Plantar fasciitis & foot pain

If the first few steps out of bed in the morning have become a wince, or your heel hurts after sitting for a while and then eases as you walk, you're not unfit and you haven't suddenly turned 90. The plantar fascia — the thick band of connective tissue along the sole of your foot — is densely populated with estrogen receptors. When estrogen drops, the fascia gets stiffer, less hydrated, and far more prone to micro-tearing.

The plantar fascia is connective tissue, and it responds to estrogen. Like tendons, the plantar fascia has estrogen receptors and depends on estrogen signalling to stay elastic and well-hydrated. When estrogen drops in perimenopause, the fascia gets stiffer and more brittle. The classic 'first steps in the morning hurt the most' pattern happens because overnight the stiffened fascia shortens, then has to suddenly stretch under your weight.

It's a degenerative tendinopathy, not just inflammation. The name 'fasciitis' implies inflammation, but newer evidence shows it's mostly a degenerative change in the collagen of the fascia (fasciosis). This matters because anti-inflammatories alone rarely fix it — the fix is to remodel the collagen with progressive loading.

The midlife foot is also changing shape. Years of standing, possibly years of pregnancy and breastfeeding, plus collagen change, often mean the midfoot drops slightly in perimenopause — many people genuinely go up half a shoe size. The combination of less-supported arch + stiffer fascia + same mileage is what tips the system into pain.

Weight, calf tightness and footwear all amplify it. A 10% increase in body weight roughly doubles plantar fascia load. A tight gastrocnemius (calf) pulls the heel up and yanks the fascia. Cushioned but unsupportive shoes (worn-out trainers, flat slippers, ballet flats) remove the arch support the fascia is now relying on. None of this means it's your fault — it means there are several levers.

It rarely needs an MRI; rule out the few things that do. Pain in a different location (front of foot, top of foot, all over), pain with numbness, pain that doesn't follow the morning-pattern, or pain after a sudden 'pop' should be assessed for stress fracture, tarsal tunnel syndrome or fascia rupture rather than assumed to be plantar fasciitis.

Most cases resolve within 6–12 months with a combination of proper loading, footwear and patience. A small number need targeted procedures.

Heavy, slow calf raises — the protocol with the best evidence. Single-leg heel raises with a towel scrunched under the toes (to lock the big toe up), 3 sets of 8–12 reps with a 3-second lift / 2-second hold / 3-second lower, every other day. Add weight (backpack with books, dumbbell) as you progress. Most people see clear improvement in 8–12 weeks. This is the highest-evidence intervention.

Stop walking barefoot at home, this season. If your kitchen floor is tile or hardwood and you're padding around barefoot or in flat slippers, you're loading the fascia all day with zero arch support. Get supportive house shoes (Birkenstocks, Oofos, Vionic slides) and wear them every step out of bed. This alone fixes a meaningful number of mild cases.

Decent inserts before custom orthotics. Over-the-counter Superfeet, Powerstep, or Currex inserts in your everyday shoes are nearly as effective as custom orthotics for most plantar fasciitis and cost a tenth as much. Try OTC for 8 weeks before escalating.

Calf and fascia stretching, but not as the only intervention. Calf stretches against a wall and a 2-minute frozen-water-bottle roll under the arch in the evening do help, but they're a supporting cast. The loading protocol is the lead.

Ask about MHT as part of the picture. If you have plantar fasciitis plus a stiff shoulder plus achy hands plus disturbed sleep, that's a hormonal pattern. Transdermal MHT improves connective tissue tolerance for many people, and the menopause specialist conversation is worth having even if a podiatrist is your immediate point of care.

Shockwave, PRP and steroid injection — escalation, not first line. Extracorporeal shockwave therapy has solid evidence for resistant cases and is often offered after 3–6 months of failed conservative care. Steroid injection brings short-term relief but raises the risk of fascia rupture and is now used cautiously. Platelet-rich plasma (PRP) is increasingly used but with mixed evidence. These are decisions for a podiatrist or sports-medicine doctor.

Don't ignore the calf. A genuinely tight calf is one of the most reliable causes of plantar fasciitis. If you can't comfortably squat down with your heels flat, your calves probably need 5 minutes of daily stretching for the fascia to ever fully calm down.