16 June 2026 · By Dra. Alba Solís
Plantar fasciitis: why your heel hurts on the first steps and how to fix it
«Doctor, the worst part is the morning: I put my foot on the floor and it's like standing on a nail. Then, ten minutes into walking, it almost goes away». I hear this description almost word for word in clinic, and it is so typical that the diagnosis is often made before I even examine the foot. It is plantar fasciitis, the most common cause of heel pain.
What the plantar fascia is (and why it becomes irritated)
The plantar fascia is a strong, elastic band of tissue running from the heel bone to the base of the toes, along the whole sole of the foot. It works like the string of a bow: it holds up the arch of the foot and absorbs the impact of every step. When it is overloaded, it develops tiny tears where it anchors to the heel, becomes irritated and starts to hurt. More than pure inflammation, we now know it is a degeneration caused by overload of the tissue — which is why complete rest doesn't cure it, and well-directed progressive work does.
Why it appears
There is almost never a single cause. The ones I see most in clinic:
- A sudden increase in load: starting to walk or run a lot all at once, a change of footwear or of surface.
- Tight calf muscles: if the calf pulls, the foot compensates and the fascia pays the price. It is one of the most underrated factors.
- Unsupportive footwear: spending a lot of time barefoot on hard floors or in very flat soles.
- Excess weight: every extra kilo is extra load on every footfall.
- Foot type: very flat and very high-arched feet distribute load poorly.
First things first: confirming it really is the fascia
Heel pain isn't always fasciitis. With musculoskeletal ultrasound in the consultation itself I can measure the thickness of the fascia (in fasciitis it is thickened), see whether there is fluid or degeneration, and rule out other causes that get confused with it: overload of the heel fat pad, a stress fracture or a trapped nerve. Getting the diagnosis right is what saves you months of the wrong treatment.
The treatment that really works
The vast majority of cases of fasciitis resolve without surgery and without injections, with a consistent plan. These are the pillars:
1. Stretches and exercises (the foundation of everything)
Stretching the fascia and the calf, and strengthening the foot, is the treatment with the strongest scientific backing. The single most important move is very simple: stretch the fascia before taking your first step of the morning, while you are still sitting on the bed. In the consultation I go through each exercise with you, step by step, so you can keep doing them at home. Plantar fasciitis behaves like the rest of the overload injuries of tendons and fascia, and the principles are the same:
👣 Read more about tendinopathies
2. Footwear and, sometimes, insoles
Shoes with good cushioning and a little arch support take load off the fascia. In some feet (very flat or very high-arched) a custom insole helps to spread the load better. It isn't essential in every case, but in stubborn ones it makes a difference.
3. Controlling the pain during flare-ups
Applying cold after activity (rolling the foot over a frozen bottle works very well) and adjusting how much load you put through the foot on bad days lets you keep making progress with the exercises without the pain getting in the way.
4. Ultrasound-guided injection (only if it's needed)
When several months of well-done treatment have gone by and the pain is still limiting you, I consider an ultrasound-guided injection. In selected cases PRP can also make sense, for its biological effect on degenerated tissue. Doing it under ultrasound is key: it lets us place the treatment at the right spot and protect the fat pad of the heel.
The most common mistake
Stopping the exercises as soon as the pain improves. The fascia takes time to recover fully, and giving up at the first sign of improvement is the number one cause of relapse. My advice is always the same: keep the stretches as a daily habit, even when it no longer hurts, especially if you are about to increase your activity or change your footwear.
Frequently asked questions
Why does my heel hurt most on the first steps of the morning?
While you sleep, the foot is relaxed and the plantar fascia shortens. When you put your weight on it for the first time, that stiff fascia is stretched all at once and it hurts. That's why the pain is at its worst on the first steps and eases as the tissue warms up and regains its elasticity. The same thing happens when you stand up after sitting for a long while.
How long does plantar fasciitis take to get better?
It's an injury that calls for patience. With treatment done properly, most people improve noticeably in 2-3 months, although some cases take longer. The key is being consistent with the stretches and exercises: dropping them as soon as things improve a little is the most common reason it comes back.
Is an injection any use in plantar fasciitis?
In most cases it isn't needed: it resolves with exercise, stretching and sometimes insoles. An ultrasound-guided injection is reserved for stubborn cases that don't improve after several months of well-done conservative treatment. Doing it under ultrasound matters, because it lets us place the treatment at the exact spot and protect the fat pad of the heel.
Are plantar fasciitis and a heel spur the same thing?
Not exactly. The spur is a small calcification on the heel bone that shows up on an X-ray, but plenty of people have one without any pain. The problem that hurts is almost always the fascia, not the spur. That's why treatment is aimed at the fascia, not at «removing the spur».