Heel pain and plantar fasciitis in perimenopause

The morning clue

The diagnostic feature is the pattern rather than the location: sharp pain under the heel on the first few steps after getting out of bed, easing after five or ten minutes of walking, then returning after prolonged standing or at the end of the day.

The explanation is that the fascia shortens and stiffens while at rest, and the first steps stretch it abruptly. Pain that is worst after rest and better with initial movement is characteristic of fascia and tendon, and it distinguishes this from most other causes of foot pain.

Why this age

The plantar fascia is a thick band of collagen running from heel to toes, supporting the arch. Like tendon, it is affected by the reduced collagen synthesis and altered tissue properties that follow falling estrogen.

The heel fat pad, a specialised shock-absorbing structure, also thins and loses elasticity with age, reducing cushioning under the heel bone.

Weight gain around the transition increases load on both. The condition peaks in women aged 40 to 60, which is not a coincidence of the epidemiology.

The name is also wrong

As with tendonitis, the -itis is misleading. Tissue studies show degeneration rather than inflammation, which is why plantar fasciopathy or plantar heel pain are increasingly preferred.

The practical consequence is the same: anti-inflammatory treatment gives limited and temporary benefit, while progressive loading of the fascia has better trial support. Steroid injection provides short-term relief but carries a risk of fat pad atrophy and fascia rupture, which is why it is used cautiously.

What else causes heel pain

• Fat pad atrophy, causing a deeper bruise-like ache in the centre of the heel rather than sharp first-step pain
• Calcaneal stress fracture, where pain is present with every step and squeezing the heel from both sides hurts — more likely with low bone density
• Nerve entrapment, causing burning or tingling rather than sharp mechanical pain
• Achilles insertional problems, where pain is at the back of the heel rather than underneath
• Inflammatory arthritis, which can cause heel pain and should be considered with pain in multiple joints or morning stiffness lasting over an hour

When to see someone

See a physiotherapist or podiatrist for a loading programme. Recovery is typically measured in months rather than weeks, and abandoning a programme at six weeks is the most common reason it appears not to work.

See someone promptly for heel pain present with every step from the outset, pain after a fall or a sharp increase in activity, numbness or tingling, or heel pain alongside pain in several other joints.