By Dr. Christiane Gardner
Perhaps the most common and most frustrating overuse injury in runners is chronic heel pain that just won't go away! (Achilles tendonitis is a close second!) It seems all of us have either experienced this nagging injury or knows someone who suffers from it. This article will give you the nitty-gritty on plantar fasciitis:
- what it is,
- what it isn't,
- how to cure it, and
- how to avoid it recurring.
Just remember: nothing can take the place of a good sports physician or podiatrist.
Let’s start with the basics.
What plantar fasciitis is…
The plantar fascia is a strong ligament which lies just beneath the skin on the plantar surface of the foot. It extends from its attachment at the heel distally to the toes. Its purpose is to provide integrity to the bottom of the foot and allow some "spring" action in the push off phase of gait.
The plantar fascia works very closely with the calf muscles and Achilles tendon. The tighter your calf muscle, the more strain is placed on the Achilles tendon and plantar fasciia. The reason your heel hurts worse in the morning is that when you sleep, your foot is plantarflexed (toes point down) a bit. This causes the calf muscle to tighten which in turn causes the Achilles tendon and plantar fascia to tighten. When you first step on the floor in the morning, the tight plantar fascia is suddenly stretched causing pain. The patient with plantar fasciitis typically complains of pain first thing in the morning. This pain usually goes away after a few steps, only to return after a period of inactivity such as driving to work. We runners have a tendency to ignore small aches and pains. However, if you ignore heel pain, it will likely become worse and therefore much more difficult to heal.
What plantar fasciitis isn't…
If your heel is always painful especially with weight-bearing, and there is pain when you cup your heel with your hand and squeeze, then you may be suffering from a stress fracture of the calcaneus (heel bone). Time to get an X-ray or bone scan.
If you experience a tingling sensation like a mini electrical shock in your arch and heel, then a condition called tarsal tunnel syndrome may be the cause of your pain. This is the foot version of carpal tunnel syndrome where a ligament becomes very tight across a nerve causing the tingling. This is usually caused by excessive pronation and is often cured with an orthotic.
Pain in the medial arch is often confused with plantar fasciitis, but is usually an inflammation of the posterior tibial tendon. Lastly, chronic back pain due to arthritis of the lower back can cause referred pain in the heel. A sports medicine physician or podiatrist should be able to diagnose your condition and get you back running again.
How to cure plantar fasciitis.
Plantar fasciitis by definition is caused by inflammation of the ligament. Initial treatment consists of early recognition of the problem and reducing the inflammation. Ice, stretching and anti-inflammatory medications can help in the early stages of plantar fasciitis. Try and look back over your training log to see if your training changed which may have caused this overuse injury:
- Have you increased your mileage too much too soon?
- Are your running shoes past their expiration date?
- Have you added speed work or hill repeats?
If ice, stretching, ibuprofen, and change in running shoes do not resolve your symptoms, an orthotic may be necessary to reduce the pronation or flattening of your foot. These do not have to be expensive. While some patients will require a custom orthotic made from an impression of their feet, most patients do quite well with off the shelf orthotics such as the "Sole Orthotic". These are heat- moldable inserts which run about $50. They can be found in most running stores or at Zombie Runner (I have no financial interest in anything!).
A night splint may also be beneficial. This is a brace which holds your foot at 90 degrees thus gently stretching your achilles tendon and plantar fascia. Patients find the splint is very easy to wear especially when reading, watching TV or sleeping. I find the dorsal night splint to be the most comfortable. Google "night splint for plantar fasciitis" for a listing of suppliers.
Massage therapy and physical therapy are also beneficial in reducing the inflammation and relieving the tight plantar fascia. Injection therapy is an option if the above does not relieve your symptoms. While I am against injecting a steroid directly into a tendon, I do often inject the plantar fascia. The injection will usually reduce the inflammation to a point where conservative measures can now work more effectively. Again, the key is reducing the inflammation.
Surgery is sometimes necessary to resolve plantar fasciitis which is not improving with any of the above treatment measures. Only about 5% of patients require surgery. In general there are two types of surgical procedures:
The first is aimed at cutting part of the plantar fascia thus elongating the ligament (picture cutting through one half of a large rubber band).
The other surgery involves no incision, but rather a series of shock waves is applied to the heel. The body does not respond to chronic inflammation very well, however it does respond quite well to acute inflammation. The shock wave therapy is aimed at changing the chronic inflammation into acute inflammation so the body can begin to heal.
How to avoid a recurrence
OK, so now you have finally gotten rid of the dreaded plantar fasciitis, how can you stop it from recurring? As always, watch your training, stretch gently and replace your shoes when needed. Having said all that, I have become a big advocate of running barefoot for short periods of time each week. When a foot is encased in a supportive shoe with a heel, the muscles of the foot do not have a chance to strengthen. Try standing on one foot without shoes. Do you wobble a lot? This may be due to weak muscles in the foot. Running shoes with a high heel can predispose a runner to achilles tendonitis and plantar fasciitis by shortening these tendons and ligaments. I am not saying get rid of your favorite shoes! I am suggesting gently running a half mile or so barefoot on a soft surface once or twice a week. This will strengthen muscles you never knew you had as well as teach you to run gently thus allowing your foot and leg to absorb shock rather than relying on the shoe.
Remember: early recognition of the symptoms is key to healing quickly!
Previous articles from Dr Chris:
Chronic Achilles Tendonitis