Plantar Fasciitis – Heel Pain when Running
I’ve wanted to write this article for a while so i’m glad I finally got my behind in gear and sat down to put pen to paper (or finger to keyboard maybe??) I wanted to write this article to help people out, because I remember when I was learning about this condition it was a difficult condition to get my head around.
Most of the articles you would read would be along the lines of: If you’ve got plantar fasciitis you probably pronate too much so get yourself some supportive shoes, stretch your calves and roll an iced bottle under your foot – that will do it! They also used to mention this thing called the windlass mechanism and then proceed to explain it using the most difficult to understand medical terminology they could muster, leaving me feeling a little bit thick and none the wiser.
For me, if you are putting out information e.g. writing an article that others are going read and hopefully be helped by, your goal should be making it as easily understood as possible not massaging your ego by trying to display how clever you are. As Einstein said… ‘if you can’t explain something simply enough you probably don’t know it well enough’, or words to that effect.
So i’ve set myself up nicely for a fall here, but i’m hoping that the following article will be put across in a way that makes sense and is easily applicable. Let me know how I’ve got on with that!… So without further a do …Plantar Fasciitis…
Plantar Fasciitis – What’s in a name?
Many of you will have heard the term plantar fasciitis before so I felt it best to work with this terminology for familiarity. However, the suffix itis in a medical condition denotes inflammation. So the term Plantar fasciitis literally means inflammation of the plantar fascia.
However, many studies over the last decade or so have postulated that the condition may be more of a degenerative, non-inflammatory process, which means the suffix itis doesn’t really fit as a good descriptor of the condition. This has lead to the condition being termed plantar fasciosis or plantar fasciopathy in an effort to better describe the condition.
So if you see the terms fasciitis, fasciosis, or fasciopathy when reading around the subject, know that they are all talking about the same condition but using different suffixes based on their understanding of the process.
Therefore, i’ll use fasciopathy for the rest of this article as current evidence seems to point to this mechanism strongest. That being said some recent evidence suggests that the condition is on a continuum starting with inflammation and progressing to degeneration. So who knows where we’ll end up with terminology perhaps it will be described as plantar fasci-itis-opathy…remember you heard it here first folks!
Either way, whilst the researchers work that out the main thing to understand is that they all agree that the issue is with the plantar fascia, so lets move onto this.
Plantar Fasciitis – Anatomy 101
Let’s start with the basics: What is the plantar fascia? Where is it? and What does it do? I think you’ve got to get your head around this if we want to be successful in treating it.
As you can see from the above pictures, the plantar fascia is located on the underneath of your foot. It is a thick band of fascia that arises from the inside of the heel bone (medial calcaneous) and splits into 5 slips that attach to the far side of the knuckles of the toes (just distal to the metatarsalphalengeal joint). It does have some attachments to the small muscles of the foot and not seen in the picture is the fact that the plantar fascia has connections to the posterior fascia of the calf (also know as the paratenon).
The key clinical points from this quick visit to the underside of the foot are:
1) The plantar fascia is located on the underside of the foot
2) It starts at the inside of the heel bone and ends just the other side of the toe joint – This is important to understand because any movement of the toes, especially extension (pulling your toes up), influences the tension of the plantar fascia.
3) The plantar fascia has connections up into the calf – Therefore any movement or issues in the calf area can influence the tension of the plantar fascia.
Understanding the anatomy of the plantar fascia helps us to understand the movements that can cause tensioning/loading of this structure and therefore how injury may develop… and then further how we might decrease tension and loading as one part of our treatment plan. Let’s go through these movements:
1) Any movement that increases the distance between the heel and the toe joints will cause the origin and insertion of the plantar fascia to move apart, increasing the tension and thus loading the plantar fascia. So looking at the structure of the foot – if the arch of the foot flattens, as occurs in pronation of the foot, it will lead the heel and the toes being pushed away from each other and therefore tensioning/loading the plantar fascia.
2) Extension of the toes, especially the big toe, will tension the plantar fascia as it attaches on the far side of the joint.
