Why Does My Heel Hurt When I Take My First Steps in the Morning?

Why Does My Heel Hurt When I Take My First Steps in the Morning? A Physical Therapist Answers

By Nova Physical Therapy | North Hollywood, CA

Patient Question

“When I first get out of bed in the morning, I have sharp pain underneath my heel. After I walk for a while it sometimes feels better, but the pain returns after sitting or being on my feet for a long time. Could this be plantar fasciitis, and can physical therapy or shockwave therapy help?”

The Short Answer

Pain underneath or toward the inside of the heel that is especially noticeable during the first few steps after getting out of bed or after sitting for a while is commonly associated with plantar heel pain, including a condition often called plantar fasciitis.

However, heel pain can have several causes.

Symptoms alone should not be used to diagnose plantar fasciitis.

A physical therapist may evaluate:

• Where the pain occurs
• When symptoms are most noticeable
• Ankle and foot mobility
• Calf flexibility
• Foot and ankle muscle performance
• Walking
• Balance
• Activity level
• Footwear
• Recent changes in exercise or standing demands

Current American Physical Therapy Association-supported clinical practice guidelines recommend several conservative physical therapy interventions for plantar heel pain, including plantar fascia-specific stretching, calf stretching, manual therapy, taping, resistance exercise, and individualized multimodal treatment. 

Shockwave therapy may also be considered in selected patients, particularly with persistent symptoms, but current evidence does not support describing shockwave therapy as a guaranteed cure or as universally superior to exercise-based rehabilitation.

Why Does Plantar Fasciitis Hurt So Much in the Morning?

The classic symptom patients describe is:

“The first few steps are the worst.”

After sleeping or sitting for an extended period, the plantar tissues and surrounding structures have not been exposed to normal walking loads for some time.

When you suddenly stand and begin walking, those tissues are loaded again.

This can produce pain around the plantar-medial heel in people with plantar heel pain.

The 2023 APTA clinical practice guideline describes plantar fasciitis as commonly presenting with:

• Plantar-medial heel pain
• Pain with the first steps after inactivity
• Pain following prolonged weight-bearing

This symptom pattern is so characteristic that morning first-step pain is frequently used as an outcome measure in plantar fasciitis research.

The newest August 2026 shockwave therapy trial specifically measured morning pain as one of its primary clinical outcomes. 

What Is the Plantar Fascia?

The plantar fascia is a strong band of connective tissue along the bottom of the foot.

It extends from the heel region toward the toes and contributes to the mechanical function of the foot during standing and walking.

When walking, the foot must repeatedly:

• Accept body weight
• Adapt to the ground
• Store and release energy
• Provide stability
• Help propel the body forward

The plantar fascia participates in this system.

Repeated or changing physical demands can therefore influence symptoms around the plantar heel.

Is Plantar Fasciitis Actually Inflammation?

The name “plantar fasciitis” suggests inflammation because of the “-itis” ending.

However, persistent plantar heel pain is more complicated.

Research has identified both inflammatory and degenerative tissue characteristics, which is why some clinicians and researchers use the term plantar fasciopathy rather than assuming the condition represents simple inflammation. 

For patients, the terminology is less important than understanding this:

Persistent heel pain does not necessarily mean the foot is continuously inflamed or damaged every time it hurts.

The goal of rehabilitation is generally to improve symptoms, mobility, tissue-loading capacity, and function rather than simply attempting to eliminate “inflammation.”

Why Does My Heel Hurt Again After Sitting?

The same pattern that occurs in the morning can occur after prolonged inactivity during the day.

A patient may say:

“Once I get moving, I'm okay. But if I sit for 30 minutes and stand back up, the heel hurts again.”

This is often called post-static pain.

The foot transitions relatively quickly from an unloaded position to accepting body weight.

The first several steps may therefore be uncomfortable before symptoms settle.

This pattern is commonly associated with plantar heel pain but does not by itself establish a diagnosis.

Why Does My Heel Hurt After Walking or Standing All Day?

Some patients experience the opposite pattern later in the day.

