Heel Pain in the Winter Build: Plantar Heel Pain and Load-Based Management

Plantar heel pain usually starts quietly. The first steps out of bed feel sharp under the heel, then ease off as you walk around. A run might feel fine once you're warm, but the heel is sore again afterwards. Over a few weeks the morning pain lasts longer, and eventually it starts to hurt during runs.

For triathletes, the timing is predictable. The off-season is when many athletes shift time from the bike to the run, sign up for a winter half marathon or start a run-focus block. That makes a winter run build one of the more likely times for plantar heel pain to appear. This article covers what plantar heel pain is, what the treatment trials actually show, why it often takes months to settle, and how to manage your running load. It isn't a diagnosis or a rehab programme, and the safety notes cover when to see a clinician.

What plantar heel pain is

The plantar fascia is a thick band of connective tissue that runs from the underside of the heel bone towards the toes. It helps support the arch and stiffens the foot as you push off. Plantar heel pain usually refers to pain where the fascia attaches to the heel.

The older name, plantar fasciitis, suggests inflammation, but long-standing cases often show thickening and degeneration of the fascia rather than ongoing inflammation. That's why researchers increasingly use "plantar fasciopathy" or simply "plantar heel pain". The terms overlap and this article uses them interchangeably, as the research does.

Typical features include:

• Pain on the first steps in the morning or after sitting.
• Pain at the inside of the heel, often tender to press.
• Pain that eases once you're moving, then returns later or the next day.

Other conditions can cause heel pain, including heel bone stress fractures, nerve entrapment, fat pad problems and inflammatory conditions. That's why the safety notes matter.

How common is it in runners?

A 2012 systematic review by Lopes and colleagues in Sports Medicine pulled together 8 studies covering about 3,500 runners. Plantar fasciitis was one of the three main running injuries, alongside medial tibial stress syndrome (shin splints) and Achilles tendinopathy:

• Incidence ranged from 4.5% to 10.0%.
• Prevalence ranged from 5.2% to 17.5%.

These figures come from general runners, not triathletes. Inference: triathletes run less than pure runners of a similar standard, but they often increase run volume in blocks, which is the pattern the training-load research links with injury.

Why a winter build can trigger it

No study has looked specifically at plantar heel pain in a triathlete's winter. What the evidence does show is a set of risk factors, and a winter run block tends to stack several of them.

The 2023 clinical practice guideline from the American Physical Therapy Association, by Koc and colleagues in the Journal of Orthopaedic & Sports Physical Therapy, lists these risk factors for clinicians to assess:

• Limited ankle dorsiflexion (how far your shin can move forward over your foot).
• Running.
• Work-related weight-bearing, particularly on hard surfaces with poor shock absorption.
• Higher body mass index in non-athletic people.

A 2016 meta-analysis by van Leeuwen and colleagues in the British Journal of Sports Medicine looked at 51 studies, almost all of them case-control designs that compare people who already have heel pain with people who don't. Higher body mass index was the only clinical factor that was significantly associated, and mostly in non-athletic groups. Mechanical measures of foot and ankle function, such as foot posture, didn't have good evidence behind them. Thicker plantar fascia on ultrasound was consistently linked to heel pain, though that's more a feature of the condition than a cause.

Inference: for a lean, active triathlete, body size is unlikely to be the main factor, and foot shape probably matters less than many people think. The more likely triggers in a winter build are changes in load:

• Run volume rising quickly while bike volume falls, often with a new long run or a winter race.
• New surfaces, such as more road and pavement, or a switch to the treadmill. TriForward's "Treadmill Miles" covers what changes on the belt.
• New or worn shoes. TriForward's "One Pair or Three?" covers shoe rotation and mileage.
• Changes in running technique, such as a deliberate switch to forefoot running. TriForward's "Switching to a Forefoot Strike Over Winter?" covers how that shifts load to the calf and foot.
• More time standing in hard shoes at work after the summer.

TriForward's "Forget the 10% Weekly Rule" explains why big single-session jumps in run distance seem to matter more than gradual weekly increases.

What the treatment trials show

Plantar heel pain has been studied in many trials, but most are small, and the people in them are usually patients seen in clinics, not runners or triathletes. That's an important gap.

Heavy heel raises versus stretching

The trial that made strength training popular for heel pain was published by Rathleff and colleagues in the Scandinavian Journal of Medicine & Science in Sports (2015). It randomised 48 patients with ultrasound-confirmed plantar fasciitis.

