Plantar Fasciitis – From Injury to Recovery
It all started with a niggle in my foot. The underside of the right foot to be precise, with a dull ache in the heel/arch area. A few days of persistent (no, stubborn) running later, I awoke and got out of bed only to sit right back down again due to a shooting pain across the bottom of my foot, like an ice pick in my heel/arch.
I sought out my physiotherapist for a consultation and found out that I had Plantar Fasciitis – one of the most debilitating injuries for runners.
If you are interested, you can read my blog post.
Plantar Fasciitis : What is it?
Plantar Fasciitis is an inflammation of the plantar fascia, which left untreated and with continued running, can lead to a tear or even a complete rupture. Common symptoms are dull pain in the heel/arch area that progresses to acute pain in the heel if the causative factor is not removed. This pain is often present upon waking and taking the first few steps, but can ease off as the plantar fascia warms up and stretches.
Constant inflammation, ongoing tears and/or ruptures can lead to calcification of the area, which can result in bone spurs on your heel. These bone spurs may not necessarily be painful however they result in a permanent shortening of the plantar fascia and a corresponding loss of range of motion.
One Step Back : What is a Plantar Fascia?
The plantar fascia is the structure that forms the basis of the arch of your foot. Connected to your heel is a strong fibrous sheath (the fascia) that fans out towards your toes. The plantar fascia is crucial for controlling pronation (the way your foot/ankle/lower leg move on foot strike), acts as a shock absorber when you land and, when in the toe-off phase of your gait, returns energy to your stride like a spring.
The plantar fascia is ‘dynamic’ throughout your gait (your running motion) meaning that it changes shape throughout the cycle of your gait. When your foot contacts the ground the fascia begins to elongate (stretch), and continues to elongate until just after mid-stance when your foot is flat on the ground and weight is evenly spread.
This elongation on foot-strike absorbs shock and stores energy from the impact via the elongation, like a stretching spring. As you move past mid-stance and your weight begins to roll forwards into the toe-off phase of your gait, the plantar fascia begins to tighten, returning some of the energy stored. As you prepare to strike the ground again the toes flex and the plantar fascia becomes tense through the windlass effect, resulting in elevation of the arch and shortening of the foot, ready for the next cycle.
Plantar Fasciitis : Why does it happen?
The cause can be different for different people, and affects both runners and non-runners, although runners are predisposed to developing the condition due to the repetitive strain of running.
In runners, common causative factors are over-training, radical changes in training (be that in type or volume, or both) or ongoing excessive tension in the calf muscles and Achilles heel (calf tightness or restricted range of motion through the Achilles causes an upwards pull on the rear of the heel, causing additional strain on the plantar fascia).
While plantar fasciitis is normally associated with repetitive strain of the plantar fascia over a long period of time, sudden attacks have been known to be caused by intensive hill workouts or runs on uneven ground.
Hill running adds additional stress to the plantar fascia due to the elevated angle of the foot required for foot strike, keeping the calf muscle elongated. This adds additional resistance against the plantar fascia as it tightens in the toe-off, and can cause micro-tears. During an intensive hill workout these micro-tears can quickly develop into larger tears.
Uneven ground, particularly constant running across a slope, can cause additional pronation that strains the arch of the foot as it must stretch more facilitate the additional pronation. If you find yourself running the same routes make sure to switch sides of the road regularly in order to ensure you are not always running on the same camber.
How to cure Plantar Fasciitis : finding the silver bullet
Hopefully you are reading this article because you want to prevent getting plantar fasciitis, however if you are only here now because you already have it then don’t despair – You’ve joined thousands of runners who have plantar fasciitis, and with good treatment, a well structured recovery and follow-on preventative care you will hopefully join the many thousands of runners who have found the silver bullet to kill off this injury.
There are 3 phases in the treatment of plantar fasciitis:
- acute phase
- sub-acute or chronic phase
- recovery phase
After your recovery you will need to enter a maintenance routine to prevent recurrence. If you don’t have plantar fasciitis then pay attention to the prevention section below as a way to avoid getting it.
The acute phase
During the acute phase the main focus is to control inflammation and decrease pain. During the latter part of the acute phase you can begin other exercises and stretches to increase your body’s repair rate. If you have access to a physiotherapist, visit them as soon as possible and as often as possible. Plantar fasciitis often responds well to early treatment, especially if it is being caused my chronic muscle tightness. Following the below steps will help you get through the acute phase faster and get you to the recovery phase sooner:
- Stop running – Don’t run during the early acute phase of the injury. For most runners, this will be 3-7 days. If it hurts to walk, then don’t think about running. I use Ibuprofen to reduce the inflammation and help with the pain, though this isn’t for everyone. Speak with your pharmacist and whatever you do, don’t exceed the maximum dose!
