Alongside runner's knee and achilles tendinopathy, plantar fasciitis is one of the most common running injuries. Although it's a frustrating and, for some, slow-healing condition, there are several things you can do to fast-track your recovery. Here, sports medicine physician Dr Jordan Metzl and charted physiotherapist Matt Bergin explain everything you need to know.
The plantar refers to the area on the bottom of the foot, and the plantar fascia is the thick band of connective tissue running from your heel bone to the front of your foot. This tissue helps support your foot's arch and gives it shape, and it aids in stability when your foot strikes the ground and then pushes off.
Historically, plantar fasciitis was thought of as an inflammatory condition, however, more recent studies have suggested that there is often a lack of any true inflammatory signs, and that it is, instead, a degenerative process that brings with it a thickening of the plantar fascia heel attachment. In a similar fashion to that of an achilles tendinitis injury, plantar fasciitis is more commonly known as plantar fasciopathy (like tendinopathy) in the medical world.
An injury to the fascia usually begins where the fascia connects to the bony bump on the bottom of the heel called the calcaneal tuberosity. The inflammation and pain come from excessive tension. The muscles above, and the shape of the foot below, contribute to its development. The calf muscles (specifically, the gastrocnemius and soleus) connect to the heel bone via the achilles tendon. When those muscles are tight, the tendon pulls on the bone from above, stretching the fascia and causing strain. People with high arches are especially prone to plantar fasciitis because the arch itself also contributes tension to the fascia.
A mild case can turn major very quickly if ignored. Tears, although less common, can also occur in the plantar fascia. These are a totally different injury - and an article for another time - but are not to be missed. Tears to the plantar fascia will typically be much more acute and symptoms will be more severe. And there will often be a moment of sudden injury that a runner can quite clearly remember.
To confuse things further you can also have a chronic, long standing plantar fasciitis (- fasciopathy) alongside an acute plantar fascia tear. If this sounds like your symptoms, visit a physiotherapist.
The main symptoms are a nasty pain in the bottom of the foot, especially at the inner attachment point into the heel, and usually felt when taking your first steps out of bed in the morning or those first few minutes of a run.
Plantar fasciitis has many causes, so there is no definitive answer to that question, frustratingly. As ever, training errors are often to blame, for example, suddenly ramping your mileage up, or jumping into speedwork or hill intervals.
There are a number of biomechanics that also may predispose someone to developing plantar fascia type injuries, and especially around the foot-ankle complex. Stiffness in the ankle and big toe joints have been shown to have contribute to stress on the plantar fascia. Both the small intrinsic and larger extrinsic muscles of the foot and ankle have been shown to impact loads placed on the plantar fascia as well - and especially if these muscles are weak. Conversely, people with high arches often run into issues as well, with the raised arch of the foot stiffening the mid-foot and impacting it's shock absorbing affect on landing, when running.
Employ dynamic rest: Take a break from the activity causing the problem. The earlier you address plantar fasciitis, the better. How long you need to rest depends on the severity, but expect at least a couple of weeks. Stick with intense upper-body activity that doesn't load your foot. This may be frustrating, but think long term - it's better than being out of the game for months.
Stretch: Use the stretches described below. Be gentle. Go slow. You're trying to relieve the tightness in the area, not prepare for a game or race. As the injury heals, adopt this stretching routine permanently.
Consider a NSAID: An anti-inflammatory such as ibuprofen or aspirin can help reduce pain, if necessary.
Consider splints: Foot splints are available and can help if worn at night. It's best to have a doctor recommend one, though, as there are several varieties.
Ease yourself back into the game: Don't restart strenuous lower-body activity until you're pain-free. You'll just aggravate the injury and be out even longer.
Extracorporeal Shockwave Therapy (ECSWT): Another tool that can be useful - especially in the more chronic cases where things have become a little stagnant - is shockwave therapy. This is administered by physiotherapist using a machine which produces shockwaves to initiate a more localised healing response at a cellular level. This prescribed alongside managing your training load, resolving any underlying biomechanical issues and strengthening the tissues. Not all physiotherapists use, or have access to, these machines so check with them first.
Put your toes and the ball of your foot against the top of the vertical edge of a step with your heel on the floor and slowly lean forwards, keeping your leg straight, until you feel the stretch at the top of your calf. Repeat with your knee bent, feeling the stretch farther down the leg. Hold each stretch for 15 to 20 seconds and repeat several times in each position. Do this daily, before and after exercise.
A simple preventative measure you can do anywhere, even sitting at your desk. Roll a tennis ball back and forth under each foot for a few minutes a day. The ball massages and loosens the fascia. Also, working into your lower calf and especially the musculotendinous junction - the bit between the bulk of your calf muscle and the achilles tendon - can help to take some tension off the plantar. Some research has shown a continuous connection between the plantar fascia and the achilles through the achilles-calf complex can contribute to an increase in plantar fascia loads.
Just like an achilles tendinopathy, to expect a successful return to running you must ensure the tissues can tolerate the loads you are placing upon them. Try the following strength and movement control exercises.
Strength exercises
Isometric heel raise (perform with knee bent and with knee straight)
Eccentric heel drop (perform with knee bent and knee straight)
Double leg raise to single leg lower
Ankle inversion with resistance band
Movement control
Reverse lunge
As with the running you must monitor your symptoms once you initiate these exercises. You want there to be no increase in symptoms immediately after or within the 24 hours following. Worsening of that morning stiffness is a sign we are pushing things too much, so adjust things as required.
My prescription for repetitions, sets, weight and frequency would be individual based, depending on current volume of running and the extent of the plantar fasciitis.
Once you're confident in your ability performing these exercises, and are not experiencing symptoms afterwards, you can progress to plyometric strengthening exercises like double-leg pogo hops and single-leg pogo hops.
Over-the-counter insoles can be helpful, especially for high-arched runners. Prescription orthotics are another option - they are custom-made for your foot - but try the (much cheaper) over-the-counter orthotics first - and if they don't work, see a podiatrist.
Running shoes with a higher heel-toe drop may help in the short-term, especially if you're currently running in a shoe with a low drop (4-5mm) or have recently transitioned.
If first treatments don't go according to plan, it might be worth speaking to your doctor or physiotherapist about getting an injection, to get the foot into a less inflammatory state.
Your doctor might add a bit of numbing medicine mixed with cortisone to the foot. This is a high does anti-inflammatory that's usually targeted right at the plantar fasicia origin as it comes off the calcaneus (heel bone). After the injection, it's important to take a few days off of running to give the medication time to work.
In today's medicine, when cortisone doesn't help, we're getting some traction from platelet rich plasma (PRP). This is harvested by taking blood from the arm, spinning it in a centrifuge, isolating the platelets and their associated platelet derived growth factors (PDGF), and then injecting them into the area of the chronic pain. This treatment can be quite helpful, especially if the cortisone doesn't work, but it takes weeks rather than days to kick in and it's a quite a bit more painful.
Some of this article is extracted from The Athlete's Book of Home Remedies by Dr Jordan Metzl.