Plantar Fasciitis in Runners

Correctly referred to as Plantar Fasciopathy (FP) or Plantar Heel Pain due to there been an absence of inflammatory cells in this condition. This is an overuse condition of the plantar fascia at its attachment to the calcaneous (heel bone).

PF is a common condition amongst runners and can be often challenging and frustrating for both injury therapist and runner. The plantar fascia plays an important role in normal foot biomechanics, offering static support and dynamic shock absorption during the foot’s contact phases of running. The plantar fascia may be overloaded at the push off phase when the toes are dorsiflexed (pulled up towards the shin) and the calf muscles are the main contributors to propulsion

The development of PF appears to be linked with increased load on the plantar fascia. This can be due to a number of things like increased mileage, poor or worn down trainers, muscle weakness and poor motor control. However some recent research suggests we may be able to change how we run to help combat this injury?

Although we may associate PF with increasing mileage too quickly a study by Nielson et al 2013 suggests we also need to consider rapidly increased running pace. Other injuries that maybe affected by this speed change include Achilles tendinopathy and calf injuries. It was found that marathon runners were at less risk of PF compared to runners running shorter distances, suggesting PF is more easily developed at shorter distances.

This leads us to the next study which asks ‘is it possible to alter the loading on the plantar fascia?’ A study by Wellenkoiter 2014 suggests a 5% increase in cadence (steps taken) may benefit. For me this flags up a few questions, how do you increase your cadence and does this go against the above paragraph by increasing cadence, does this increase you speed? Are you sacrificing stride length to increase cadence? Is this about reducing foot contact time and how does this affect how much force you push off with, which in turn gives you your propulsion forward?

Another study by Crowell 2011 found running with a softer/quieter footfall reduced vertical loading rate which can be linked to PF. I would love to see how you would explain and get your average runner to try and land more quietly without them looking like they are prancing around.

The findings from the studies above do sound like positive solutions for runners suffering from PF but for your average runner they may be hard to practically implement. Running style and technique are very hard to change. There is also no evidence it will improve pain or function in PF.

This next study suggests a more practical and effective way to treat PF. Rathleff et al 2014 looked at high load strength training compared to a standard plantar specific stretching program in the treatment of PF. The stretch group were told to sit with the affected leg over the other and grasp the base of toes and pull them up to wards the shin for 10 seconds repeat for 10 reps and perform 3 times a day. The high load strength group performed a heel raise off a step with a towel under the toes to mimic the high load phase on the plantar fascia. Each rep would take 3 seconds going up, hold for 2 seconds in the up position and lower back down taking 3 seconds. Every other day they would perform 3 sets of 12 reps and throughout the weeks they would progressively add weight by using a back pack loaded with books (set and reps were adjusted accordingly). At 3 months the high load group were showing better results but at 6-12 months there were no differences in outcome. If you were to choose between two treatments that have similar long term effects but one will give a quicker reduction in pain, it makes sense to prescribe the one with the quickest reduction in pain.

Conclusion

Each person seen with PF needs to have their own treatment approach to suit them, if they have brought in speed work too soon, it may have been the trigger. If they have a slow cadence and/or land very heavily then getting to them to speed up their cadence and land lighter may help. Implementing a progressive loading program to strengthen the plantar fascia and structures around (calf, hips, core.) to cope with load may play a more effective approach.

Tips for runners with plantar fasciitis from the study by Rathleff et al 2014

  1. It is important to complete the exercises instructed to you by your injury therapist. It is more likely that your heel pain will decrease if you comply.
  2. You should not run before your heel pain has been pain free for 4 weeks and you can walk 10k without pain during or the morning after. (pain scale 3-4 /10 acceptable, 5 and above not acceptable)
  3. If you need to wear flat shoes (dress shoes) use heel gel inserts in both shoes.
  4. It is important to keep your exercises going even if your pain might have gone, this will decrease risk of recurrence
  5. Use the pain scale guidance. Some pain 3-4/10 is acceptable but let us know if pain suddenly gets worse after the exercises and lasts for more than 24 hours.
  6. Make sure you are performing your exercise correctly
  7. It is important to try and avoid activities which cause your heel pain to flare up. When you want to start up with these exercises again you should be careful and slowly progress. Refer to number 2 which can be used to help you understand when you are ready run again.

 

Studies referenced

Rathleff et al 2014. High load strength training improves outcome in patients with plantar fasciitis: a randomised controlled trial with 12 month follow- up. Scand J Med Sci Spor. doi 10.1111/sms12313

Nielson et al 2013. Classifying running related injuries based upon etiology, with emphasis on volume and pace. Int J Sports Phys Ther Apr; 8 (2);172.9

Wellenkotter et al 2014. The effects of running cadence manipulation on plantar loading in healthy runners. Int J Sports Med. Aug;35(9);779-84

Crowell et al 2011. Gait retraining to reduce lower extremity loading in runners. Clin Biomech (Bristol, Avon). Jan;26(1);78-83