The first few steps may hurt, symptoms improve after warming up, and then the heel becomes painful again after:

• Long periods of standing
• Long walks
• Work shifts
• Shopping
• Exercise
• Running
• Repeated stair use

This may reflect the relationship between the physical demand placed on the foot and the current capacity of the tissues to tolerate that demand.

Physical therapy may therefore involve gradually building tolerance rather than simply avoiding all weight-bearing activity.

Can Suddenly Walking More Cause Heel Pain?

A rapid increase in activity can sometimes contribute to symptoms.

Examples include:

• Starting a new walking program
• Increasing daily step count
• Returning to running
• Beginning a job requiring prolonged standing
• Traveling and walking substantially more than usual
• Increasing hiking
• Changing exercise frequency

This does not mean walking is harmful.

Walking is an important form of physical activity.

The issue may be the rate at which activity increased relative to current physical capacity.

Physical therapists may therefore help patients temporarily modify and then progressively rebuild activity.

Can Tight Calves Contribute to Plantar Heel Pain?

Limited ankle dorsiflexion is one finding that may be relevant in some individuals with plantar heel pain.

The calf muscles and Achilles tendon influence ankle movement during walking.

If ankle mobility is limited, movement demands may be redistributed elsewhere.

The APTA-supported clinical practice guideline recommends gastrocnemius and soleus stretching together with plantar fascia-specific stretching to improve pain and function in individuals with plantar fasciitis. 

However, not every patient with heel pain has the same mobility limitations.

An examination can help determine whether calf flexibility is relevant for that individual.

What Is Plantar Fascia-Specific Stretching?

Plantar fascia-specific stretching targets the tissues along the bottom of the foot.

The 2023 clinical practice guideline strongly supports plantar fascia-specific stretching for both short- and long-term improvements in pain and function. 

Research reviewed by the guideline found that plantar fascia-specific stretching may be particularly useful when combined with other interventions.

That does not mean every patient should perform exactly the same stretch at exactly the same intensity.

Exercise dosage should be individualized.

Does Strengthening Help Plantar Fasciitis?

Strengthening can be an important component of rehabilitation.

Depending on examination findings, exercises may address:

• Foot muscles
• Calf muscles
• Ankle muscles
• Hip muscles
• Functional lower-extremity strength

The current clinical practice guideline reports evidence supporting combined interventions that include resistance training, stretching, education, and other individualized treatment components. 

The objective is not simply to stretch the painful tissue indefinitely.

Rehabilitation may also work toward increasing the foot and lower extremity's ability to tolerate everyday loading.

Should I Stop Walking Until My Heel Pain Goes Away?

Not automatically.

Complete avoidance of activity is not necessarily required for plantar heel pain.

Instead, activity may sometimes be temporarily adjusted.

For example, depending on symptoms, someone might modify:

• Walking distance
• Walking speed
• Running volume
• Hill walking
• Prolonged standing
• High-impact exercise

while progressively improving strength, mobility, and load tolerance.

The appropriate amount of activity differs between patients.

Physical therapy can help establish a progression based on symptoms and function.

Can Physical Therapy Help?

Yes.

Physical therapy can play an important role in conservative management of plantar heel pain.

The APTA-supported 2023 clinical practice guideline recommends interventions including:

• Plantar fascia-specific stretching
• Gastrocnemius and soleus stretching
• Manual therapy when relevant mobility restrictions are present
• Foot taping as part of treatment
• Resistance exercise
• Patient education
• Multimodal rehabilitation

Orthoses may also be useful for selected patients when combined with other treatments, but the guideline specifically advises against relying on orthoses alone as an isolated short-term treatment. 

The appropriate rehabilitation program depends on what is found during the evaluation.

What Is Shockwave Therapy?

Extracorporeal shockwave therapy, or ESWT, uses externally generated acoustic pressure waves applied to a targeted region.

Different shockwave technologies exist, including radial and focused systems.

In rehabilitation and musculoskeletal care, shockwave therapy has been studied for several persistent tendon and soft-tissue conditions, including plantar heel pain.

