Heel Pain: Why It Happens and How Podiatry Gets You Back on Your Feet
That first step out of bed in the morning — the one that feels like a nail driving through your heel — has a name. It’s called post-static dyskinesia, and it’s the hallmark of plantar heel pain, the most common condition seen in podiatry clinics Australia-wide. If you’ve been wincing through your mornings or cutting your walks short because of heel pain, you’re not alone — and more importantly, you don’t have to live with it.
Plantar heel pain affects roughly 10% of the population at some point in their lives, with runners, people who stand for work, and those carrying extra weight at highest risk.1 The condition accounts for an estimated 1% of all visits to healthcare professionals — and yet a surprising number of people wait months before seeking help, hoping it will resolve on its own. It rarely does.
What’s actually happening under your heel?
The plantar fascia is a thick band of connective tissue that runs from the heel bone (calcaneus) to the bases of the toes. It supports the arch of the foot, absorbs shock during walking and running, and acts as a windlass mechanism — tightening as the toes extend to create a rigid lever for push-off.
When the plantar fascia is overloaded beyond its capacity, it develops a degenerative process that we now understand is not primarily inflammatory. The old term “plantar fasciitis” implied acute inflammation (“-itis”), but research over the last 15 years shows the pathology is closer to a tendinopathy — a failed healing response with collagen degeneration, increased ground substance, and neovascularisation.2 This is why anti-inflammatory medications alone rarely provide lasting relief.
Common causes and risk factors
- Training load errors: Sudden increases in running volume, hill work, or speed sessions overload the plantar fascia faster than it can adapt.
- Footwear changes: Switching abruptly to minimalist shoes, worn-out trainers, or unsupportive work shoes alters the mechanical load on the fascia.
- Calf tightness: A restricted gastrocnemius-soleus complex limits ankle dorsiflexion, increasing strain on the plantar fascia with every step.
- BMI and metabolic factors: Higher body weight increases the tensile load through the fascia. There is also emerging evidence linking plantar heel pain to metabolic conditions including type 2 diabetes.
- Foot posture: Both excessively flat (pronated) and excessively high-arched (supinated) foot types can predispose to overload through different mechanisms.
- Occupation: Jobs requiring prolonged standing — teaching, nursing, hospitality, retail — are strongly associated with plantar heel pain.
Is it actually plantar fasciitis? — differential diagnosis
Not all heel pain is plantar fascia pain. A thorough clinical assessment is essential because the management of each condition differs significantly.
Fat pad atrophy
The heel fat pad is a specialised shock-absorbing structure that thins with age. Pain is typically central, directly under the calcaneus, and worse on hard surfaces. Unlike plantar fascia pain, there is no morning first-step pain — discomfort builds through the day.
Baxter’s nerve entrapment
The first branch of the lateral plantar nerve can become entrapped between the abductor hallucis and quadratus plantae muscles. Pain is often more medial and may radiate. There is frequently tenderness at a specific point inferior to the medial malleolus rather than at the plantar fascia origin.
Calcaneal stress fracture
More common in runners and military recruits. Pain is often constant rather than just with first steps, and the heel squeeze test (medial-lateral compression of the calcaneus) is positive. Suspect this when pain is unremitting and not responding to typical plantar fascia management.
Tarsal tunnel syndrome
Compression of the posterior tibial nerve produces burning, tingling, or shooting pain that may extend into the sole of the foot. Tinel’s sign (tapping over the tarsal tunnel) is often positive.
Why resting won’t fix it — the evidence for active treatment
Complete rest is a common instinct but a poor strategy for plantar heel pain. The plantar fascia is a load-bearing structure — completely unloading it leads to deconditioning, reduced tissue capacity, and a high recurrence rate when activity resumes. The evidence strongly supports load management — reducing aggravating loads to a tolerable level while maintaining activity — combined with targeted strengthening.
A landmark randomised controlled trial by Rathleff et al. (2015) demonstrated that a simple progressive high-load strengthening program (heel raises with a towel under the toes) produced superior outcomes compared to stretching alone at 3, 6, and 12-month follow-up.3 The mechanism is thought to be increased tendon stiffness and capacity through collagen adaptation.
How podiatry treats heel pain
1. Accurate diagnosis
Your first consultation with a sports podiatrist includes: detailed history (onset, aggravating/relieving factors, training history, footwear), gait analysis (walking and running if relevant), biomechanical assessment of foot posture and lower limb alignment, calf flexibility testing, and diagnostic ultrasound if indicated to visualise plantar fascia thickness and integrity.
2. Load management and activity modification
We don’t tell runners to stop running — we modify the load. This might mean: reducing weekly volume by 30-50% temporarily, substituting some running with cross-training (cycling, swimming), avoiding hill work and speed sessions during the early rehab phase, and using relative rest principles — keeping pain below 3-4/10 during and after activity.