3) Any tension in the calf muscle or any movement that causes tension in the calf muscle, think dorsiflexion of the ankle during mid stance, can tension the plantar fascia due to its connections into the calf.
** Keep these points in mind for when we talk about treatment **
Plantar Fasciitis – Function of the plantar fascia
As I mentioned above no discussion on the plantar fascia can be complete without discussing the windlass mechanism. This leads us from anatomy to function. What’s the plantar fascia’s role in the body?
Here we go…A windlass is the tightening of a rope or cable. The foot bones above (calcaneus, midtarsal joints and metatarsal heads form an arch). The plantar fascia acts as the cable that attaches the heel bone (calcaneus) to the metatarsals (toes).
In running, as body weight comes down to the foot through the tibia, during mid-stance, the loading flattens the arch, separates the heel bone and the metatarsal heads and thus causes tension in the plantar fascia as it attempts to resist this movement. This tensioning stores elastic energy. As the runner then progresses to toe off, the heel lifts simultaneously as toe extension occurs. As the heel comes off the ground and the plantar fascia winds up around the toes (especially the big toe), the plantar fascia recoils and in effect pulls the heel forward, shortens the distance between the heel and the metatarsal heads and thus reforms the previously flattened arch.
This movement therefore assists in propulsion and is an incredibly ingenious process and a vital part of running. Some studies have suggested that the plantar fascia alone aids propulsion by a whopping 17%.
So that’s really the windlass mechanism of the foot, so called because the plantar fascia acts as a tightened cable. Hope this makes sense because it is quite a complicated thing to get your head around…took me years!
Symptoms – What does it feel like if you’ve got plantar fasciitis?
So let’s take the next turn on our journey through plantar fasciopathy and began to get into pathology. What does it feel like if you have plantar fasciopathy. Well, the overriding symptom is…It hurts!..a lot! Usually this is described as a sharp pain and is located around the inside of the heel, where the plantar fascia originates, but i’ve also seen plenty of cases where the pain manifests more centrally on the heel, the arch of the foot or slap bang in the middle of the plantar fascia.
It is often most severe in the morning and after periods of prolonged rest, with the first few steps being incredibly painful before abating after 10-12 steps or so. Pain is often linked to prolonged standing especially on hard surfaces and if you have a sway back posture. In this type of posture your centre of mass is forward and the weight tends to be directly over your mid arch. I haven’t quite worked out whether this is because the body weight is flattening the arch or whether its due to a tightening of the calves, and thus plantar fascia, as the calves resist dorsiflexion. Either way the tension and pain can be reduced by bringing body weight more over the heels.
It’s usually painful to palpate the medial heel or plantar fascia itself (no shock there) and the pain can be brought on by recreating the windlass mechanism (tightening the plantar fascia) – basically by keeping some pressure over the painful spot and extending the toe up to 65 degrees.
What causes plantar fasciitis?
Hmmm… so i’ve managed to write down another heading that opens up a massive can of worms. Well done me!…This heading is a bit of a problem because the answer is actually a bit more complex than you may be anticipating.
To truly answer the question you have to first understand pain in the first place. Once you understand pain you will know that it is a protective response to what you as an organism (brain and body combined) have perceived to be potentially dangerous. So in the case of plantar fasciopathy the organism (you) have perceived that there may be danger around the plantar fascia so pain manifests there.
What leads the organism to that decision could be many, many things and I will not go into the finer points of that in this article but for the vast, vast majority of cases that I see, the primary driving factor behind the pain state is excessive loading. In short the organism is sensing, via information from the body, that there is a lot of load going through the plantar fascia and not enough rest to allow for the plantar fascia to adapt to this amount of load. At this point (and this critical point will be different for everyone, because it’s about the brains perception of what is happening and your brain is different to everyone else’s) the brain will want to protect the plantar fascia and reduce the load going through it. It protects you via pain.
Basically the brain says every time you load the plantar fascia i’m going to give you some pain to remind you that I don’t want you to do this right now. So, if we know that excessive (to re-iterate: excessive is determined by your own, individual brain) loading is the main driver behind the pain state, we can now employ strategies that deal with this problem.
