The most painful first steps of the day

Getting out of bed and feeling intense heel pain in the first steps — improving after a few minutes of walking — is the classic pattern of plantar fasciitis. But what most patients do not know is that the calcaneal spur, frequently blamed as the culprit, is present in about 50% of people without any heel pain. The spur is an incidental radiologic finding in most cases — it is not the cause of the pain.

Even more surprisingly: a substantial proportion of heel pain originates not in the foot but in the calf. The soleus muscle — the deepest layer of the calf — is the main generator of referred pain in the heel. Its trigger points project pain directly to the insertion of the Achilles tendon and to the sole of the foot, perfectly mimicking plantar fasciitis. The differential diagnosis completely changes the treatment.

Plantar fasciitis in numbers

10%
OF THE POPULATION
will develop plantar fasciitis over a lifetime — it is the most common cause of heel pain in adults
50%
OF RADIOGRAPHS
of people without heel pain show a calcaneal spur — confirming that a spur is not synonymous with pain
80%
OF CASES
resolve with conservative treatment in 12 months — but adequate treatment accelerates this process to 6–8 weeks
3–5
SESSIONS
of dry needling in the soleus and gastrocnemius are associated with relief of referred plantar pain in clinical studies — average number, individualized according to chronicity

The soleus as a generator of heel pain

  1. Shortening of the posterior chain

    Sedentary lifestyle, high-heel use, and running without warm-up chronically shorten the triceps surae (gastrocnemius + soleus). The soleus, being biarticular only with respect to the ankle, suffers more from the functional shortening.

  2. Trigger points in the soleus

    An energy crisis in the soleus sarcomeres creates trigger points in the medial and lateral muscle belly of the distal calf. These points refer pain directly to the heel and plantar insertion.

  3. Plantar fascia overload

    Shortening of the posterior chain increases tension on the plantar fascia at the calcaneal insertion, especially in the first steps after nighttime rest — when the fascia is stiffer.

  4. Repetitive microtrauma

    Each step generates microtrauma at the fascia insertion. The chronic low-grade inflammatory response maintains local sensitization. The spur, when present, forms as an adaptive response to this chronic traction — not as the cause.

  5. Distal dry needling

    Needling of the soleus and gastrocnemius (proximal trigger points) deactivates the source of referred pain and reduces tension in the posterior chain, relieving traction on the plantar fascia.

Recognizing the plantar pain pattern

Critérios clínicos
08 itens

Plantar fasciitis and referred soleus pain — clinical presentation

  1. 01

    Intense pain in the first steps on getting out of bed or after sitting

  2. 02

    Improvement after 5–10 minutes of walking (distinguishing feature of fasciitis)

  3. 03

    Pain at the heel insertion (medial plantar surface) on pressure

  4. 04

    Worsening when climbing stairs or walking barefoot on a hard surface

  5. 05

    Sensation of a "stone in the shoe" or "burning" in the heel

  6. 06

    Stiff calf, tender to deep palpation (soleus)

  7. 07

    Worsening at the end of the day after long periods standing

  8. 08

    Relief when wearing sandals with a slight heel (which reduces fascia tension)

Myths and facts about the heel

Myth vs. Fact

MYTH

I need surgery on the spur for the pain to go away

FACT

Surgery for a calcaneal spur is rarely indicated and has controversial results. Since the spur is not the primary cause of pain in most cases, removing it without addressing perpetuating factors (trigger points, muscle tension, overweight) does not resolve the problem.

MYTH

Acupuncture in the foot for heel pain?

FACT

Dry needling is applied mainly to the calf (soleus and gastrocnemius) — not necessarily to the foot. Treating the proximal pain generator, not just the painful site, is the fundamental principle of myofascial medicine. Distal points from the Chinese tradition (KD3, BL60) are also used to modulate calcaneal pain.

MYTH

Insoles resolve plantar fasciitis

FACT

Orthotic insoles can reduce mechanical tension on the fascia and provide temporary pain relief, but they do not eliminate trigger points in the soleus or resolve shortening of the posterior chain. They are a useful adjunct, not a definitive isolated treatment.

Treatment protocol

Biomechanical assessment
1st visit

Palpation of the plantar insertion and the soleus. Ankle dorsiflexion test (triceps surae shortening). Assessment of body mass index and footwear type. Exclusion of secondary causes (arthritis, neuropathy).

Proximal dry needling
Sessions 1–3

Needling of the soleus and medial gastrocnemius — trigger points identified by palpation. Local twitch response confirms point activation. Frequent immediate relief after release of the soleus.

Local and systemic treatment
Sessions 4–6

Dry needling of the plantar insertion when indicated. Acupuncture at points KD3, BL60, SP6 for pain modulation and anti-inflammatory effect. Electroacupuncture at 2 Hz for central analgesia.

Recurrence prevention
Sessions 7–8

Medical prescription of eccentric stretching of the gastrocnemius and soleus. Footwear guidance. Assessment of need for an insole. Discharge with an exercise program.

Clinical pearl: the soleus shortening test

Frequently asked questions

FREQUENTLY ASKED QUESTIONS · 04

Frequently Asked Questions

Generally, complete cessation is not necessary. We recommend reducing running volume by 50%, avoiding downhill runs and hard surfaces, and always running after warm-up. The physician evaluates individually. Runners who stop completely frequently have more intense pain on resuming — progressive load is part of the tendon rehabilitation process.

Corticosteroid injection offers rapid relief (in 1–2 weeks), but the effect tends to last only 4–8 weeks, and repeated injections may weaken the plantar fascia, increasing the risk of rupture. Medical acupuncture with dry needling of the soleus produces equivalent results in the medium term (6–8 weeks) with greater durability and without risk to fascia integrity.

For acute plantar fasciitis (less than 3 months), 4–6 sessions are frequently sufficient. For chronic cases (more than 6 months), 8–12 sessions are generally needed. Significant relief usually occurs after the 3rd–4th session, especially when the soleus is treated adequately.

Shockwave therapy (extracorporeal lithotripsy) has good evidence for chronic resistant plantar fasciitis, especially when there is calcification. It can be combined with medical acupuncture for a superior result — shockwaves treat the local inflammatory component while dry needling addresses the trigger points in the calf that perpetuate the picture.