- Cold therapy – Ice your arch and heel for 20 minutes three times a day. If you can, cycle the icing as 20 minutes ‘on’, 20 minutes ‘off’. Use an ice pack if you can, it gets into the contours of your foot better than ice blocks. If you can stand the cold and discomfort, put your whole foot into a bucket of ice water. If the pain has subsided enough to take pressure and massage, freeze a polystyrene cup of water, peel off the top centimetre and use that to give yourself a foot massage. If you can handle it, use the sharp edge of the ice block to massage deep into the plantar fascia.
- Rest, but don’t slob! – If you have a cross training regime (if not, now is the perfect time to start one!) keep going with your strength and core routine, making sure to skip any calf exercises or foot exercises that involve too much weight bearing on your foot.
- Eat and sleep well – Your plantar fascia is trying to heal itself, so don’t use your time off running to eat out and party on. Stay healthy by continuing to eat right and getting enough rest. Your plantar fascia is largely collagen in nature, so you can try collagen supplements. There is little to no evidence to suggest supplements like this have any effect but if you think it helps (and doesn’t hurt) then feel free. I’m a big believer that positive frame of mind helps active healing so if you think it is helping then it probably is.
The sub-acute or chronic phase
Once you are over the acute phase you move into the sub-acute phase. Depending on the severity of your fasciitis it may clinically be referred to as ‘chronic’ if it is ongoing for more than about four weeks. Regardless of the timescale, this phase is identified by ongoing pain, continued restriction of movement and an inability to return to pain-free running. Once in the sub-acute or chronic phase you can commence more exercise, but whatever you do, don’t go running! Here is what you should be doing instead:
- Active Rest – Once you are past the acute phase and the pain and inflammation have subsided, get into an ‘active rest’ routine that includes cycling or swimming. These workouts should be about the same time and intensity as your running to keep your cardio fitness up. You can try pool running as well if you have access to a suitable swimming pool. Just because your substitute exercise isn’t running, don’t neglect a proper warm-up including dynamic stretching, and a proper cool-down.
- Foot-specific exercises – After your cool-down, spend 5 or 10 minutes doing foot exercises to strengthen your feet. Good exercises include scrunching your towel with your toes or picking up a golf ball or marbles. Do your injured foot first, and then match the reps and time for your good foot. This will allow you to determine how much imbalance exists between both feet (to gauge recovery) and make sure you don’t train your good foot more than your bad foot. Symmetry is everything in running!
- More ice, more massage – Ice your feet and do tennis or golf ball massage. Make sure to massage around your arch and the base of your heel. If you can handle the pain, get stuck into the areas that are sore or feel lumpy or knobbly. These areas are scar tissue forming and need to be broken up. You can be aggressive but don’t massage so hard that it causes a wincing pain. Find the right balance between deep massage and excessive pain. Remember, if you have iced a lot and your foot is still a bit numb, go a bit easier as your nerves will be a bit deadened and you might be massaging harder than you think. If you have a foam roller then use it extensively on your calf muscles.
- Static stretches – keep going with your static stretching routine, focussing on your upper and lower calves and stretching your Achilles heel. You should be doing these throughout the day and at night-time. Remember; don’t do static stretches closer than one hour to a work-out.
- Eat and sleep well – same as the acute phase – keep looking after yourself and helping your body to heal.
This routine is about getting you going and getting you running as fast as possible, and it’s what I used to get over the acute and sub-acute phase of my plantar fasciitis as quickly as possible.
However – words of warning – this is a pretty demanding routine and probably a lot more than your doctor would prescribe. Maybe more than some physiotherapists as well, however I doubt there would be many sports physiotherapists or injury rehabilitation specialists that would have a problem with this routine. Mine certainly didn’t.
As always, make sure to speak to the medical professionals you trust before you start!
The recovery phase
The recovery phase is the period during which you return to running and ends when you have recovered to your previous ability. Depending on the severity of your injury or the cause, this could be merely weeks if caused by an over-training or over-stress injury or months if your injury was caused by a biomechanical problem, like over-pronation or excessive tightness through your calf and Achilles.
The best recovery will be made in partnership with a physiotherapist or injury rehabilitation specialist, they will be able to guide you on specifics and monitor your recovery. If you don’t have access to one, then just keep reminding yourself that this issue will take some time to get over and to take things slowly. Pay close attention to your recovery. If your recovery plateaus or regresses, you are probably doing too much, too soon and you need to ease up.
- Identify the root causes – work with your physiotherapist to identify the root causes. Be honest about what you were doing preceding your injury. Did you rapidly increase your training, were you always running on the same camber, was your warm-up and cool down routine poor? Were you neglecting your cross training or static stretching routine? Is your daily footwear lacking in support or are your trainers worn? Anyone who has read my blog post knows I did all the above things, and look where it got me!
- Implement change – after working out what went wrong, implement the changes to make it right. Remember; don’t change too much, too soon. The body is remarkably adaptive, but it won’t change to suit new things overnight. Have patience and persevere with your treatment.