It is important to distinguish shockwave therapy from an electrical shock.

The treatment involves mechanical acoustic energy, not an electrical shock being passed through the foot.

Does Shockwave Therapy Help Plantar Fasciitis?

Research suggests that shockwave therapy can improve pain and function in some patients with persistent plantar heel pain.

However, the evidence requires careful interpretation.

A randomized controlled trial published in Foot & Ankle International in February 2026 compared:

• Radial shockwave therapy plus exercise
• High-intensity laser therapy plus exercise
• Exercise alone

All three groups improved in pain, plantar fascia thickness, and function.

At 12 weeks, however, adding shockwave therapy or laser therapy to the structured exercise program did not produce a meaningful additional clinical benefit compared with exercise alone. 

That is an important finding.

It reinforces that shockwave therapy should not replace a comprehensive rehabilitation program.

What Did the New August 2026 Shockwave Study Find?

A new randomized, double-blind controlled trial was published in Scientific Reports on August 10, 2026.

Researchers studied chronic plantar fasciitis and compared two radial shockwave approaches:

• Shockwave treatment directed at the plantar fascia
• Shockwave treatment directed at both the plantar fascia and gastrocnemius region

Both groups experienced reductions in pain.

The combined-treatment group demonstrated faster improvement in morning pain and pain frequency after the first treatment session, although the researchers specifically cautioned that these early findings were hypothesis-generating.

By longer-term follow-up, outcomes between the groups were comparable. 

This is a good example of why a new study should not be interpreted as:

“Shockwave cures plantar fasciitis immediately.”

The more accurate conclusion is that different treatment approaches may influence early symptoms, while long-term differences may be smaller.

Is More Shockwave Treatment Better?

Not necessarily.

The August 2026 study found a possible early advantage from treating two locations rather than the plantar fascia alone, but the long-term outcomes were comparable. 

Treatment dosage and location should therefore be based on:

• Clinical presentation
• Available evidence
• Appropriate professional training
• Patient tolerance
• Treatment goals

More treatment is not automatically better treatment.

Is Shockwave Therapy Better Than Other Treatments?

Not clearly.

A systematic review and meta-analysis published in June 2026 analyzed 14 randomized controlled trials involving 797 patients.

Researchers compared radial shockwave therapy with other electrophysical modalities.

Radial shockwave therapy did not demonstrate superiority for either pain reduction or functional improvement.

The authors also noted substantial variation between studies and a generally high risk of bias, limiting certainty. 

This reinforces an important principle:

Shockwave therapy can be one tool within rehabilitation, but it should not be presented as universally superior to other evidence-based treatment approaches.

Does Shockwave Therapy Replace Exercise?

Current evidence says no.

The 2026 randomized trial comparing shockwave plus exercise with exercise alone found meaningful improvement in all groups but no meaningful between-group difference at 12 weeks. 

Exercise remains important because it can address:

• Mobility
• Strength
• Functional capacity
• Walking tolerance
• Activity progression
• Long-term self-management

Shockwave therapy cannot replace those components.

For selected patients, it may potentially complement rehabilitation.

Does Shockwave Therapy Hurt?

Patients may experience discomfort during treatment.

The intensity can often be adjusted according to the specific device, treatment protocol, clinical goals, and patient tolerance.

Patients should communicate with their treating clinician about how the treatment feels.

Shockwave therapy should not be interpreted as a treatment where more pain means better results.

How Many Shockwave Sessions Are Needed?

There is no universal number appropriate for every patient.

Research protocols vary.

For example, the 2026 Foot & Ankle International randomized trial used three radial shockwave sessions performed once weekly. 

Other studies use different treatment parameters and schedules.

Therefore, one research protocol should not automatically become a universal prescription.

Do Heel Spurs Cause Plantar Fasciitis?

Heel spurs may be visible on imaging in some individuals with heel pain, but the presence of a spur does not automatically explain symptoms.

People can have structural imaging findings without experiencing pain.

Similarly, heel pain can occur without a clinically meaningful heel spur.

