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

"Why does the bottom of my heel hurt when I first get out of bed in the morning, and can physical therapy help?"

The Short Answer

Heel pain that is especially noticeable during the first few steps after getting out of bed or after a period of rest is commonly reported by people with plantar heel pain, including presentations often referred to as plantar fasciitis.

However, heel pain can have multiple causes, and morning pain alone cannot establish a diagnosis.

Factors such as recent changes in walking or running activity, prolonged standing, foot and ankle mobility, calf muscle performance, footwear, occupational demands, body load, and the capacity of the tissues to tolerate physical activity may contribute to symptoms.

A licensed physical therapist can evaluate your foot and ankle mobility, muscle performance, walking mechanics, activity tolerance, and functional limitations to determine whether physical therapy is appropriate and develop an individualized rehabilitation program.

Why Does My Heel Hurt Most in the Morning?

A characteristic symptom reported by many people with plantar heel pain is discomfort during the first few steps after a period of inactivity.

This may occur:

• When getting out of bed
• After sitting for a long time
• After driving
• After resting following exercise
• When standing after a prolonged period at a desk

Symptoms may temporarily improve after several minutes of movement but return later after prolonged standing, walking, or other activities.

The exact symptom pattern varies between individuals.

What Is Plantar Heel Pain?

Plantar heel pain generally refers to pain experienced around the bottom or inner portion of the heel.

The plantar fascia is a strong band of connective tissue extending along the bottom of the foot and contributing to normal foot function.

Symptoms associated with plantar heel pain may include:

• Pain under the heel
• Pain during the first steps in the morning
• Pain after prolonged sitting
• Discomfort with prolonged standing
• Pain during or after walking
• Reduced tolerance for running or exercise

Because several conditions can cause heel pain, an individualized evaluation is important.

Is Plantar Heel Pain the Same as Plantar Fasciitis?

The term plantar fasciitis is widely used by patients and healthcare professionals.

However, the biological processes involved in persistent plantar heel pain may be more complex than simple inflammation alone.

For this reason, terms such as plantar heel pain or plantar fasciopathy may also be used depending on the clinical context.

The terminology does not change the importance of identifying the patient's specific functional limitations and contributing factors.

Why Did My Heel Pain Start?

There may not always be one identifiable cause.

Symptoms may develop following changes such as:

• Suddenly increasing walking
• Beginning a running program
• Increasing exercise intensity
• Spending more time standing
• Changing work demands
• Returning to activity after inactivity
• Changes in footwear
• Increased recreational activity

Reduced ankle mobility and deficits in foot or lower-extremity muscle performance may also be relevant in some individuals.

Should I Stop Walking?

Not necessarily.

Complete rest is not automatically required for plantar heel pain.

Depending on your symptoms and examination findings, your physical therapist may recommend temporarily modifying:

• Walking distance
• Running volume
• Standing duration
• Exercise intensity
• Hills or stairs
• Recreational activities

The goal may be to reduce excessive aggravation while gradually improving the body's capacity to tolerate activity.

Can Physical Therapy Help Plantar Heel Pain?

Yes. Current clinical practice guidelines support several physical therapy interventions for plantar heel pain.

Depending on examination findings, treatment may include:

• Therapeutic exercise
• Foot and ankle strengthening
• Calf strengthening
• Plantar fascia-specific stretching
• Calf stretching when appropriate
• Mobility exercises
• Balance training
• Walking or movement assessment
• Manual therapy when clinically indicated
• Taping when appropriate
• Footwear education
• Activity modification
• Home exercise programs
• Progressive return to walking, running, or sports

Treatment should be individualized rather than using the same program for every patient.

What About Orthotics?

Foot orthoses may be appropriate for some individuals, but they should not automatically be considered the only treatment for plantar heel pain.

Clinical practice guidelines suggest that orthoses may be used as part of a broader treatment program in selected patients rather than as an isolated intervention.

Your physical therapist can evaluate whether footwear modifications, orthoses, exercises, or other interventions may be appropriate for your presentation.

Can Shockwave Therapy Help Persistent Heel Pain?

Extracorporeal Shockwave Therapy (ESWT) has been studied as a non-invasive treatment option for plantar heel pain, particularly in some persistent cases.

Research suggests that shockwave therapy may improve pain and function in selected patients, although outcomes vary.

Shockwave therapy is not appropriate for every patient and should not automatically replace exercise-based rehabilitation.

When clinically appropriate, it may be incorporated into a broader rehabilitation program that also addresses:

• Strength
• Mobility
• Activity tolerance
• Progressive loading
• Walking demands
• Patient education

An evaluation is necessary to determine whether shockwave therapy may be appropriate.

What Does Research Say?

The Academy of Orthopaedic Physical Therapy's 2023 Clinical Practice Guideline for heel pain and plantar fasciitis supports several interventions that physical therapists may incorporate depending on the patient's presentation.