• Both groups received shoe inserts.
• The stretch group did daily plantar-fascia-specific stretching.
• The strength group did progressive, high-load, single-leg heel raises with a towel rolled under the toes, every second day. The towel pulls the toes up, which tightens the plantar fascia during the raise.

Results:

• At 3 months (the main time point), the strength group scored 29 points better on the Foot Function Index, with a wide confidence interval of 6 to 52 points.
• At 1, 6 and 12 months, there was no difference between groups.

The authors concluded that high-load strength training may help reduce pain and improve function more quickly. Note what the trial didn't show: it didn't show that heel raises produce a better long-term result than stretching, and it was small, with both groups also using inserts.

Does the exact dose matter?

A 2019 trial by Riel and colleagues in the Journal of Physiotherapy compared two ways of doing heavy-slow heel raises for 12 weeks in 70 adults with ultrasound-confirmed plantar fasciopathy.

• One group chose their own dose, doing as many heavy sets as they could, with weights no lighter than their 8-repetition maximum.
• The other group followed a fixed, progressive programme.

There was no meaningful difference in pain between the groups. More strikingly, few participants in either group reached a pain level they considered acceptable after 12 weeks: 3 of 35 in the self-dosed group and 1 of 35 in the fixed group. The authors concluded that neither programme was enough on its own for most people within that timeframe.

Inference: heavy heel raises are a reasonable part of managing plantar heel pain, but they aren't a quick fix, and they're unlikely to be enough by themselves.

What the guidelines recommend

Two recent guidelines pull the wider evidence together, and they don't agree completely.

A 2021 best-practice guide by Morrissey and colleagues in the British Journal of Sports Medicine combined a systematic review of 51 randomised trials with 4,351 participants, interviews with 14 international experts and a survey of 40 people with plantar heel pain. It recommended:

• Core treatment for everyone: education, footwear advice, taping and stretching, framed as self-management.
• Second line, if progress isn't good enough: shockwave therapy.
• Third line: custom foot orthoses.

The 2023 APTA guideline graded the evidence differently:

• Grade A (strongest): manual therapy, plantar fascia and calf stretching, taping for short-term relief (up to six weeks), and night splints for people with persistent first-step pain.
• Grade B: don't use orthoses on their own for short-term pain; dry needling.
• Grade C (weaker): therapeutic exercise including resistance training of the foot and ankle; orthoses combined with other treatment.

So strengthening appears in both, but neither guideline treats it as the single best treatment.

Comparing treatments head to head

A 2019 network meta-analysis by Babatunde and colleagues in the British Journal of Sports Medicine compared treatments across 31 randomised trials with 2,450 adults. It found no clear evidence that any commonly used treatment is better than the others. Corticosteroid injections and shockwave therapy ranked most likely to be effective across short, medium and long term, and exercise appeared beneficial for long-term pain and function. The authors described the evidence as equivocal and called for larger trials. Injections and shockwave are medical decisions to discuss with a clinician, not something to plan around a training block.

Why recovery is often slow

Plantar heel pain has a reputation for lingering. A 2018 study by Hansen and colleagues in the Orthopaedic Journal of Sports Medicine followed 174 patients (91 women, 83 men) who had been diagnosed with plantar fasciitis using ultrasound, for an average of nearly 9 years after diagnosis.

• 54% were symptom-free at follow-up, and their symptoms had lasted 725 days on average.
• 46% still had some symptoms.
• Women and people with pain in both heels were more likely to have persistent symptoms.
• Heel spurs made no difference to prognosis.

This was a clinic population, not runners, and people with heel pain bad enough to be scanned may have more persistent problems than the average runner. But it's a useful reality check. Inference: the earlier you start managing load and treatment, the less likely you are to be dealing with it next season.

Managing running load

Neither guideline recommends complete rest as a treatment, and none of the trials above stopped people walking or being active. The practical approach most clinicians use is to adjust load to a level the heel tolerates while the other treatments work. The following is inference from the research, not a tested protocol:

• Use morning pain as a guide. If first-step pain the morning after a run is worse than usual, the previous day's load was probably too much.
• Reduce rather than stop. Shorter runs, more frequent shorter runs instead of one long run, and softer or more varied surfaces may be tolerated better.
• Lean on the bike and pool. Triathletes have an advantage here: cycling and swimming usually load the plantar fascia far less than running, so aerobic fitness can be kept while run volume drops. TriForward's "Can't Run?" covers aqua jogging and the elliptical.
• Hold back on hills, speedwork and new shoes until symptoms settle, because they change how the foot is loaded.
• Build back gradually and avoid big single-session jumps in distance.