The physical therapy evaluation focuses heavily on symptoms, movement, functional limitations, and examination findings, not imaging alone.

Do I Need an MRI for Heel Pain?

Not necessarily.

The APTA-supported guideline notes that imaging is generally not required when the clinical presentation is clearly consistent with plantar fasciitis. 

Imaging may become relevant when:

• Symptoms are atypical
• There was significant trauma
• Another condition is suspected
• Symptoms are not progressing as expected
• A healthcare professional determines imaging is medically appropriate

Physical therapists do not use imaging to independently diagnose disease outside the scope established by California law.

What Does Research Say?

The current evidence strongly supports a multimodal rehabilitation approach.

The 2023 APTA-supported clinical practice guideline recommends plantar fascia-specific and calf stretching, manual therapy when appropriate, taping, resistance exercise, education, and individualized combinations of interventions. 

The guideline specifically reports strong evidence that combined interventions involving manual therapy, patient education, stretching, resistance training, and other appropriate rehabilitation strategies can improve pain and function. 

New research in 2026 adds important perspective on shockwave therapy.

The February 2026 randomized trial found that shockwave plus exercise, laser plus exercise, and exercise alone all improved outcomes, with no meaningful difference between groups at 12 weeks. 

The June 2026 systematic review and meta-analysis of 14 randomized trials found that radial shockwave therapy was not superior to other electrophysical modalities for pain or function. 

Most recently, the August 10, 2026 randomized trial found that treating both the plantar fascia and gastrocnemius region with radial shockwave therapy may produce faster early improvement in morning pain than treating the plantar fascia alone, while longer-term outcomes were similar. 

Taken together, the evidence supports a balanced message:

Shockwave therapy may help selected patients with persistent plantar heel pain, but exercise-based and multimodal rehabilitation remain important, and shockwave therapy should not be marketed as a guaranteed or stand-alone cure.

Why Is This Topic Especially Relevant Right Now?

Heel pain demonstrates a measurable seasonal search pattern.

A Google Trends analysis examining searches from multiple countries found statistically significant seasonal variation in U.S. searches for “heel pain,” with peak search interest occurring around July. 

That timing overlaps with periods when many people increase:

• Walking
• Running
• Travel
• Hiking
• Outdoor exercise
• Recreational activity

At the same time, plantar fasciitis research has been unusually active in 2026.

Three notable studies this year have examined shockwave therapy:

• February 10 — shockwave plus exercise versus exercise alone
• June 10 — systematic review and meta-analysis of radial shockwave therapy
• August 10 — randomized trial specifically examining chronic plantar fasciitis and morning pain

For patients searching:

“Why does my heel hurt in the morning?”

and

“Does shockwave therapy actually work for plantar fasciitis?”

this is an especially timely evidence-based topic.

What Happens During a Physical Therapy Evaluation?

At Nova Physical Therapy, an evaluation for heel pain may include:

• Medical history review
• Symptom history
• Location of pain
• Morning pain pattern
• Walking tolerance
• Standing tolerance
• Foot and ankle mobility
• Ankle dorsiflexion
• Calf flexibility
• Foot and ankle muscle performance
• Lower-extremity muscle performance
• Walking assessment
• Balance assessment when appropriate
• Functional movement assessment
• Footwear discussion
• Exercise and activity history
• Work-related standing or walking demands
• Patient goals

A physical therapist also screens for findings that may indicate the need for evaluation by a physician or another appropriate healthcare professional.

California Business and Professions Code §2620 defines physical therapy to include physical therapy evaluation, treatment planning, instruction, consultation, and active, passive, and resistive exercise. It also specifically states that a physical therapist license does not authorize the diagnosis of disease. 

That is why a physical therapist evaluates the patient's movement and functional presentation rather than assuming every case of heel pain is plantar fasciitis.

When Should You Seek Medical Attention?

Heel pain is often musculoskeletal, but some presentations require additional medical evaluation.