These include plantar fascia-specific and gastrocnemius/soleus stretching, manual therapy, taping, therapeutic exercise addressing relevant muscle performance, and other individualized interventions.

Research also supports progressive exercise and load management as important components of rehabilitation.

For persistent plantar heel pain, extracorporeal shockwave therapy has also been studied as a conservative treatment option.

The appropriate treatment should be determined from the patient's complete clinical presentation rather than from one symptom alone.

What Happens During a Physical Therapy Evaluation?

At Nova Physical Therapy, every patient receives an individualized evaluation that may include:

• Medical history review
• Symptom history
• Foot and ankle mobility assessment
• Strength testing
• Calf muscle performance assessment
• Functional movement assessment
• Balance assessment
• Walking assessment
• Activity tolerance assessment
• Review of footwear when relevant
• Review of work or recreational demands
• Goal setting

Your physical therapist also screens for findings that may require additional medical evaluation.

Following the evaluation, an individualized plan of care is developed based on your examination findings, functional limitations, and personal goals.

When Should You Seek Medical Attention?

Heel pain should receive appropriate medical evaluation when symptoms include:

• Significant trauma
• Inability to bear weight
• Significant swelling
• Redness or warmth with systemic symptoms
• Fever
• An open wound or signs of infection
• Progressive numbness or weakness
• Severe or rapidly worsening pain

Heel pain can have causes other than plantar fasciitis, so unusual or progressive symptoms should not be self-diagnosed.

Why Patients Choose Nova Physical Therapy

At Nova Physical Therapy, our mission is simple:

We Care.

We believe patients deserve more than simply being told to stop walking until their heel feels better.

Our treatment philosophy emphasizes:

• Evidence-based care
• Individualized treatment plans
• Patient education
• Progressive strengthening
• Functional outcomes
• Movement optimization
• Appropriate activity progression
• Long-term health and wellness

Our goal is to understand how your heel symptoms affect your ability to stand, walk, work, exercise, travel, and participate in the activities that matter to you.

Frequently Asked Questions

Why is my heel pain worse when I first get out of bed?

First-step pain after a period of rest is commonly reported with plantar heel pain. However, this symptom alone cannot establish a diagnosis.

Is plantar fasciitis caused by a heel spur?

Not necessarily. Heel spurs may be identified in individuals with or without symptoms, and their presence does not automatically explain heel pain.

Should I walk if I have plantar fasciitis?

Walking may remain appropriate, but the amount may need to be temporarily modified depending on your symptoms and activity tolerance.

What shoes are best for plantar heel pain?

There is no single shoe that is best for every patient. Comfort, activity demands, foot characteristics, and individual response should be considered.

Can strengthening help plantar fasciitis?

Strengthening may be an important component of rehabilitation, particularly when deficits in foot, ankle, calf, or lower-extremity muscle performance are identified.

Can shockwave therapy help plantar fasciitis?

ESWT may be considered for selected patients with persistent plantar heel pain. Whether it is appropriate should be determined through an individualized clinical evaluation.

Schedule an Evaluation

If heel pain is making your first steps in the morning difficult or limiting your ability to stand, walk, work, exercise, or participate in everyday activities, Nova Physical Therapy can help.

Our licensed physical therapists provide comprehensive evaluations and individualized rehabilitation programs focused on improving mobility, strength, activity tolerance, and function.

Contact Nova Physical Therapy today to schedule your comprehensive physical therapy evaluation and learn which treatment options may be appropriate for you.

Disclaimer

The information provided in this article is intended for educational and informational purposes only and should not be considered medical advice, diagnosis, or 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 or pain during walking does not establish a diagnosis of plantar fasciitis or any other specific condition. Treatment recommendations should be individualized based on a licensed physical therapist's examination, clinical judgment, medical history, patient presentation, current evidence, and applicable scope-of-practice requirements.

Shockwave therapy is not appropriate for every individual or every cause of heel pain. Physical therapists screen patients and refer to physicians or other appropriate healthcare professionals when findings require additional medical evaluation.

If you experience significant trauma, inability to bear weight, fever, signs of infection, progressive neurological symptoms, or other concerning findings, seek appropriate medical attention.

Individual results may vary. Nova Physical Therapy does not guarantee specific outcomes from physical therapy, shockwave therapy, exercise, or any healthcare intervention discussed in this article.

References

1. Koc TA Jr, et al. Heel Pain—Plantar Fasciitis: Revision 2023 Clinical Practice Guideline. Journal of Orthopaedic & Sports Physical Therapy. 2023.
2. Martin RL, et al. Heel Pain—Plantar Fasciitis: Revision of the 2014 Clinical Practice Guideline. Academy of Orthopaedic Physical Therapy / JOSPT.
3. American Physical Therapy Association (APTA). Guide to Physical Therapist Practice.
4. World Health Organization (WHO). Musculoskeletal Health.
5. Physical Therapy Board of California (PTBC). Physical Therapy Practice Act.

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