Heel spur and plantar fasciitis: why the heel hurts in the morning

Sharp heel pain on the first step in the morning is most often plantar fasciitis: an overload of the fascia stretched along the sole of the foot. A heel spur, a bony outgrowth of the heel bone, is rarely the cause of pain. Most people are helped by daily stretching, the right footwear and a change in load, although recovery often takes months.

What plantar fasciitis is

The plantar fascia is a band of dense tissue stretched along the sole of the foot from the heel to the toes. It supports the arch and takes load with every step.

Plantar fasciitis is an overload of the fascia where it attaches to the heel bone. The typical picture:

• sharp pain on the first steps in the morning or on standing up after sitting for a long time;
• the pain eases as you get moving, but returns at the end of the day or after standing for a long time;
• a tender spot under the heel, more towards the inner side.

Heel spur or fasciitis: what the X-ray shows

An X-ray often shows a bony outgrowth of the heel, known as a heel spur. It is common even without pain and does not in itself explain pain: many people have a spur and no heel pain, and many have pain and no spur.

That is why treatment is aimed at the fascia rather than the spur, and removing the spur is usually unnecessary. Ultrasound shows what is really happening: thickening of the fascia where it attaches.

Who gets it most often

• people who stand for long periods on hard floors;
• people who have recently gained weight;
• people who have suddenly increased running or walking;
• people with a tight calf muscle, whose foot does not bend upwards well;
• people who wear flat, hard shoes or worn-out trainers.

How it is treated without surgery

What	What it does
Stretching	Daily stretching of the calf and the fascia reduces tension on the heel
Footwear	A soft, slightly raised heel and support for the arch
Insoles	Spread the load and reduce pressure on the heel
Change in load	Temporarily reduces running and long periods of standing
Weight control	Reduces the load on the fascia with every step
Shockwave therapy	Considered when other methods are not enough; available at the BAU rehabilitation centre
Injection	In some cases, under ultrasound guidance

The most important things are daily stretching and the right footwear: no procedure can replace them. An injection is a supporting measure. A steroid often reduces pain quickly, but repeated injections thin the fat pad under the heel, so I give it rarely. For long-standing pain, PRP is considered. On steroid injections: steroid injection.

Exercises for the heel

These exercises are done several times a day, especially in the morning before getting up. Stretching should be slow and should not cause sharp pain.

1. Fascia stretch before getting up. Sitting on the bed, cross the painful foot over the other knee, pull the toes up towards you with your hand and hold for a few seconds. You should feel a stretch along the sole of the foot.
2. Calf stretch against a wall. Stand facing a wall, put the painful foot behind you, press the heel into the floor and lean forward towards the wall until you feel a stretch in the calf.
3. Bottle roll. Sitting on a chair, roll a small bottle or ball back and forth under the sole of the foot. A chilled bottle also eases pain, but if diabetes has reduced the feeling in your feet, do not use a cold bottle.

When other tests are needed

Not all heel pain is fasciitis. See a doctor if:

• the heel started hurting after an injury, a fall or a jump;
• the pain bothers you at night, at rest;
• the heel is swollen or warm;
• the foot burns or goes numb: this may be a sign of a nerve problem;
• both heels and other joints hurt: this may be a sign of an inflammatory condition, see osteoarthritis or arthritis;
• you have diabetes and a wound or redness has appeared on your foot.

Key points

• Heel pain on the first step in the morning is most often plantar fasciitis.
• A heel spur is common even without pain, and removing it is usually unnecessary.
• The foundation is daily stretching, the right footwear and a change in load.
• Shockwave therapy and injection are supporting measures when that is not enough.
• Recovery takes months, but most cases resolve without surgery.

On other foot and ankle pain: foot and ankle pain. If your heel has hurt for more than a week, book a consultation.