There is a particular kind of pain that announces itself first thing in the morning. You swing your legs out of bed, put a foot on the floor, and a sharp stab runs through the heel. You hobble to the kitchen. By the time the kettle has boiled it has eased off, and you forget about it until you stand up after sitting through the news that evening, when it does exactly the same thing. Most people in this situation are told to stretch and buy better shoes. That is not wrong, but it is only part of the answer, and for a good number of people it is not even the right condition.
TL;DR
- Plantar heel pain peaks between the ages of 40 and 60, and roughly 80% of cases settle within 12 months, but that is a long time to limp.
- Pain that is worst on the first few steps after rest and eases as you walk points to the plantar fascia. Pain that is worst underfoot on hard floors and in bare feet points to the heel fat pad instead, and the two are managed differently.
- The condition is degenerative rather than inflammatory, which is why loading the tissue works better than resting it. A Danish trial found progressive heel raises beat stretching by a wide margin at three months.
- The HSE advises contacting your GP if self-care has not helped after two weeks, or sooner if you have diabetes, tingling or numbness.
- HSE chiropody and podiatry access in Ireland depends heavily on where you live. Priority usually goes to medical card holders aged 66 and over, and to people with diabetes, arthritis or a disability. Private fees qualify for tax relief at 20%.
Three different problems, one sore heel
Almost all heel pain in this age group comes down to one of three things, and telling them apart matters because the treatments diverge.
Plantar fasciopathy is the big one. The plantar fascia is the thick band of tissue running from the heel bone to the base of the toes, and it takes an enormous amount of load every day. The classic sign, and the one the HSE leads with on its own guidance, is that the pain is much worse when you start walking after sleeping or resting, gradually improves as you keep moving, and makes it awkward to lift your toes off the floor or climb stairs. Press your thumb into the inside edge of the heel, just where it meets the arch, and you will usually find a very specific tender spot.
Heel fat pad atrophy is the one that gets missed. Underneath the heel bone sits a shock-absorbing cushion of fat held in a honeycomb of fibrous chambers, and with age it loses elasticity and moisture, and thins. The pain sits centrally under the heel rather than at the inside edge, it is worst on hard floors and in bare feet or thin slippers, and it builds up over a day of standing rather than spiking after rest. It is more common in people living with diabetes, and in people who have spent working lives on hard floors. Crucially, it does not respond to the stretching and loading that helps the fascia, and some of the treatments offered for plantar fasciopathy can make it worse.
Achilles tendinopathy sits at the back rather than underneath. It comes in two forms: midportion, felt two to six centimetres above the heel bone, and insertional, felt where the tendon meets the bone. The distinction matters, because insertional problems tend to flare with the deep calf stretches and heel drops that help the midportion variety.
Why loading beats resting
You will see “plantar fasciitis” everywhere, and the “-itis” implies inflammation. When researchers examine the tissue, what they find is degeneration: disorganised collagen, tissue quietly failing to keep up with repair rather than tissue that is inflamed. Hence the growing preference among clinicians for “fasciopathy”, or simply “plantar heel pain”. That is not pedantry. If you believe you have an inflammation, the logical response is to rest and wait. If you understand it as tissue that has lost its capacity to handle load, the logical response is to rebuild that capacity gradually, and the second model produces better results.
The most useful study for anyone with plantar heel pain is a Danish randomised trial published in 2015. Forty-eight people with ultrasound-confirmed plantar fasciitis were all given shoe inserts, then split between the standard daily plantar stretch and progressive high-load strength training every second day. The exercise was deliberately simple: stand on the affected foot on a step with a rolled towel under the toes so they bend upwards, then rise slowly onto the ball of the foot and lower slowly back down.
At three months the strength group scored 29 points better on the foot function index. That is a large difference. By twelve months both groups had converged, which fits the natural history: around 80% of plantar heel pain resolves within a year regardless. The point is not that stretching fails. It is that loading gets you there considerably faster, and a year of limping costs you walks, sleep, and often the exercise habit that was keeping everything else in good order.
The dosing is unglamorous: three seconds up, three seconds down, on both feet if one is too sore, building the repetitions slowly over weeks. Some discomfort during the exercise is expected. Pain that is markedly worse the next morning means you went too hard, not that the approach is wrong.
