Why your heel hurts when you get up in the morning

You put your foot down as you get out of bed and it hurts. You limp a few steps and within five minutes it has almost gone. You sit on the sofa for a while, stand up, and there it is again.

That pattern —worst on starting, better with movement, worse again after resting— is the most characteristic of heel pain. It points the way, although it is not enough to know what is causing it, and it is worth understanding why it happens: it also explains what makes it better.

Running from the heel to the base of the toes there is a band of fibrous tissue, the plantar fascia, which supports the arch of the foot as you load it. It works hard: with every step it tightens and relaxes.

When it is overloaded, the point where it anchors into the heel becomes irritated. While you sleep the foot is at rest and the tissue shortens slightly; when you get up, the first steps stretch it abruptly, and that is what hurts. Then, with movement, the tissue adapts and the pain drops. It is the same reason it returns after sitting.

When that irritation persists it is called plantar fasciitis, and its page sets out what is looked at in the clinic to confirm it.

It is almost never one single thing. When it appears, several of these have usually come together over recent weeks.

If the way you load the foot seems to play a part, a gait assessment helps to check it before anything is decided.

It is the thing people hear most and the thing that confuses most. An X-ray may show a small bony prominence on the heel —the calcaneal spur— and it is easy to conclude that this is what is stabbing.

But plenty of people have a spur and no pain at all, and plenty have this pain and no spur. The spur is often the consequence of years of traction in that area and does not explain today’s pain on its own. That is why the approach does not centre on the spur but on what the examination finds, which is often an overloaded fascia.

Not all heel pain is fasciitis. If the pain came on suddenly after an effort or a jump, if it does not settle over weeks, if it wakes you at night, if it comes with swelling, or if the heel is hot and red, it should be examined: it may be a tendon injury, a stress fracture or a nerve problem, and each is approached differently.

If what hurts is the top of the foot rather than under the heel, the question is a different one: top-of-foot pain without a knock explains what to watch for and when to seek advice.