Plantar fasciitis

Plantar fasciitis is a painful condition that affects the heel of many runners. I have both personal and professional experience in treating this one. And I’m going to be honest, my sensible, evidence-based head went well and truly out of the window when it came to dealing with my own frustrations, as you’re about to read! So what is plantar fasciitis and more importantly, what are you going to do about it?

Getting to know your plantar fascia

The plantar fascia is a band of fibrous connective tissue, often referred too medically as an aponeurosis. None the wiser? Basically, it’s a big, flat tendon-like thing that spans the arch of your foot connecting your heel to your big toe (and your other toes in fact). It’s a bit like the white, super tough connective tissue you see when preparing meat!

Its job is to support the inside arch of your foot and act like a spring during walking and running to propel you forwards. If you are really keen, the more complex explanation for this is called the windlass mechanism. I’m not going to dig any further into it here, but it probably helps to know that windlass is a very old fashioned word to describe the pulley systems that were used to shift a large weight (like your body weight) with greater ease. It’s another one of those incredible things your body does without you even realising.

How do you know if you have a problem?

The simple answer is that when you put your foot to the floor first thing in the morning, it screams at you like the devil himself has just stuck his burning poker in your heel. As a result you walk like you’re 90 years old for at least the first few minutes. Think I’m being dramatic? Then you’ve not had plantar fasciitis. The above cycle repeats in varying intensities depending on how long you’ve been sedentary before trying to walk. And quite frankly, how much you’ve done to piss off said plantar fascia beforehand.

The more professional answer is below:

  • Start up pain (pain on starting to walk after a period of being sedentary. Usually worse first thing in the morning).
  • Pin point tenderness on the inside of your heel
  • A sensation of tightness in the inside arch of your foot
  • Pain can ease with activity, but will often then be worse afterwards.

Why is your plantar fascia punishing you?

This isn’t always so simple, but in my own case, and the many I treated in clinic, there is usually a change in activity involved.

Things your plantar fascia likes:

  • Consistency

Things your plantar fascia doesn’t like:

  • Enthusiastically starting a marathon training programme with 30 miles a week, when you’ve previously only been doing 10 (on a good week)
  • Suddenly adding a long hill session to the same plan you’ve been doing for years
  • Changing your trainers and going straight out for a long run to christen them
  • Not changing your trainers and finding you’ve trained for, and run, three marathons/years in them
  • Going for a spontaneous 8 mile walk in flip flops

As you can see, it’s relatively high maintenance. The list of things it doesn’t like is potentially endless, but top of it, is definitely surprises. Almost all of my patients would report some sort of recent activity change when questioned.

What goes wrong in plantar fasciitis?

In a nutshell, the change in activity, or loading (that you’re plantar fascia has not been prepared for) causes micro trauma. This leads to tissue degeneration.

Now feels like a good time to mention that the ‘itis’ suffix is somewhat of a misnomer. Most large scale studies agree that very little, if any inflammation is present after the initial onset. This is almost part of the problem. Your body needs a degree of inflammation to kick start a healing process. That’s partly why the problem becomes chronic and lasts for months on end, the healing process fails to progress.

Knowing this helps. Plantar fasciitis usually comes on gradually. As it’s often just a niggle to start with, and what we call ‘self limiting’, most runners keep on running. My best advice, is at the first sign of that niggle, heed the warning and ease back. Don’t keep poking the fire, or it might well still be burning 6 months later.

So, being a trained physio, that’s exactly what I did, right? Wrong. You’re forgetting one thing. Runner trumps physio any day of the week. In my defence: ‘I should stop running until the pain goes away’ said no runner ever. But I’m warning you, even if I didn’t, learn from my mistakes! A week of rest and a month rebuild, may well turn into a 6 month non-starter otherwise.

Treating the beast

So, you’ve ignored the warning signs, and now you’re here. At full blown plantar fasciitis. Welcome! I’m guessing you want to know what your options are now.

1. Stop trying to be a martyr! 

Clearly running through it isn’t going well for you. It’s time to stop and start the cross training. A bike is an ideal alternative. I still ran once or twice a week during the recovery phase, but I swapped most of my training for spinning classes, or just long (boring) bike sessions in the gym.

2. Stretch

Your plantar fascia is an extension of your calf and achilles complex. Tightness though the calf will often make symptoms worse. This is partly why pain is worse when you’ve been resting with your foot pointed, like in bed. You can buy extravagant boots that splint your foot up during the night. Or you could just get your act together and make sure you stretch your two calf muscles (gastrocnemius and soleus). To target both you need to do your standard lunge calf stretch with the back knee straight and then bent. I found little and often worked for me, but evidence varies on the ideal number, so it’s probably worth experimenting.

3. Look at the ‘small’ details

How old are your trainers? Do you need to get some advice on how to gradually build up your training plan? Have you had numerous other foot problems where seeing a podiatrist would make sense? Are you still wearing flip flops or ballet pumps? If so…. it might be a time for a trip to Clarks for some really cool new shoes. Seriously though, listen to the Team Sky approach that has revolutionised cycling. Marginal gains. All of these little things matter.

4. Other ‘treatments’

There are a ton of things that could go here. Everything from massage to taping and from shockwave to rolling a squash ball under your foot to heaven forbid, ‘therapeutic’ ultrasound. They may offer you short term benefit, and I’m not saying they’re entirely wrong, but from my experience, none of them is likely to ‘fix’ you.

So, obviously I tried them all. I’ve already told you, I’m not proud of it. I was desparate, and blinkered. Bournemouth marathon was in 12 weeks, and I did not have time to not be running. I think the highlight of my insanity was the moment I attempted to acupuncture the sole of my own foot. It went something like that scene from Cast Away. You know, the one where Tom Hanks took an ice skate to an abscess on his own tooth! Okay, so I’m being a little bit dramatic, but seriously, there was a moment I thought I might faint and I definitely wouldn’t recommend it. It didn’t work incidentally.

Steroid injections were another old favourite. I’d see patients who had voluntarily, even willingly, let someone inject their heel with steroid. Firstly, steroid injections are usually successful for inflammatory problems, and so as we’ve already established the lack of inflammation, the logic here escapes me. Secondly, there is a fairly reasonable chance that your plantar fascia will rupture. Now, it might seem like this is the answer to your problems, but trust me, it won’t be.

5. Come back stronger

Perhaps the most important of all of the options. Start some strength training, from day 1. The fact that you’ve got this injury in the first place suggests that your body was underprepared for the demands you were putting on it. Remember, plantar fasciitis is really a symptom of an underlying problem, that you’re going to need to fix. Often, even bio-mechanical problems can be improved by strengthening weak areas. Make sure you hit your calf complex, but also it’s important to target more global lower limb and core exercises.

Take home message

If you’re plantar fascia hates you, you’re probably to blame. Dwelling on that won’t make things any better though. Ease back on running and start cross training and strengthening at the first sign of a problem. As much as you don’t want to stop running, the options might be 1 month now, or 6 months if you stick your head in the sand. Only you can make that choice.

Plantar fasciitis is notoriously stubborn, and as always, seeing a Chartered Physiotherapist who can give you specific advice, identify problems and tailor strengthening exercises to you is probably your best bet.

Final thought:

For Cinderella, a pair of shoes changed her life. The rest of us live in the real world, and are probably going to have to put some hard work into achieving that same outcome!

Happy running!

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