Plantar Fasciitis: Why Your Heel Hurts in the Morning (and How to Fix It)
The classic pattern
Sharp stab in the heel with the first few steps out of bed. Eases after 5–10 minutes of walking. Flares again after sitting for a while, or at the end of a long day on your feet. Sound familiar? Welcome to plantar fasciitis — one of the most common foot conditions we see across our Liverpool, Cabramatta, Fairfield and Bankstown catchment.
Epidemiology estimates that around 10% of adults will experience plantar fasciitis at some point, with runners, office workers who suddenly increase walking, people who have gained weight, and those starting new jobs on their feet all at elevated risk.
What's actually wrong?
The plantar fascia is a thick band of connective tissue that runs from your heel bone to the base of your toes. It supports the arch of the foot and transmits load during walking, running and jumping.
When load exceeds capacity — through a sudden spike in walking volume, new shoes, weight gain, or training errors — the fascia tissue becomes overloaded and painful. Modern literature increasingly uses the term "plantar fasciopathy" because imaging rarely shows acute inflammation after the first few weeks; it's more of a chronic tissue overload problem, similar to other tendinopathies.
Who we commonly see in clinic
- Runners who have increased weekly mileage rapidly — very common after signing up for a half marathon
- Warehouse and construction workers in Liverpool and Bankstown who spend 10+ hours a day on concrete
- Healthcare and childcare staff on their feet all shift
- People who have recently gained weight or are pregnant
- People over 45 — the plantar fascia loses some tensile capacity with age
- People with very flat or very high-arched feet — though foot shape alone isn't usually the main cause
What doesn't work (or is overrated)
- Rest alone. Plantar fasciitis is an overload injury — total rest deconditions the tissue. Load management matters; bed rest doesn't.
- Cortisone injections. Short-term relief, no long-term benefit, rare but real risk of rupture or fat-pad atrophy.
- Custom orthotics for everyone. Evidence is modest. A decent supportive shoe usually does more.
- Stretching alone. Helps, but isn't the main driver. Strength is.
- Shockwave therapy (ESWT). Mixed evidence — sometimes useful for stubborn chronic cases, not first-line.
What works — the Rathleff protocol and beyond
In 2015, Michael Rathleff and colleagues published a landmark trial comparing plantar-fascia-specific stretching versus a simple heavy-slow resistance calf-raise program. At 3 months, the strength group reported significantly better pain and function than the stretch group.
The protocol is simple:
- Stand on a step with a rolled towel under your toes (to extend the big toe — this pre-stretches the plantar fascia)
- Perform slow heel raises on the painful foot — 3 seconds up, 2 seconds pause at the top, 3 seconds down
- Start at 3 sets of 12 reps, progress to 5 sets of 8 reps with added weight in a backpack
- Every second day — NOT daily. The tissue needs recovery time.
Most people do this for 12 weeks. Pain during the exercise is acceptable provided it settles within 24 hours and doesn't escalate week on week.
What else helps
- Load management — temporary reduction in running volume or standing hours, rebuilt gradually
- Footwear — supportive shoes (even around the house); avoid going barefoot on hard floors temporarily
- Calf flexibility — tight calves contribute; stretch daily
- Body weight management — where relevant, small reductions meaningfully reduce heel load
- Hands-on therapy — soft-tissue release and joint mobilisation for short-term symptom relief
- Night splints — useful for a minority of stubborn cases
- Taping — low-dye taping can provide short-term comfort for long days on your feet
Expected timeline
- Weeks 1–3: morning pain starts to shorten; load management kicks in
- Weeks 3–8: heavy-slow resistance phase — gradual, consistent improvement
- Weeks 8–12: most people largely pain-free; returning to running or previous activity volume
- Months 3–6: consolidation; maintenance loading 1–2 times per week prevents recurrence
When to scan
Imaging is usually unnecessary. Occasionally an ultrasound is used to rule out partial plantar fascia tear, or X-ray for heel spurs (which are usually incidental). Persistent burning pain with tingling or numbness in the foot may need investigation for nerve entrapment rather than plantar fasciitis.
Not every heel pain is plantar fasciitis
Differential diagnoses worth ruling out:
- Fat-pad contusion or atrophy — pain under the centre of the heel rather than the arch
- Achilles tendinopathy — see our Achilles guide
- Tarsal tunnel syndrome — nerve entrapment, causes burning/numbness
- Calcaneal stress fracture — pain on compression of the heel bone, often in runners
- Reactive arthritis or inflammatory causes — rarer, usually bilateral and involving other joints
Book a heel pain assessment
Heel pain that's hung around more than a couple of weeks doesn't tend to resolve itself without a plan. If you're in Liverpool, Cabramatta, Fairfield, Bankstown or anywhere in Southwest Sydney and mornings have become painful, book a plantar fasciitis physio assessment at Evolve Physio & Mastery. We'll give you a clear diagnosis, set up the loading program, and have you back on your feet pain-free.
References: Rathleff et al. 2015 "High-load strength training improves outcome in patients with plantar fasciitis: a randomized controlled trial" (Scand J Med Sci Sports); Riddle & Schappert 2004; David et al. 2017 Cochrane review on injection therapies for plantar heel pain; RACGP guidelines on musculoskeletal foot pain.
Frequently Asked Questions
Why does my heel hurt most when I first get out of bed?
Classic plantar fasciitis / plantar fasciopathy. Overnight the plantar fascia tightens slightly. The first few steps in the morning rapidly load the irritated tissue before it's warmed up — hence the sharp pain. It usually eases after 5–10 minutes of walking, then returns after periods of sitting.
Will a cortisone injection cure it?
Usually no. Short-term pain relief, yes, but studies show injections don't improve outcomes at 6–12 months and carry a small risk of plantar fascia rupture or fat-pad atrophy. Exercise-based loading programs outperform injections in the medium term.
Do I need custom orthotics?
Not usually. Evidence for custom orthotics is modest at best. A supportive, well-cushioned shoe — particularly for walking around home and at work — helps more than most custom inserts. Minimalist shoes and barefoot at home are often aggravating factors.
How long does plantar fasciitis take to heal?
With good treatment, most people improve significantly over 8–12 weeks and fully resolve within 6 months. Without treatment, up to 50% of cases become chronic and persist for a year or more — which is why active, early management matters.
Should I stretch or strengthen?
Both, but strengthening matters more. The Rathleff 2015 protocol — heavy-slow resistance calf raises over a rolled towel — consistently outperforms stretching alone in published trials. Stretching the calf and plantar fascia has a role, but it's not the main driver of recovery.