- Biomechanics – If one of the root causes is biomechanical then have your sports physiotherapist analyse your gait. Some good running shops can do this as well (In the UK try Sweatshop or Runners Need), they will be able to suggest shoes to suit your running style. Some people respond well to shoe inserts or orthotics so discuss this with your physiotherapist or podiatrist as well.
- Warm up and cool down routine – Always do a thorough warm-up and cool-down. If you don’t have time to warm-up and cool-down, you don’t have time to go for a run. Instead, try doing cross training or core/stability training for that workout. Make sure your warm up includes dynamic stretches, not static stretches.
- Cross training – if you don’t do cross training but do a fair bit of mileage, chances are you are going to get injured again. Core strength is very important to runners, as is having strong stabiliser muscles. Look into developing a cross training routine for days you aren’t running and you won’t regret it. It also adds some variety to your training so boredom is less likely to be an issue.
- Start slowly – When you start running again, limit your speed and distance during the first week. Pay careful attention to your plantar fascia during this period. If you have recovered sufficiently then it should be fine running slowly. You may have some pain during or after your run; make sure the pain level is less after each run otherwise you are going to reverse your recovery. Make sure to keep massaging your foot and heel with ice and a tennis/golf ball. If you have a foam roller, then use it! Focus on your calf area to make sure they are supple and not contributing to stress on your plantar fascia.
- Static stretching routine – Your running routine should involve static stretching sessions anyway (after runs, never before!), however as clinical treatment for planter fasciitis often revolves around stretching of the calves and elongation of the Achilles heel you should focus on this area. Your physiotherapist will advise you if this is an issue and prescribe specific stretches and exercises, or if the condition is chronic may even prescribe the use of a night splint.
Hopefully with all of the above you will be able to recover swiftly to your pre-injury ability and will return to enjoying your running fully!
With your recovery complete, it is time to enact a maintenance and prevention routine to make sure you keep your plantar fasciitis at bay!
Plantar Fasciitis : Prevention is always better than a cure
Hopefully you don’t have plantar fasciitis, however if you’ve read this far I suspect that you have. The good news is though, if you are through the recovery phase then, well, you’ve recovered!
As with all injuries, prevention is always better than a cure! If you have recovered from your plantar fasciitis you will need to undertake ongoing maintenance to prevent any recurrence. If you are lucky enough not to be a sufferer, these preventative measures will help you to keep free from plantar fasciitis. They are also good for general lower limb strength and flexibility so may help you prevent other lower limb injuries as well.
- Release your feet – all that running in amazing fancy trainers actually weakens your feet because they are not subjected to the ‘barefootedness’ that our ancestors survived day-in, day-out. As plantar fasciitis is often caused by weakness in the foot or lower leg musculature, try running barefoot strides or repeats 2-3 times per week on grass, during or at the end of your run. While you’re at it, try some barefoot walking lunges as this will activate all your stability muscles at the same time as working out your feet. If you are an experienced runner, try adding a 10 minute barefoot session into your speed work or fartlek training session.
- Stay loose – follow a good dynamic stretching routine before running, and a good static stretching routine afterwards, paying special attention to calf, Achilles and plantar fascia stretches. If you have a foam roller use it to work on your calves, and make sure to continue with your tennis/golf ball massage.
- Strengthen you feet – keep up your foot exercises, especially if you are unable to do barefoot workouts.
- Cross train – runners who only run are more likely to get injured as big increases in endurance can be made with relatively less improvement in core strength and stability. Cross training with low-impact cardio work, strength workouts, core strengthening sessions and stability exercises will help you be a better runner, and will help you to minimise the risk of injury.
- Beware of the slope – make sure not to run across the same camber all the time. Doing this keeps your feet tilted in the same direction all the time, stressing your plantar fascia, as well as your hips, ITB and other muscles. If you can, run in the park or on trails. The uneven surfaces will work your stability muscles more making you a stronger runner, the surfaces are generally softer than tarmac or concrete so won’t contribute as much to overuse injuries, and the more pleasant environment will make your runs more enjoyable.
- Slowly, slowly – always increase your training gradually. Plantar fasciitis is often caused by overuse or by excessive calf and Achilles tightness. Keep your increase in mileage to a maximum 10% increase in mileage per week. Definitely don’t try to increase speed and mileage at the same time. If you are preparing for a race, work on your speed before you start your mileage increases. Trying to run further and faster during a race build-up is going to add double stress to your feet and calf muscles.
With frequent and aggressive treatment during the acute phase, ongoing effort during the sub-acute or chronic phase, a structured recovery and ongoing preventative maintenance, you should be able to return to your previous ability without any lasting effects. As the preventative tips include cross training, core strength and stability training, you might even become a better runner if you aren’t doing these things already!
All the best for your return to injury free running!
Get Going, Get Running!