Why is heel pain worse in the morning?
The characteristic twinge on placing the foot on the floor for the first time in the morning is a pathognomonic sign of plantar fasciitis — inflammation of the plantar fascia, a dense sheet of connective tissue that runs from the calcaneus (heel bone) to the base of the toes. During sleep, the fascia is in a shortened resting position (foot in plantar flexion). On rising, body weight instantaneously stretches it, generating microruptures in the already inflamed fibers — hence the acute twinge.
After a few steps, the fascia warms up and pain typically improves — until the next rest. This characteristic of "improvement with walking and worsening with sitting" is fundamental to distinguish plantar fasciitis from other causes of heel pain, such as S1 radiculopathy or ankle arthritis.
The problem is more common than it seems
The hidden role of calf muscles
A frequently overlooked factor is the contribution of trigger points in the gastrocnemius and soleus. These calf muscles refer pain to the heel and sole of the foot, perfectly mimicking plantar fasciitis. In addition, shortening of the gastrocnemius-soleus complex increases tension on the plantar fascia during gait — perpetuating the injury even after local treatment.
Fascia overload
Flatfoot, overweight, running on hard surface, or use of unsupportive footwear increase tension at the calcaneal insertion of the fascia.
Repetitive microinjury
Small ruptures of collagen fibers at the calcaneal insertion generate local inflammatory response and acute pain.
Local needling
Needles at the fascia insertion and at trigger points in the soleus are associated, in experimental models, with tissue repair pathways (growth factors, TGF-β, VEGF, IGF-1) — hypothesized mechanisms still under investigation in humans.
Distal needling
Trigger points in the gastrocnemius and soleus are treated to reduce the proximal tension that may perpetuate plantar fascia overload.
Tissue remodeling
It is proposed that mechanical stimulation of the needles activates fibroblasts and favors synthesis of type I collagen — a mechanistic hypothesis based on preclinical studies.
Medical treatment protocol
Assessment
1st visitPalpation of the calcaneal insertion and plantar arch. Assessment of the gastrocnemius-soleus complex. Analysis of footwear, biomechanics, and body mass index. Differentiation of heel spur (X-ray if necessary).
Initial phase
Sessions 1–4Needling of trigger points in the soleus and gastrocnemius (proximal approach to reduce tension). Electroacupuncture in parameters appropriate for muscle relaxation.
Repair phase
Sessions 5–9Direct needling at the plantar fascia (periosteal pecking on the calcaneus) to stimulate tissue remodeling. Combination of 2 Hz and 100 Hz.
Maintenance
Sessions 10–12Consolidation of gains. Guidance for L-shaped stretching (towel on the foot upon waking) before stepping on the floor. Insole indication if necessary.
Recognize plantar fasciitis
Heel pain \u2014 characteristic pattern
- 01
Severe pain on taking the first step in the morning or after a long period sitting
- 02
Improvement after 5–10 minutes of walking (fascia "warms up")
- 03
Worsens at the end of the day, especially after prolonged standing
- 04
Tenderness on palpation on the medial side of the calcaneus (fascia insertion)
- 05
Worsens with walking barefoot on hard surfaces
- 06
Sensation of "stab" or "twinge" on stepping on the heel
- 07
History of recent increase in physical activity or change of footwear
Heel spur: the great misunderstanding
Myths and facts
Myth vs. Fact
Heel spur is the cause of plantar pain
The spur is a bony adaptation to chronic tension, present in people without pain. The cause of pain is inflammation/degeneration of the plantar fascia and hypertonia of the calf muscles.
Absolute rest cures plantar fasciitis
Prolonged rest weakens the intrinsic foot musculature and does not treat fasciosis. The correct protocol combines active treatment (needling, stretching) with reduction of load — not total immobilization.
Cortisone injection is the best treatment
Injection may offer rapid relief, but repeated injections have been associated with weakening of fascia collagen and increased risk of rupture. Recent reviews suggest that periosteal needling presents comparable results in some outcomes, without that specific risk — evidence continues to be built.
Frequently asked questions
Frequently Asked Questions
Periosteal needling on the calcaneus may cause momentary local discomfort, but is generally well tolerated. The physician uses thin needles and may apply local topical anesthesia if necessary. Discomfort during the session is much less than the daily pain the patient experiences.
In general, it is recommended to reduce running volume by 50–70% during the first 4 weeks of treatment, with gradual progression as improvement occurs. The physician evaluates case by case, considering severity and patient history.
Surgery is reserved for cases that do not respond to 6–12 months of adequate conservative treatment (including acupuncture, physician-prescribed physical therapy, insole, and exercise program). Less than 5% of cases reach this stage.
Yes — it is one of the interventions with the most evidence for plantar fasciitis. Stretching of the gastrocnemius and soleus 3x a day, especially before taking the first step in the morning, reduces the load on the plantar insertion. The medical acupuncturist advises on correct technique.