Shoes, floors and the barefoot question
The HSE’s advice here is sound: wide comfortable shoes with a low heel and soft sole, soft insoles or heel pads, and swimming or other activity that keeps you moving without loading the foot. On the avoid list are long periods of standing, high heels, tight pointed shoes, flip-flops and backless slippers, and walking barefoot on hard surfaces.
That last one deserves emphasis for anyone with a thinning fat pad. Modern Irish homes are full of tiled and timber floors, and padding around them in bare feet or thin house slippers is a genuine aggravating factor. A supportive indoor shoe worn at home is one of the cheapest and most effective changes available, and one of the least often suggested. Off-the-shelf orthoses are also worth a go: the evidence shows small short-term gains in pain and function with no clear long-term advantage over a sham insole, so try a pharmacy pair before spending several hundred euro on custom devices.
Injections, shockwave and a word of caution
A corticosteroid injection into the heel gives real short-term relief for many people. It also carries two risks worth understanding before you consent: it can cause atrophy of the heel fat pad, which may be permanent and is difficult to treat, and it can weaken the fascia enough to rupture it. Both risks rise with repeat injections. One injection into a genuinely stubborn case is a reasonable conversation. A series of them is not.
Extracorporeal shockwave therapy is increasingly offered privately in Ireland. The evidence is of low certainty but consistently positive on function, with success rates in the region of 50% to 65% for long-standing cases. It is a reasonable next step after several months of honest conservative treatment, and an expensive first one.
One more thing worth knowing: the fluoroquinolone antibiotics, including ciprofloxacin and levofloxacin, are associated with tendon damage and rupture. The risk concentrates in people over 60, and taking oral corticosteroids at the same time raises it dramatically. If you are on one of these antibiotics and your Achilles becomes painful, that is a same-day phone call, not a wait-and-see.
When heel pain is not what you think
Most heel pain is mechanical and will improve. A few patterns warrant a proper assessment rather than another insole:
- A sudden pop or tearing sensation followed by bruising and difficulty weight-bearing, which can indicate a ruptured fascia or tendon.
- Pain in both heels arriving alongside morning back stiffness that eases with movement, which can point to an inflammatory arthritis rather than a local problem.
- Tingling, burning or loss of feeling spreading into the sole, which points to a nerve rather than the fascia.
- Heel pain that is constant, present at night and worsening, particularly after a recent increase in walking, which can indicate a stress fracture of the heel bone.
- Any foot problem at all if you live with diabetes. The HSE is explicit on this point, and a national footcare screening pathway exists to refer higher-risk patients to a Foot Protection Team.
Getting seen in Ireland
HSE chiropody and podiatry services exist, but as Citizens Information puts it, access depends on the area you live in, and some services are delivered by voluntary organisations on the HSE’s behalf. Where the service runs, priority generally goes to people who hold a medical card and are aged 66 or over, people with a Health Amendment Act card, people with an illness such as diabetes or arthritis, and people with a disability. In some areas you can apply for a chiropody treatment card through your local primary care centre if you hold a medical card and are either over 65 or living with diabetes.
If you are going privately, check the register first. Podiatrists and chiropodists are regulated by CORU, and both titles have been legally protected since March 2023, so anyone using them should be on the public register. You can search it on CORU’s website in under a minute.
Keep the receipts. Chiropody and podiatry fees qualify as health expenses, and Revenue grants relief at the standard rate of 20%, claimed through myAccount. You have four years from the end of the year in which you paid, so a course of treatment that stretched across last winter is still claimable.
The unglamorous conclusion
Heel pain rarely needs a scan, an injection or a surgeon. What it needs is an accurate label, a shoe you wear indoors as well as out, and about twelve weeks of a boring exercise done every second day. The people who recover quickly are almost always the ones who started loading the tissue early rather than waiting to see whether it would go away on its own. If it has been sore for more than a fortnight despite doing the sensible things, that is the HSE’s own threshold for ringing your GP. A sore heel is not a thing to put up with for a year, and it is certainly not a thing to stop walking over.
Críonna Health publishes practical, evidence-informed guidance on ageing well in Ireland. This article is general information and not a substitute for individual medical advice from your GP, podiatrist or physiotherapist.
📷 Photo by Arek Adeoye on Unsplash
