The Runner's Guide to Plantar Fasciitis

Plantar fasciitis, or more correctly plantar fasciopathy (as an –itis suffix denotes inflammation of the area), is so common in runners it has even been called “runner’s heel”.

The Plantar Fascia is constructed of the same thick tissue type as the ITB, and shares some common traits with ligaments and tendons. Pain for many suffering from this often first forms near the front of the heel on the bottom of the foot during running and later becomes more noticeable when getting up in the morning forcing him or her into a painful flat-footed shuffle, trying not to extend at the ankle or push off with the big toe. 

The PF itself is made up three strands, with the central one being the largest and most prominent. As the foot bears weight the PF undergoes a tightening, and it’s been estimated it carries as much as 14% of the total load of the foot.

During gait the PF elongates during contact, storing energy like a spring. As the toes are dorsiflexed in the propulsion phase the PF tenses, shortens the foot and acts as a windlass. Its function is often tied to that of the Achilles as there is a continuous fascial connection between the two. As such the Achilles is often a target for treatment of PF conditions.

Like with most running injuries the most likely causes are often a sudden increase in mileage or intensity, or a shoe change. However a number of other risk factors have been linked such as: obesity (BMI >30), Achilles tendon tightness, reduced ankle dorsiflexion, and foot posture, with high arched, stiff feet being more problematic than a flatter foot.

PF issues can take a long time to resolve – six to eighteen months is common. Perhaps the number one reason for this is that affected runners are not discouraged from running, as long as the pain is stable. On a scale of zero to ten with ten being unbearable pain, runners are actually encouraged to continue as long as the pain doesn’t go beyond five out of ten. Given the way pain can change motor control I feel that this is setting people up for further trouble in the future.

Common treatment is to stretch the calf complex on the belief that the Achilles tendon needs to be unloaded. I would suggest that what is most important is that people’s feet work properly. When the feet are inflexible the muscles are forced to work over time to deal with the lack of range from within the support structure itself. Stretching the muscles responsible for ankle range is fine, but only addresses 50% of the problem – the other 50% of your plantar and dorsiflexion comes from movement within the foot itself. We’ll look at some drills later to address this issue.

One of the biggest culprits of causing PF is a switch to barefoot or minimalist running. I know it’s really sexy right now to run in the thinnest, flattest shoes possible but you’re not a Tarahumara Indian, and chances are you’re too heavy and that your feet are too weak to deal with that kind of stress right now. Barefoot running can take years to get your body ready for, and with the increased loading on the forefoot when running in minimal shoes, particularly on harder surfaces, the calf complex is overloaded. And if your feet are tight and stiff that problem will be doubled.

The best strategy should be to reduce training load by using softer surfaces such as grass and dirt to train on – but not sand as that may make the problem worse – decreasing volume, and adding in stretching for the calf complex as well as mobility exercises for the foot. During this period care will have to be taken that pain isn’t increasing in the PF, and this may mean an abbreviated schedule for an extended period of time until it heals.

But you can make the lower leg strong enough to better deal with running quite easily. Barefoot calf raises will help to strengthen the entire chain that contains the plantar fascia. Often when a part of the body complains it is doing so because a neighboring part is weak and it is forced to over compensate. If the calf is too weak to properly deal with deceleration forces involved in running the plantar fascia will tighten up to cope. Next thing you now you’ve got PF.

The normal protocol is to raise up on two legs, take one foot off the ground, and then slowly lower the heel to the ground. Repeat for sets of thirty reps, three times on each leg. These are actually part of my ongoing maintenance plan for myself these days and I will randomly do sets throughout the day to safeguard my lower legs from any more troubles.

With the obvious reduction in fatigue tolerance to high reps, there’s an association between reduced calf endurance and medial tibial stress syndrome. My take on it – if you get a calf strain/tear, rebuild fatigue tolerance to minimise likelihood of suffering shin pain after the calf tear. (The following comments are by my good friend and super physio Greg Dea).

The association was those who averaged 3 sets of 23 reps were more likely to suffer MTSS than those who averaged 3 sets of 33 reps.

So for me I use the max reps for 3 sets as a test from time to time on myself. If I don’t get over 30 for 3 sets, I’m working on it

 And after achieving 3 sets of 30+, the transition to hopping in training is obvious, or double leg skipping to single leg skipping. But a test of risk for future injury is a lateral hop test performed as follows:

Get two strips of tape, lay them parallel 40cm apart.

Have the athlete hop from outside one strip of tape to the outside of the other strip of tape repetitively as many times as possible in 30 seconds.

Count the reps.

Repeat the other side.

Normal is 5% or less between both sides.

Conclusion

If you start to get PF problems don’t swap shoes as it may cause another issue elsewhere. Instead swap the surface you are training on and look for a softer surface such as dirt or grass. Finally, make sure your lower legs are strong enough and add in the three sets of thirty calf raises. Once you can hit 3 x 30 reps test yourself on the hop test to make sure that injury risk is minimal as a deficit of more than 5% from side to side is a big indicator of possible future injury.