Heel pain with the first steps in the morning: causes, red flags and when to get it checked

The plantar fascia is a thick band of tissue running from the heel bone along the sole to the toes. Overloading it causes small tears and inflammation at its attachment to the heel. After rest it tightens, so the first steps stretch it and cause pain. As it warms it loosens and pain eases.

• Plantar fasciitis: pain under the heel and inner arch, worse with first steps and after rest.

• Heel fat pad irritation or bruising, with central heel pain worse on hard surfaces.

• Achilles tendinopathy: pain at the back of the heel, stiffer in the morning.

• Calcaneal stress fracture: pain that worsens with activity and is tender on squeezing the heel from the sides.

• Nerve entrapment (tarsal tunnel or Baxter nerve) with burning or tingling.

• Inflammatory arthritis: spondyloarthritis or rheumatoid arthritis with enthesitis, often both heels and morning stiffness elsewhere.

• Gout, bursitis and Sever disease in active children.

• Rarely, infection, tumour or referred pain from the lumbar spine.

Pain at night or rest, swelling or redness, numbness or tingling, pain after an injury, inability to bear weight, fever, symptoms in both heels with back or joint stiffness, a history of inflammatory arthritis or cancer, and failure to improve after several months warrant assessment.

• A&E or same-day GP: inability to bear weight after injury, a hot red swollen heel, or fever.

• GP within days to weeks: heel pain with numbness, night pain or both heels with joint stiffness.

• GP, podiatrist or physiotherapist: heel pain that has not improved after about six weeks.

• Routine: typical first-step heel pain starting recently.

The clinician asks about onset, timing of pain, activities, footwear, weight change, injury and other joint symptoms. They press on the heel and arch, test ankle and calf flexibility, look at foot shape and walking, and check nerve function.

• Usually none; the diagnosis is clinical.

• Ultrasound: shows thickening of the plantar fascia and excludes other causes.

• X-ray: for suspected fracture; a heel spur is common and often incidental.

• MRI: for suspected stress fracture or persistent unexplained pain.

• Blood tests: inflammatory markers and HLA-B27 if inflammatory arthritis is suspected.

Stretch the calf and plantar fascia, particularly before the first step in the morning, roll a frozen bottle under the foot, use supportive shoes with a cushioned heel, avoid walking barefoot on hard floors and wear heel cups or insoles. Reduce high-impact activity, lose excess weight and use simple painkillers if suitable. Night splints and shockwave therapy may help persistent cases.

The NHS route is a GP, then podiatry or physiotherapy. Private podiatry and orthopaedic foot clinics offer orthotics, shockwave therapy and injections.