A triathlon scenario

The following example is illustrative, not drawn from a study. A 44-year-old triathlete finishes his season in September and decides to run a half marathon in February. Over October and November he goes from three to five runs a week, adds a long run that grows by 3 km most weekends, and moves most runs onto pavements because it's dark after work. In early December, he notices sharp heel pain on his first steps each morning.

An evidence-informed response might be:

• Get it checked by a physiotherapist to confirm it's plantar heel pain and rule out a stress fracture.
• Cut run volume to a level where morning pain settles, keeping two or three shorter runs a week and replacing the rest with extra bike and swim sessions.
• Start the core treatments: calf and plantar fascia stretching, taping for short-term relief, supportive shoes around the house.
• Add heavy heel raises as guided by his physiotherapist, accepting that results may take months.
• Reconsider the race. If the heel hasn't settled by January, the half marathon may not be worth it. TriForward's "The Winter Half or Marathon" covers that decision.

Common mistakes

• Running through worsening morning pain for weeks before acting.
• Stopping everything, then returning to full volume once it feels better.
• Relying on one treatment, such as a new insole or a massage ball, instead of a combined plan.
• Expecting heel raises to fix it in a fortnight. The trials measured results over months.
• Changing several things at once, such as new shoes, a new technique and more hills, during a volume build.
• Using painkillers to keep running.
• Assuming all heel pain is plantar fasciitis. Some isn't, and some needs a different response.

What we don't know

• Whether these findings apply to triathletes. The trials recruited patients from clinics, not runners or triathletes in training.
• The best way to combine treatments. Most trials compare one approach with another, not a combined plan.
• How much running is safe during treatment. No trial has tested specific running loads in people with heel pain.
• Whether cross-training helps recovery or simply maintains fitness.
• Sex differences. One long-term study found women more likely to have persistent symptoms, but most trials don't report results by sex.
• Prevention. There is no good trial evidence on preventing plantar heel pain in runners.

References

• Rathleff MS, Mølgaard CM, Fredberg U, Kaalund S, Andersen KB, Jensen TT, Aaskov S, Olesen JL. High-load strength training improves outcome in patients with plantar fasciitis: a randomized controlled trial with 12-month follow-up. Scandinavian Journal of Medicine & Science in Sports, 2015;25(3):e292–e300. doi:10.1111/sms.12313
• Riel H, Jensen MB, Olesen JL, Vicenzino B, Rathleff MS. Self-dosed and pre-determined progressive heavy-slow resistance training have similar effects in people with plantar fasciopathy: a randomised trial. Journal of Physiotherapy, 2019;65(3):144–151. doi:10.1016/j.jphys.2019.05.011
• Morrissey D, Cotchett M, Said J'Bari A, Prior T, Griffiths IB, Rathleff MS, Gulle H, Vicenzino B, Barton CJ. Management of plantar heel pain: a best practice guide informed by a systematic review, expert clinical reasoning and patient values. British Journal of Sports Medicine, 2021;55(19):1106–1118. doi:10.1136/bjsports-2019-101970
• Koc TA Jr, Bise CG, Neville C, Carreira D, Martin RL, McDonough CM. Heel pain – plantar fasciitis: revision 2023. Journal of Orthopaedic & Sports Physical Therapy, 2023;53(12):CPG1–CPG39. doi:10.2519/jospt.2023.0303
• Babatunde OO, Legha A, Littlewood C, Chesterton LS, Thomas MJ, Menz HB, van der Windt D, Roddy E. Comparative effectiveness of treatment options for plantar heel pain: a systematic review with network meta-analysis. British Journal of Sports Medicine, 2019;53(3):182–194. doi:10.1136/bjsports-2017-098998
• Lopes AD, Hespanhol LC Jr, Yeung SS, Costa LOP. What are the main running-related musculoskeletal injuries? A systematic review. Sports Medicine, 2012;42(10):891–905. doi:10.1007/BF03262301
• van Leeuwen KDB, Rogers J, Winzenberg T, van Middelkoop M. Higher body mass index is associated with plantar fasciopathy/'plantar fasciitis': systematic review and meta-analysis of various clinical and imaging risk factors. British Journal of Sports Medicine, 2016;50(16):972–981. doi:10.1136/bjsports-2015-094695
• Hansen L, Krogh TP, Ellingsen T, Bolvig L, Fredberg U. Long-term prognosis of plantar fasciitis: a 5- to 15-year follow-up study of 174 patients with ultrasound examination. Orthopaedic Journal of Sports Medicine, 2018;6(3):2325967118757983. doi:10.1177/2325967118757983