12, custom orthoses come in.
| Stage | Intervention | Effect size in the review |
|---|---|---|
| Core | Plantar fascia stretching | 1.21 (0.78 to 1.63) on first-step pain, short term |
| Core | Taping | 0.47 (0.05 to 0.88) on first-step pain, short term |
| Core | Footwear and load education | No figure of its own, included via clinical reasoning |
| If not improving | Shockwave therapy | Effect in the short, medium and long term |
| From week 12 | Custom foot orthoses | 0.41 (0.07 to 0.74) on general pain, short term |
Notice what is not in the core: heavy strength training. That is not a contradiction, but it is worth understanding why. Of the 51 trials, only 9 were judged suitable for establishing proof of efficacy, covering ten different interventions between them. Heavy strength work for the foot was not among those the review moved into its core. So the best single study points one way while the broadest synthesis is more cautious, which is an entirely ordinary state of affairs in research on slow-healing problems.
Our practical position: start with the stretch, because it has the strongest support and costs nothing. Add the heel raise if you want to speed things up. Save shockwave and orthoses until you have given the first two a real run.
Your dose is your day, not your workout
This is where plantar heel pain differs most from a classic running injury, and it is nearly always missed.
An Achilles tendon is loaded when you train. The fascia under your foot is loaded every hour you are upright. A rest day from running spent standing at the stove, in a queue, at a museum with the children, is not a rest day for the arch.
You can see it in what is still the most cited study on risk factors, published in 2003 in the Journal of Bone and Joint Surgery. Fifty people with plantar fasciitis in one foot were compared with two controls each, matched for age and sex.
| Factor | Odds ratio | Compared with |
|---|---|---|
| Ankle dorsiflexion with the knee extended, 0 degrees or less | 23.3 (4.3 to 124.4) | More than 10 degrees |
| Body mass index above 30 | 5.6 (1.9 to 16.6) | 25 or below |
| Most of the working day on your feet | 3.6 (1.3 to 10.1) | Everyone else |
Read those numbers as directions. This is a case-control study, a design that shows association without establishing what came first. The interval around the dorsiflexion figure runs from 4.3 to 124.4, which is another way of saying the true size is unknown. That a stiff ankle and long hours on your feet go with this problem still stands.
That gives you three levers no training log will ever capture:
- Wear shoes indoors. The NHS advises specifically against walking barefoot on hard surfaces, and against flip-flops and backless slippers. A supportive pair of indoor shoes does more for your arch across an ordinary weekday than any single session does.
- Break up the long standing blocks. Not by standing less in total, but by splitting it. The fascia tolerates a great deal. It tolerates it less well in one unbroken stretch.
- Work on ankle mobility. It is the single strongest factor in the table above, and the only one you can train directly. Heel raises with a full lowering off a step do two jobs at once.
If you run to work or walk long commuting distances, this matters even more, because the dose is already baked into your day. We go through what that dose looks like in the guide to run commuting.
Can I keep running?
Usually yes, on a smaller dose for a while. Sweden's national health service says that reducing or changing your activity for a period is often necessary for the problem to settle, and suggests shorter distances at an easier pace, cycling or swimming as substitutes. The NHS suggests exercise that does not put pressure on your feet, such as swimming.
Cut duration before pace. Speed sessions and hills put the most stretch through the fascia, because both push-off force and toe loading rise. Save them until the morning step has stopped hurting.
Some perspective on how common this is: in a review of 2,002 running-related injuries seen at a Canadian sports medicine clinic, plantar fasciitis was the third most common diagnosis, with 158 cases, or just under 8 per cent. That figure covers injuries that presented for care rather than all runners. You are not unusual, and this is not the end of your running. If you are new to it, the plan for the first weeks is in the guide to starting running after 40.
How long does it take?
Longer than you want, shorter than it feels. Sweden's national health service puts it plainly: you can have pain for a long time, often several months, though rarely more than a couple of years, and most people do get better.
One consoling detail from the American stretching trial: its participants had been in pain for at least ten months when they enrolled. These were not fresh symptoms that improved. Having had this for a long time does not mean you have missed your chance.
The NHS sets an early checkpoint: if you have treated it yourself for two weeks without improvement, it is time to get help.
When to get it looked at
See a GP if you have treated the problem yourself for two weeks without improvement. That is the NHS threshold. In many areas you can also refer yourself to NHS community musculoskeletal services without going through a GP first, and a physiotherapist or podiatrist can take it from there.