3. Progressive strengthening
The Rathleff protocol — heel raises with a rolled towel under the toes to isolate the plantar fascia — performed every second day, progressing from 3×12 to 3×12 with added weight in a backpack. This is the highest-evidence intervention for chronic plantar heel pain and costs nothing to perform at home.
4. Orthotic therapy — when indicated, not routine
Not every patient with heel pain needs orthotics. Custom foot orthoses are prescribed when there is a clear biomechanical driver — excessive pronation that loads the fascia asymmetrically, a leg length discrepancy affecting gait mechanics, or specific structural foot types that fail to respond to strengthening alone. When used, they are part of a comprehensive plan, not a standalone fix. 3D scanning ensures precise fit and contour.
5. Night splints and taping
Low-Dye taping provides immediate short-term pain relief by supporting the arch and offloading the plantar fascia. Night splints that maintain the ankle in a neutral position can help reduce morning pain by preventing overnight plantarflexion contracture, though compliance is variable.
6. Extracorporeal shockwave therapy (ESWT)
For chronic cases (symptoms >6 months not responding to loading programs), shockwave therapy has Level 1 evidence for reducing pain and improving function. It works by stimulating neovascularisation and disrupting dysfunctional pain signalling.
What about injections?
Corticosteroid injections provide short-term pain relief (weeks, not months) but do not address the underlying pathology, and there is some evidence of increased risk of plantar fascia rupture and fat pad atrophy with repeated injections. They have a role in breaking a severe pain cycle to allow rehabilitation to proceed, but should not be first-line or repeated treatment. Platelet-rich plasma (PRP) injections are an emerging option with some supportive evidence but remain an area of ongoing research.
The role of the wider allied health team
Heel pain is rarely just about the foot. At The Wellness Place, your team can include:
- Physiotherapy for calf and posterior chain strengthening, running retraining, and addressing any hip or knee contributions to altered gait mechanics.
- Exercise Physiology for a structured return-to-running or return-to-work program, and managing weight and metabolic factors that impair tendon healing.
- Remedial Massage for calf, hamstring, and intrinsic foot muscle release — reducing the upstream tension that increases plantar fascia load.
- Chiropractic for pelvic and lower limb alignment — because a unilateral anterior pelvic tilt shifts ground reaction force distribution through the feet.
What does a realistic recovery look like?
Tissue adaptation takes time. Here’s what to expect:
| Timeframe | What to expect |
|---|---|
| Weeks 1–2 | Reduced morning pain with load modification, taping, and gentle isometric holds |
| Weeks 3–6 | Progressive strengthening taking effect; walking tolerance improving; able to resume modified running |
| Weeks 6–12 | Significant functional gains; returning to full training loads gradually; morning pain resolved or minimal |
| 3–6 months | Full resolution in most cases; ongoing maintenance strengthening recommended to prevent recurrence |
The single best predictor of a good outcome is compliance with a strengthening program. Heel raises every second day, progressively loaded, produces better results than passive treatments alone.
When surgery should be considered
Plantar fascia release surgery is reserved for cases that have failed at least 6–12 months of comprehensive conservative management. It is rarely necessary — fewer than 5% of cases require surgical intervention. Before considering surgery, ensure that load management, progressive strengthening, orthotics (if indicated), shockwave therapy, and any metabolic contributing factors have all been addressed.
The bottom line
Heel pain is common, treatable, and in most cases responds to structured conservative care without injections or surgery. The key is getting the right diagnosis early and committing to a strengthening program that builds your foot’s capacity rather than just chasing short-term pain relief.
If you’ve been putting up with that first-step pain for weeks or months — it’s time to do something about it.
Book an appointment with Dr Aaron Gregory, sports podiatrist at The Wellness Place, or call (08) 9379 3838. Located at 103 Old Perth Road, Bassendean — comprehensive foot care with a team that treats the whole person, not just the heel.
Written by Dr Aaron Gregory (B. Pod Med, M Sports Med) and the multidisciplinary team at The Wellness Place. Evidence-based podiatry grounded in clinical experience and current research.
- Riddle DL, Pulisic M, Pidcoe P, Johnson RE. Risk factors for plantar fasciitis: a matched case-control study. Journal of Bone and Joint Surgery. 2003;85(5):872–877.
- Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process without inflammation. Journal of the American Podiatric Medical Association. 2003;93(3):234–237.
- Rathleff MS, Molgaard CM, Fredberg U, et al. High-load strength training improves outcome in patients with plantar fasciitis: a randomized controlled trial with 12-month follow-up. Scandinavian Journal of Medicine and Science in Sports. 2015;25(3):e292–300.