TREATMENT – How to treat plantar fasciitis.
Too often I see clinicians throwing everything they know at treating a condition in the hope that something works. If you truly understand the condition you can be efficient and precise with your treatment and in control of it.
At this point we have identified that loading is the main issue, so to be effective we to intervene here. Usually, I will be thinking of 2 strategies:
1) Short term offloading
2) Longer term increasing the capacity of the plantar fascia.
Plantar Fasciitis – Short term offloading
This first phase varies in length and is very individual. For me the goal is to get the pain under control, ideally it will settle down very quickly if we do a good job of this stage but pain doesn’t have to be completely gone to move on to the next stage, just well controlled and understood.
The offloading phase is all about listening to the organism. What is it telling us? Your body has more wisdom than me and you will ever have. If it is telling us that it perceives there is too much load going through the plantar fascia, let’s reduce that load to a point the organism is comfortable with. This will allow the plantar fascia to desensitise/heal/uncouple the relationship between pain and loading depending what you believe is really happening here.
How do we offload the plantar fascia? Well, this is where our understanding its anatomy and function come in. To recap…to load the plantar fascia you can:
1) Pronate the foot (decrease the arch height and thus separate the heel and the toes)
2) Dorsiflex the ankle (thus pulling the plantar fascia taught via its attachment to the calves)
3) Extend the big toe (stretch/tension to plantar fascia from the toes end).
Therefore, to reduce load we can reduce the size, rate or force of one or a combination of these movements. There are many treatment options available to help us here. My usual go to ideas are:
1) Running re-education
3) Motion controlled shoes
In truth, I don’t find running re-education to be as beneficial for plantar fasciopathy as for other common running conditions such as PFPS (patella-femoral pain syndrome) but it can be helpful to offload the plantar fascia in cases where the severity and irritability are quite low. Generally, I will try 3 things:
1) Decrease, yes decrease, cadence. I know, i’m such a heretic, aren’t we supposed to increase cadence to help with running injuries? Increasing cadence to help running injuries, especially around the knee, is very helpful but I find foot and ankle problems are made worse by increasing cadence, so by slowing cadence down a bit you will lengthen the stride, probably get a bit more of a heel strike, place more load on the knee and subsequently less load on the foot and ankle.
2) Increase step width. The aim of this cue is to try to reduce pronation. See how much you pronate when you run like John Wayne!…Obviously the key here is to be as subtle as we can. If your runner looks like they’re running like they’ve shat themselves then you’ve probably going too far with this cue and it’s very unlikely anyone is going to go away and continue running like that! A subtle change can decrease the amount you pronate though and this can be enough to offload the plantar fascia to pain free levels.
3) Increase ankle stiffness – The aim here is to reduce dorsiflexion. Although in some patients i’ve found this has worsened the symptoms, probably due to the increased tension needed in the calf to stiffen the ankle.
NB – The gait changes I use for injury recovery are not necessarily forever. If the changes to the athletes running are successful in lowering their pain, they can continue to get the physiological benefits of continued, uninterrupted running but i’m more than happy for them to transfer back to their old technique as pain settles.
Now, if running re-education does not get them pain free, and I have to say in many cases it doesn’t, then I will look to offload further using orthotics, shoes or taping.
My goal with using orthotics is, again, to decrease loading on the plantar fascia by reducing one, or a combination of the movements that tension and load the plantar fascia. Here are some options for you:
Try to effect the lowering of the arch of the foot by using a medial arch support with:
a) Rearfoot medial wedge (helps to invert or supinate the rearfoot which helps lift the arch)
b) Lateral forefoot wedge (you can check out what this looks like on google images) (sounds counter intuitive but everting the forefoot actually raises the arch).
