Foot pain when you run: your first steps in the morning narrow it down

The foot is where a lot of running injuries end up, and it is also where runners are worst at telling one from another. Everything gets called plantar fasciitis.

Two questions sort most of it out. Where can you put one finger on it, and what do the first thirty seconds after you get out of bed feel like.

The first-steps question

The second question is the one runners skip, and it splits the foot into two groups.

Tendons and the plantar fascia are stiff and sore when you have been off them, then loosen as you move. The first few steps in the morning are the worst part of the day, and by the time you are in the kitchen it has eased. That pattern is so reliable that first-step pain is the outcome the plantar heel pain trials measure.

Bone behaves the other way round. Morning is often the best it gets, and the pain builds through the day and through the run, because the bone is responding to how much you have been on it rather than to how long you were still.

Soft tissueBone

First steps

Soft tissueWorst in the first few steps, then eases within minutes.

BoneFine on waking, worse the longer you are up.

During a run

Soft tissueOften warms up and settles.

BoneComes on earlier in each successive run.

Pressing

Soft tissueSore over a broad area or along a line.

BoneOne small point you can cover with a fingertip.

Hopping

Soft tissueUncomfortable, but you can do it.

BoneSharp at the same spot, and you do not want a second go.

Over weeks

Soft tissueSlowly better as loading is adjusted.

BoneWorse while you keep running the same way.

Where the foot hurts

1. 1Under the heel, at the front edge of the heel bone
2. 2The back of the heel, where the tendon attaches
3. 3Behind the inside ankle bone, running down into the arch
4. 4One small tender point on top of the midfoot
5. 5Under the ball of the foot, or between the toes

### 1. Under the heel {#under-the-heel}

Plantar heel pain is one of the three most common running injuries recorded, with an incidence between 4.5% and 10% across studies of runners¹. It sits at the front edge of the heel bone, it is worst in the first steps of the day and after sitting, and it is stubborn.

The full picture on heel pain, including what the timelines honestly look like, is its own article.

### 2. The back of the heel {#back-of-heel}

If the sore spot is on the back of the heel bone where the tendon attaches, rather than underneath it, this is insertional Achilles pain. It matters because the loading that helps the middle of the tendon can aggravate the insertion, and because shoe drop and how much you go up on your toes both change it. The Achilles article covers the difference.

### 3. Behind the inside ankle bone {#inside-ankle}

Pain that runs behind the bump on the inside of the ankle and down into the arch is usually the tibialis posterior tendon, the main dynamic support of the inside of the arch. It is often missed, and it tends to show up as medial ankle pain with a flattening arch. Eccentric loading and arch support are the first moves, with surgery considered only after three to six months without progress³.

The mirror image on the outside of the ankle is the peroneal tendons, which get mistaken for a lingering ankle sprain³.

### 4. One small point on top of the midfoot {#midfoot}

A tender spot you can cover with a fingertip on the top of the midfoot is treated as bone until proven otherwise, and the midfoot is where the higher-risk bone stress injuries in the foot sit.

Not all bone stress injuries carry the same consequences. Return to sport is meaningfully slower after a high-risk one⁵, and the location decides which group you are in. Where a stress fracture sits is the article for that, and load is the lever that prevents the next one⁶.

### 5. Under the ball of the foot {#forefoot}

Forefoot pain splits two ways. A tender point on one metatarsal that worsens with impact is bone. Burning, numbness or a feeling of walking on a fold in your sock, usually between the third and fourth toes and worse in tight shoes, is the nerve.

What runs through all five

Across the systematic reviews of running injury, the foot and ankle account for a large share of what runners actually get⁸, and the pattern underneath is the same everywhere in this article. Something has been asked to do more than it can currently do.

When to get it looked at