The first steps out of bed hurt, the ballet flats make it worse, and the barefoot apartment is the hidden culprit. A Manhattan podiatrist on the walking woman’s most common complaint.

The short version: Sharp heel pain on the first steps in the morning is most often plantar fasciitis, an inflammation of the band of tissue under the arch. Supportive shoes, calf stretches, avoiding bare feet on hard floors and replacing worn shoes usually help. Manhattan podiatrist Dr. Rebecca Pruthi’s practice advises seeing a podiatrist if heel pain lasts more than a month.

New Yorkers like to say they don’t need a gym because they have the city. It’s half true. A Manhattan day can stack up subway stairs, crosstown avenues, a standing lunch and a walk home over the bridge because the weather turned nice. Your heart enjoys it. Your heels keep the receipts.

In a 2001 survey by the American Academy of Orthopaedic Surgeons, heel pain was one of the two most common shoe-related problems women reported, close behind calluses, and most women said their foot problems began in their twenties. In a walking city, the twenties come early and stay late.

The composite walker

Call her Jules, a composite: 44, a residential broker who shows apartments from Tribeca to Carnegie Hill and logs more miles on a Saturday than most suburbanites do in a week. Her routine is impeccable from the ankles up. Below them: ballet flats for showings, because heels scratch clients’ floors and she likes to look relaxed, and bare feet at home on her own wide-plank oak.

For months the first steps out of bed have felt like stepping on a tack. The pain fades after she moves around, then returns after a long showing day or when she stands up from a desk. She has assumed it’s the price of the job. Half the brokers she knows complain about the same thing.

What’s actually happening

The usual suspect is plantar fasciitis. Dr. Rebecca Pruthi, who owns Foot Care of Manhattan on Madison Avenue, has described the plantar fascia on the Dr. Oz blog as a tough band of connective tissue running from the heel bone to the base of the toes, one of the key players in the arch’s shock absorption. Overuse and stress inflame it. Professional athletes get it. So do brokers.

The morning pattern is the giveaway. Overnight, the fascia tightens while you sleep with your toes pointed. The first steps stretch it suddenly, and it protests. As you move around, it loosens, and the pain eases, until a long day loads it again.

She has also flagged a rarer, more dramatic version: a partial or full tear, which can follow chronic fasciitis, an abrupt force, or sometimes steroid injections and certain antibiotics that weaken connective tissue. Signs include intense pain, a painful lump or bruising in the arch, or feeling a pop. That one needs a podiatrist right away.

Not every heel pain is the same

Where it hurts matters. Pain at the back of the heel, where the Achilles tendon attaches, points to a different problem, often aggravated by tight calves and shoes that rub. A heel spur, a small bony growth on the heel bone, can show up on X-rays alongside plantar fasciitis. Pain that worsens steadily with activity and is tender to squeeze can signal a stress fracture. Burning, tingling or numbness suggests a nerve is involved.

That is why a proper exam beats guessing. Pruthi’s practice lists X-rays, orthotics, plantar fasciitis, heel spurs, Achilles tendinitis and tarsal tunnel syndrome, a pinched nerve near the ankle, among the reasons patients visit.

The barefoot apartment

Here is the twist Jules didn’t see coming. Her practice’s patient guidance warns against going barefoot when you have heel pain, because walking without shoes strains the plantar fascia. It even suggests wearing supportive shoes around the house in the evening instead of slippers, socks or bare feet. The beautiful oak floors were part of the problem.

The same guidance recommends gentle calf stretches against a wall, 20 to 30 seconds per leg, shoes with shock-absorbent soles, firm shanks and supportive heel counters, and retiring any pair with worn-down heels or soles.

The flats paradox

Many women assume flats are the healthy alternative to heels. Often they aren’t. A paper-thin ballet flat offers almost no arch support or cushioning, so every step on concrete goes straight into the heel. Flip-flops are worse. Research from Auburn University found they alter the walking stride in ways that can cause pain from the foot up to the hips and lower back.

The goal isn’t the lowest shoe. It is the most supportive one: a modest heel, a cushioned sole, a firm back and enough structure that the shoe doesn’t fold in half in your hand.

The walking wardrobe

Pruthi’s advice for city walkers adds up to a quiet wardrobe strategy:

  • Rotate. Don’t wear the same shoes every day. She has told Bustle the same pair day after day is not a good thing for your feet.
  • Mind the socks. Skip pure cotton. “When the cotton gets wet, it stays wet,” she told Bustle, recommending cotton-synthetic blends that wick moisture away.
  • Replace sneakers on schedule. Roughly every 400 to 500 miles, or when the soles show real wear, and leave about half an inch in front of your longest toe.
  • Ease into new routines. Most running injuries, she has written, come from doing too much too soon, so build up mileage gradually.
  • Dress for winter. In February she has urged New Yorkers to swap fashion heels and flimsy sneakers for warm boots, wiggle their toes to keep blood moving, and moisturize daily so heels don’t crack.

What a podiatrist can do

Most plantar fasciitis improves with conservative care, though it can take patience. A podiatrist can confirm the diagnosis, rule out a fracture or nerve problem, and build a plan that may include stretching, supportive shoes, over-the-counter or custom orthotics, and activity changes.

For stubborn cases there are more options. Pruthi has written that cortisone injections can ease the inflammation but may weaken the tissue, which is one reason they are used carefully. For a tear, she has described rest and a walking boot or cast, followed by slow stretching. She has also described platelet-rich plasma injections as an experimental option in certain cases. The right choice depends on the foot, which is the point of seeing a doctor rather than guessing.

Her practice’s rule of thumb is the one to remember: if heel pain persists longer than a month, see a podiatrist. Your feet should not hurt.

Jules on the move

Jules bought a pair of supportive house shoes she describes as hideous and wonderful. She does her calf stretches against the kitchen wall while the coffee brews, traded the paper-thin flats for cushioned loafers with a real heel counter, and saw a podiatrist when the morning pain hit the one-month mark. The X-ray ruled out anything worse, and a pair of orthotics moved into her loafers.

By spring she was walking the Brooklyn Bridge on a Sunday for fun, which in her line of work is the highest compliment a pair of feet can receive. She still shows apartments in flats. They just come with an arch now.

Frequently asked questions

Why does my heel hurt in the morning? Sharp heel pain with the first steps out of bed is a classic sign of plantar fasciitis. The tissue under the arch tightens overnight and is stretched suddenly when you stand.

Can a podiatrist help with heel pain? Yes. Podiatrists diagnose and treat heel pain, using exams and X-rays to find the cause and treatments such as stretching programs, supportive footwear, orthotics, injections or immobilization when needed.

What is the best doctor to see for heel pain? A podiatrist specializes in the foot and ankle and is a good first choice for heel pain. Orthopedic foot and ankle specialists also treat it. See someone promptly if pain lasts more than a few weeks or follows an injury.

How long does plantar fasciitis last? It varies. Many people improve over several months with stretching, supportive shoes and orthotics. Starting treatment early and avoiding bare feet on hard floors usually speeds recovery.

Back to the series pillar: Manhattan’s Most Glamorous Women Walk Miles in Heels. Related: The Two-Inch Rule Podiatrists Swear By.

Jules is a composite. This article is for general information, not medical advice.