As the rearfoot inverts the forefoot everts so helping either of the movements with wedging can help raise the arch and offload the plantar fascia
Moving on to the big toe…you could try and decrease the amount of toe extension you have by using:
a) 1st ray cut out AKA reverse morton’s extension.
b) Mortons extension
(again, you can type these into google images to see what they look like) Both of these options limit toe extension and thus the winding of the plantar fascia around the big toe, limiting tension through the plantar fascia. The morton’s extension tends to work best with someone that has a hypermobile (lots of range) big toe whereas the 1st ray cut out works better with patients with a stiff big toe (usually goes hand in hand with a higher arched foot).
You can also try to limit dorsiflexion (or indeed limit the increased pronation that results from limited dorsiflexion) by trying a heel raise, which effectively offloads the calf muscles and therefore the plantar fascia.
Another option around footwear could be to opt for motion controlled shoes, which have been shown to help some patients with offloading the plantar fascia. More then likely due to a combination of thick, soft soles (dissipating ground reaction forces = offloading), a raised heel (decreasing calf tension = offloading), a toe rocker (decreasing toe extension = offloading) and a supported arch (decreasing pronation = offloading).
If you’re looking for a good motion controlled shoe then the Brooks Beasts (below) frequently come top of reviews for motion control running shoes, although I really don’t like the look and colour if i’m honest.
A simpler offloading option could be to opt for taping. The reality is, that armed with your knowledge of the anatomy and function of the plantar fascia, you could just make your own taping techniques up, but here’s an option from Blaise Dubois from the running clinic:
So that’s my usual go-to approach for offloading the plantar fascia. Unfortunately, many clinicians think that’s job done and you wont get much more input than that.
However, we need to return the plantar fascia to a state where it can cope with the demands we are placing on it. It needs to be able to withstand a lot of force, repetitively, when we are running.
To improve its capacity we have to stress it to a point that forces the body to adapt e.g. get stronger. Give it adequate rest to allow the adaptation to occur and then repeat the process – stress followed by recovery.
Some people do get away with just offloading and then returning to running in a more gradual way that allows the plantar fascia to be stressed by running and then plenty of recovery. Usually, I will incorporate a specific strengthening programme with plyometrics, which would include a walk/run programme.
Traditionally, exercise regimes for plantar fasciopathy would be stretch your calves, bit of foam rolling and rolling a chilled bottle under your foot. Now I don’t necessarily think this is approach is wrong, but I do think that recent research has shown us that there may be a better way. If we want to cause an adaptation e.g. increase strength and power in the plantar fascia how do we create a programme that satisfies the criteria for these gains.
To create an adaptation in a tissue we have to stress that tissue to a point that creates the need in the body to use precious energy to make it stronger. If the stress placed on the tissue is not enough then no change will be elicited, or even worse, if the load is so low then de-conditioning and weakening will occur. If the stress placed on the tissue is too much then pain/injury may be the result. We have to hit the sweet spot.
Recent research has shown that both stretching and strengthening exercises load the plantar fascia. The key thing to understand though is they load the plantar fascia at vastly different magnitudes.
Plantar fascia specific stretching consists of dorsiflexing the ankle and extending toes. Rathleff and Thorborg (2015) found that this type of stretch induces a force of 146N across the plantar fascia which generates 1% strain – not much. However, when the achilles tendon is loaded by 550N (55kg) for example, the force across the plantar fascia increases 400% and strain increases fourfold to 4%.
Further, going from 0-45 degrees of toe extension doubles the force on the plantar fascia and increases strain by 50%. Rathleff & Thorborg (2015) also note that in Achilles tendons (which are similar in make up to the plantar fascia) a slower repetition (3s vs 1s) led to a superior adaptation, improving mechanical and structural properties of the achilles tendon.
This work suggests that both stretching and high load strengthening load the plantar fascia, but the strain is much larger during high load strengthening. This points towards the possible benefits of progressive strength training, including high loads performed under slow repetitions (3s or more) for the plantar fascia.
If you want to see the loading protocol that I use, including the exercise from this study then please put your e-mail in below – I’ll be happy to share it with you.
I’ll wrap up the article at this point and hope that you have a better understanding of plantar fasciopathy after this read and hopefully you have a few treatment options to get you started. If you have any questions, or want anything clarified from the article, please feel free to leave a comment and i’ll get back to you.