Sweden's national health service goes further for one situation: contact a health centre or an emergency department immediately if you are in severe pain or have difficulty walking after an injury or an accident.
The NHS also lists four situations where you should see a GP without waiting the two weeks out: if the pain is severe or is stopping you doing normal activities, if the pain is getting worse or keeps coming back, if you get tingling or loss of feeling in the foot, and if you have diabetes and foot pain, since foot problems can be more serious then.
What the week might look like
| When | What |
|---|---|
| Before the first step | Plantar fascia stretch, 10 holds of 10 seconds, sitting on the edge of the bed |
| Midday | The same stretch, ideally after a long stretch of sitting |
| Evening | The same stretch, third round |
| Every second day | Heel raise on a step with a towel under the toes, per the table above |
| Every day | Shoes indoors, standing broken into blocks, shorter and easier runs until the morning step settles |
| Week 2 | No improvement at all: book an appointment |
A missed stretch is data, not a failure. What matters here is the direction across the weeks, meaning whether the first step of the morning hurts less in week four than it did in week one.
Frequently asked questions
What is plantar fasciitis, exactly?
It is pain in the broad band of tissue running along the sole of the foot, from the heel bone to the base of the toes. The older name, heel spur, points at a bony outgrowth on the heel bone, but that link is weak. In a study of 216 people aged 62 to 94, 55 per cent had at least one plantar calcaneal spur on X-ray, far more than the number in pain. The spur appears to be a response to vertical compression of the heel rather than to the fascia pulling at its attachment.
Why does plantar fasciitis hurt most in the morning?
Because the fascia works as a windlass. J. H. Hicks described in 1954 how it winds around the heads of the metatarsals when the toes bend upwards, raising the arch and stiffening the foot for push-off. Overnight the foot lies still with the toes straight, so the fascia is short and unloaded. On the first step, full stretch and full body weight arrive in the same instant. After a few minutes of walking the tissue has worked through it, which is why the pain fades. The same thing happens after a long spell of sitting.
Does stretching help plantar fasciitis?
Yes, but it has to be the right stretch. In a randomised trial that allocated 101 people with at least ten months of symptoms, a stretch aimed at the fascia beat a calf stretch on both first-step pain and function after eight weeks. It is done sitting with the leg crossed over, pulling the toes back towards the shin until the arch stretches, 10 holds of 10 seconds, three times a day. In the broadest review of 51 trials, plantar fascia stretching was the strongest single intervention for first-step pain in the short term, with an effect size of 1.21.
Can I run with plantar fasciitis?
Usually yes, on a smaller dose for a period. Standard advice is that reducing or changing activity for a while is often necessary for symptoms to settle, with shorter distances at an easier pace, cycling or swimming as alternatives. Cut duration before pace. Speed sessions and hills load the fascia hardest, because both push-off force and toe loading rise, so save them until the morning step has stopped hurting.
How long does plantar fasciitis take to go away?
Count in months. Sweden's national health service says you can have pain for a long time, often several months, though rarely more than a couple of years, and that most people get better. Having had it a long time does not make it unfixable: participants in the American stretching trial had been in pain for at least ten months when they enrolled, and at the two-year follow-up 92 per cent of those who responded reported total satisfaction or satisfaction with minor reservations.
Sources used on this page: NHS on plantar fasciitis (last reviewed 14 February 2025), 1177 (Sweden's national health service) on heel pain, Hicks 1954 in the Journal of Anatomy (PMID 13129168), Menz et al 2008 in the Journal of Foot and Ankle Research (PMC2553779), Lemont et al 2003 in the Journal of the American Podiatric Medical Association (PMID 12756315), Riddle et al 2003 in the Journal of Bone and Joint Surgery (PMID 12728038), Taunton et al 2002 in the British Journal of Sports Medicine (PMID 11916889), DiGiovanni et al 2003 and the two-year follow-up in 2006 (PMID 16882901), Rathleff et al 2015 in the Scandinavian Journal of Medicine and Science in Sports (PMID 25145882), Morrissey et al 2021 in the British Journal of Sports Medicine (PMID 33785535) and Whittaker et al 2019 in BMC Musculoskeletal Disorders (PMC6698340). This page gives general health information. It does not diagnose anything and does not replace an assessment by a clinician.
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