Seek appropriate medical care for symptoms such as:

• Significant trauma
• Inability to bear weight
• Severe or rapidly worsening pain
• Significant unexplained swelling
• Redness or warmth associated with systemic symptoms
• Fever
• Open wounds
• Significant numbness
• Progressive weakness
• Major changes in foot color or temperature
• Other unexplained or concerning symptoms

Persistent heel pain that is not responding as expected should also be reassessed rather than simply continuing the same treatment indefinitely.

Why Patients Choose Nova Physical Therapy

At Nova Physical Therapy, our mission is simple:

We Care.

Heel pain may seem like a small problem until every step becomes uncomfortable.

It can interfere with:

• Walking
• Standing at work
• Running
• Exercising
• Shopping
• Traveling
• Hiking
• Playing with children
• Everyday mobility

Our treatment philosophy emphasizes:

• Evidence-based care
• Individualized treatment plans
• Patient education
• Mobility restoration
• Progressive strengthening
• Activity modification when appropriate
• Gradual return to activity
• Functional exercise
• Appropriate use of rehabilitation technologies
• Long-term self-management

Our goal is not simply to temporarily reduce heel pain.

We want to understand what activities are difficult and help patients progressively improve their ability to perform them.

When shockwave therapy is clinically appropriate, it should be considered within the context of a comprehensive rehabilitation program rather than as a replacement for movement, exercise, and functional progression.

Frequently Asked Questions

Why does my heel hurt when I first get out of bed?

First-step pain after sleeping or prolonged inactivity is commonly associated with plantar heel pain and plantar fasciitis. However, symptoms alone do not establish a diagnosis. 

Why does my heel feel better after I walk for a few minutes?

Some patients with plantar heel pain experience post-static pain that is most noticeable during the first few steps after inactivity and temporarily improves as they continue moving.

Why does the pain return after sitting?

After prolonged sitting, the foot transitions again from relative unloading to weight-bearing, which may reproduce symptoms in individuals with plantar heel pain.

Can physical therapy help plantar fasciitis?

Yes. Current APTA-supported guidelines recommend plantar fascia-specific stretching, calf stretching, manual therapy, taping, resistance exercise, education, and individualized multimodal rehabilitation. 

Does shockwave therapy work for plantar fasciitis?

Shockwave therapy can improve symptoms in some patients, but evidence does not show that it is universally superior to other approaches. A 2026 randomized trial found that exercise alone and exercise combined with shockwave therapy both produced improvements. 

Is shockwave therapy better than exercise?

Current evidence does not support that conclusion. In a 2026 randomized trial, adding radial shockwave therapy to a structured exercise program did not produce a meaningful additional benefit at 12 weeks. 

What did the newest plantar fasciitis shockwave study find?

An August 10, 2026 randomized trial found that radial shockwave treatment targeting both the plantar fascia and gastrocnemius region may have produced faster early improvement in morning pain than plantar-fascia treatment alone, but long-term outcomes were comparable. 

How many shockwave treatments do I need?

There is no universal number. Research protocols vary, and treatment should be individualized.

Does shockwave therapy replace physical therapy exercises?

No. Current evidence supports exercise and multimodal rehabilitation as important components of plantar heel pain management.

Should I stretch my plantar fascia?

The APTA-supported clinical practice guideline recommends plantar fascia-specific stretching for improving pain and function in individuals with plantar fasciitis. 

Should I stretch my calves?

Calf stretching involving the gastrocnemius and soleus is also recommended as part of treatment for plantar heel pain. 

Do I need custom orthotics?

Not necessarily. The clinical practice guideline advises against using either custom or prefabricated orthoses as an isolated short-term treatment. Orthoses may be considered as part of a broader treatment program for selected patients. 

Should I stop walking because of plantar fasciitis?

Not automatically. Activity may sometimes need to be temporarily modified and then progressively increased according to symptoms and functional tolerance.

Does a heel spur mean I need surgery?

No. A heel spur on imaging does not automatically determine the cause of pain or indicate that surgery is required.

How long does plantar fasciitis take to improve?

Recovery varies according to symptom duration, activity demands, physical findings, adherence to rehabilitation, health factors, and individual response. A specific recovery timeline cannot be guaranteed.

