Why runners wake up with heel pain – and why it keeps coming back
A common complaint runners have is heel pain. Many medical diagnoses can be grouped under the symptom of heel pain, including Achilles tendonitis, Achilles tendonosis, plantar fasciitis and flexor tendonitis. As a physical therapist who specializes in treating running injuries, a frequent question I ask my patients is, “ How intense is your heel pain when you stand and take your first steps in the morning?”
Why do my heels hurt in the morning?
Why are the symptoms so severe in the morning? Why is it that a runner can frequently “walk it off” and continue with training only to experience the same (or worse) symptoms the next day? Treating this common and complicated condition requires that runners understand the physiology of the healing process.
What’s actually happening inside your heel: collagen, tendons, and the healing cycle
The tendons and fascia that surround the calcaneus (heel bone) are primarily composed of fibrous, rope-like cells called collagen. These tissues are in a daily flux of breaking down and rebuilding. This tissue turnover is especially active in runners because of the increased stresses they put on their bodies.
The Achilles tendon, plantar fascia, and toe flexor musculature must withstand huge stresses because of their role in decelerating the impact of up to 6–10 times our body weight during running. At the cellular level, the decelerating forces tear collagen fibers. One of the most amazing things about this process is that the tissues can repair themselves. And if we don’t overstress our tissues — by running too far, too fast, or both — our tendons and tissues can come back stronger. That is how we accomplish those PRs!
If runners do not allow their tissues to recover properly, injuries occur.
Runners can experience acute or chronic injuries. The following explanation and advice will focus on runners with chronic heel pain. With a chronically injured tissue, the body produces collagen in an excessive and disorganized manner. A good analogy is that instead of the collagen fibers’ normal alignment appearing as uncooked spaghetti noodles lined up in a box, the traumatized and damaged fibers appear as cooked spaghetti in the bottom of the pot. This process is called collagen cross-linking.
How your sleeping position makes morning heel pain worse
Much of our healing occurs at night while we sleep. Before maturation, collagen fibers are quite delicate and malleable. During sleep, a pointed foot position (due to the weight of our foot and the bed covers) causes the collagen fibers of the foot and ankle to shorten. Upon standing and stepping out of bed in the morning, the shortened collagen fibers have not had adequate time to reach their full strength. That sharp pain that occurs with weight bearing is the shortened collagen fibers tearing apart. And so the process starts again – every morning.
I cannot stress enough the importance of proper positioning of tendons during bouts of prolonged immobilization, such as sleeping.
How to relieve morning heel pain: stretching, night splints, and footwear
If collagen fibers are allowed to shorten and undergo cross-linking, runners’ tissues will not adequately support their body weight without re-tearing. Placing a light stretch on healing tissues influences the length and alignment of the new collagen before it reaches the maturation phase and extensive cross-linking occurs. A gentle, sustained stretch throughout the night followed by a gentle manual stretch is vital in preparing the tissues for weight bearing.
After the stretch, it is important to protect the tissues with proper shoe wear. Shoes or sandals must be right next to the bed and convenient to put on first thing.
3 PT-recommended tips to stop morning heel pain
- Wear a splint that stretches the heel and plantar foot structures (night splint, Strassberg sock).
- Very gently stretch the tissues before getting out of bed. Sit with knee straight and towel looped around left foot. Gently pull on towel until stretch is felt in calf. Hold 30 seconds.
- Slip into a supportive shoe or sandal for your first steps. If you have Achilles problems, a higher heeled shoe is effective. Plantar fasciitis may respond better to a softer sandal with arch support.
[Note: some severe cases of Achilles tendonitis/tendinosis may not tolerate a night splint or stretching]
Now that those first steps in the morning are feeling better, you’re on the right path, but managing morning pain is only half the equation. The next phase is strengthening the fascia and loading it progressively so you can get back to running.
Managing and keeping plantar fasciitis from getting worse means not just recognizing symptoms and causes, but also practicing home treatment. You can address your pain and discomfort at home with exercises and stretches recommended by physical therapists to ease plantar fasciitis pain.
Strengthening and stretching your feet just might be the missing link in your race training program.
Check out these additional resources to kick off your running season right this year!
How to Choose the Perfect Shoes for Trail Running
Choosing the wrong trail shoe can lead to pain or injury. Learn how to pick the right fit, grip, and support based on your terrain and foot type.
Build Strength, Run Stronger: Your Essential Marathon Training Circuit
Ready to take your marathon training to the next level? Check out our video demonstrations of essential strength-building exercises.
Should Runners Stretch Before or After Running? A PT Explains
Static or dynamic? Before or after? PT Shelby Hyde cuts through the noise on stretching for runners and explains exactly when to do each type so you stay injury-free all season.
Dealing with heel pain? A PT can help you run again.
Hopefully this information will allow you to understand and treat your pain. If you continue to be challenged with heel pain, our physical therapists are ready to help. You don’t need a doctor’s referral to see a physical therapist in most states — you can request an appointment directly.
Did You Know?
Physical therapists play a key role in helping runners of all levels stay strong, prevent injuries, and reach their goals — whether it’s finishing their first 5K or competing on the world stage. From personalized training plans to expert recovery strategies, PTs support every step of the journey. Check out this patient success story to learn how physical therapist Patrick Bridge helped a local athlete succeed on her path to the 2021 Olympics!
Running Toward the Rings
It might not be something you hear a lot about, but even professional athletes lean on physical therapists to maintain their high level of physical performance and to help them fight through potential setbacks. For elite runner Sarah King, PT was part of her 2021 journey to Tokyo.
