Why the first steps hurtStrong evidence
Standing up loads the foot all at once after it has been still, so problems that stiffen with rest show up on the first steps. The commonest is plantar heel pain (plantar fasciitis). The NHS says it's more likely if "the pain is much worse when you first start walking after sleeping or resting" and gets better as you move but worse if you stand, walk or run for a long time. The US physiotherapy guideline's first feature is heel pain "most noticeable with initial steps after a period of inactivity".
It's common: 9.6% of UK adults aged 50 and over had it in the past month in a survey of 5,109 people, and Dutch GPs saw 3.8 new cases per 1,000 people a year, more in women. The NHS says you're more likely to get it aged 40 to 60, after starting exercise on hard surfaces, with a tight calf, if you do a lot of standing or walking, or if you're overweight. In one small study, a stiff ankle, a higher body weight and being on your feet most of the workday went with it.
Sources 1, 2, 3, 4, 5
First-step pain is a clue, not a diagnosisEmerging evidence
No study has measured how well first-step pain diagnoses plantar heel pain. In 250 people at one heel pain clinic, 88% of those with plantar fasciitis had first-step pain, but so did 43% of those with a thinned heel fat pad. The guideline treats it as one feature among several, so this guide uses it as a starting point, not a diagnosis.
Sources 6, 2
Other causes that stiffen with restStrong evidence
The Achilles tendon: "It is common to have pain when you get up in the morning, or when you start to walk after resting for a while", an NHS trust leaflet says. Dutch GPs saw 2.35 new cases per 1,000 adults a year, and only about a third were linked to sport.
Osteoarthritis: the NHS describes "increased pain and stiffness when you have not moved your joints for a while", and NICE diagnoses it from 45 when morning stiffness lasts 30 minutes or less. Painful foot osteoarthritis affects about 1 in 6 UK adults aged 50 and over (16.7%), most often at the big toe (7.8%) and the joints of the midfoot.
Rheumatoid arthritis often starts in "the small joints in the hands and feet", and its morning stiffness "often lasts longer" than osteoarthritis's 30 minutes, the NHS says. NICE asks GPs to refer suspected rheumatoid arthritis urgently when the small joints of the hands or feet are affected, even if blood tests are normal, because early treatment can prevent joint damage.
Sources 7, 8, 9, 10, 11, 12, 13, 14
Gout, the heel's tendon attachments and infectionStrong evidence
Gout comes on with a "rapid onset (often overnight)" of severe pain, redness and swelling, most often in the big toe joint, NICE says. In 724 people followed for a year, attacks were 2.36 times as likely to start between midnight and 8am as in the daytime. 2.49% of people in UK general practice records had gout in 2012. An attack "usually lasts 1 to 2 weeks if left untreated", the NHS says, and a hot joint with a fever could be an infection instead, which is urgent.
Heel pain where tendons attach to the bone, with psoriasis, back pain that eases with movement, or eye or bowel inflammation, can be a spondyloarthritis, and NICE advises a rheumatologist's assessment. In psoriatic arthritis, 41.6% have tendon-attachment inflammation (enthesitis) somewhere.
Sources 18, 19, 20, 21, 22, 15, 16, 17
Nerves, bones and the circulationEmerging evidence
Tarsal tunnel syndrome, a squeezed nerve behind the inner ankle, causes burning, tingling or numbness in the sole that "usually worsen with weight-bearing activities (prolonged standing or walking)" and eases with the foot raised; it's uncommon (0.8% of one heel pain clinic). Burning or numb feet on both sides can be peripheral neuropathy, which affects almost 1 in 10 people aged 55 and over in the UK, most often from diabetes.
A stress fracture of the heel bone hurts with activity and later at rest, and squeezing the sides of the heel hurts; X-rays often look normal early (only 15% of heel stress injuries in military recruits showed on X-ray), so MRI may be needed. A severe burning pain in the feet that carries on at rest, with pale, shiny skin or sores that don't heal, can mean the blood supply is failing, the NHS says.
Sources 23, 24, 6, 25, 26, 27, 28
Heel spurs don't explain first-step painStrong evidence
Heel spurs showed on X-rays in 15.5% of 400 people without heel pain and in 55% of 216 adults aged 62 to 94. They're commoner with heel pain (over 8 times as likely across 7 X-ray studies), but a spur didn't predict how heel pain went over 5 to 15 years. The American Academy of Orthopaedic Surgeons (AAOS) says "Heel spurs do not cause plantar fasciitis pain", and treatment doesn't need the spur removed.
Sources 29, 30, 31, 32, 33
When a scan or test helpsStrong evidence
Not at first for typical heel or Achilles pain: the heel pain guideline says imaging is "usually not indicated" until simple treatment has been tried, and "imaging is not required to diagnose Achilles tendinopathy". A suspected stress fracture needs MRI (or another scan) if X-rays are normal. Suspected rheumatoid arthritis needs X-rays of the hands and feet and blood tests, which shouldn't delay referral; gout, a blood urate test, and a joint fluid sample if it's unclear; a suspected Charcot foot with diabetes, an X-ray taken standing, then MRI if it's normal. Osteoarthritis from 45 with typical symptoms is diagnosed without imaging.
Sources 2, 35, 27, 14, 18, 36, 11
How it usually goes: often monthsMixed evidence
Figures differ by setting. In 174 people referred to a Danish hospital, 80.5% still had heel symptoms at a year, 50% at 5 years and 44% at 15 years, more often in women and with both heels affected. The AAOS says "More than 90% of patients with plantar fasciitis will improve within 10 months", but it cites no study. In trials, 68% improved over 12 weeks of simple care, and 92% were satisfied 2 years after starting a sole stretch.
NHS inform expects new foot pain to "begin to settle within 6 weeks". Most people with Achilles pain need "6 to 9 months of rehabilitation", an NHS trust says; a gout attack lasts 1 to 2 weeks untreated; and a heel stress fracture takes 6 to 8 weeks to heal. No one can promise a date.
Sources 32, 33, 39, 40, 41, 7, 21, 26