Schedule an Evaluation

If heel pain is making your first steps in the morning uncomfortable or interfering with walking, standing, work, running, exercise, or everyday activities, Nova Physical Therapy can help determine whether physical therapy is appropriate.

Our licensed physical therapists provide individualized evaluations and rehabilitation programs focused on improving mobility, muscle performance, walking tolerance, physical capacity, and function.

When clinically appropriate, treatment options may also include shockwave therapy as part of a comprehensive rehabilitation approach.

Contact Nova Physical Therapy today to schedule a comprehensive physical therapy evaluation in North Hollywood.

Disclaimer

The information provided in this article is intended for educational and informational purposes only and should not be considered medical advice, diagnosis, or individualized treatment. Reading this article does not establish a physical therapist-patient relationship with Nova Physical Therapy or any of its providers.

Heel pain can have multiple causes. Morning heel pain, pain after inactivity, tenderness around the plantar heel, or pain with walking does not by itself establish a diagnosis of plantar fasciitis.

Physical therapists evaluate movement and functional impairments and provide treatment within the scope established by California law. California Business and Professions Code §2620 specifically states that a physical therapist license does not authorize the diagnosis of disease. 

Shockwave therapy is not appropriate for every patient or every cause of heel pain. Treatment selection should be based on appropriate clinical evaluation, professional training, current evidence, patient-specific factors, contraindications and precautions, and applicable laws and regulations.

Current research does not establish shockwave therapy as a guaranteed cure or universally superior treatment for plantar fasciitis. Exercise, stretching, education, progressive loading, and other physical therapy interventions may remain important components of rehabilitation.

Seek appropriate medical care for significant trauma, inability to bear weight, severe or rapidly worsening symptoms, significant swelling, systemic symptoms, progressive neurological changes, wounds, circulation concerns, or other concerning findings.

Individual results may vary. Nova Physical Therapy does not guarantee pain elimination, tissue healing, prevention of recurrence, specific recovery times, or particular outcomes from physical therapy, shockwave therapy, exercise, orthoses, manual therapy, or any other intervention discussed in this article.

References

1. Saengsin J, Chalidapong P, Aiumporn P, et al. Efficacy of Combined Versus Single-Site Radial Shockwave Therapy for Chronic Plantar Fasciitis: A Randomized, Double-Blind Controlled Trial. Scientific Reports. Published August 10, 2026. 
2. Kosehasanogullari M, Büyükvural Şen S, Okur Yılmaz N, et al. Home Exercise With or Without High-Intensity Laser or Radial Shockwave Therapy for Plantar Fasciitis: A Randomized Controlled Trial. Foot & Ankle International. 2026;47(3):386–397. 
3. Guede-Rojas F, Rodriguez-Lagos L, Carvajal-Parodi C. Effectiveness of Radial Extracorporeal Shockwave Therapy Versus Other Electrophysical Modalities on Pain and Functionality in Patients With Plantar Fasciitis: A Systematic Review and Meta-Analysis. Foot & Ankle Specialist. Published June 10, 2026. 
4. Martin RL, et al. Heel Pain—Plantar Fasciitis: Revision 2023. Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Academy of Orthopaedic Physical Therapy and American Academy of Sports Physical Therapy of the American Physical Therapy Association.Journal of Orthopaedic & Sports Physical Therapy. 2023;53(12). 
5. American Physical Therapy Association. Heel Pain—Plantar Fasciitis: Revision 2023 Clinical Practice Guideline.
6. Wong J, et al. Seasonal Variation for Plantar Fasciitis: Evidence From Google Trends Search Query Data.Healthcare. 2022;10(9):1676. 
7. California Business and Professions Code §2620. Physical Therapy Scope of Practice.

Current resources: August 2026 randomized shockwave therapy trial · 2026 randomized trial comparing shockwave plus exercise with exercise alone · 2026 systematic review and meta-analysis of radial shockwave therapy · APTA Heel Pain–Plantar Fasciitis Clinical Practice Guideline · Full 2023 plantar fasciitis clinical practice guideline