Plantar Fasciitis in Runners Over Explained

**Disclaimer, if you are experiencing pain, you should go to your primary care and get it checked out**

Hi, guys. Back with another installment of "Running Injuries Explained." 

Just in case you have missed any other articles in these series: 

IT band pain

Achilles Tendonitis

Shin Splints

This time I'll be talking about the dreaded Plantar Fasciitis... That sharp shooting pain at the bottom of your foot making it feel like you are walking on eggshells in the morning.

It's pretty popular among runners. Unfortunately, around 10-19% of runners will deal with plantar fasciitis during their running lifetime, making it the third most frequent running injury. [1]

The good news is most cases resolve without surgery (only around 5-10% require surgery). The bad news is research shows it can take approximately 6-18 months to heal. [2]

You may be thinking, "Wow, that's a lot of time." And I would have to agree with you. Six-eighteen months seems long to me. Once you actively start to fix your plantar fasciitis, you should notice an improvement after three weeks. Total resolve should take around 2-6 months, depending on how severe it is. Generally, the longer it has been going on, the longer it takes to heal. 

Either way, the best treatment for an injury is understanding it. So that's my goal in this article. Explain what plantar fasciitis is, the function of the plantar fascia, how the plantar fascia becomes injured, and provide some research-backed treatment approaches.

Plantar Fasciitis Definition

So what is plantar fasciitis?

We'll grab the definition from the Mayoclinic website here: 

"Plantar fasciitis (PLAN-tur fas-e-I-tis) is one of the most common causes of heel pain. It involves inflammation of a thick band of tissue that runs across the bottom of each foot and connects the heel bone to the toes (plantar fascia)."

This is a good definition. The only thing I don't like is the inflammation part. There is no actual inflammation with plantar fasciitis [3]. So it makes sense why anti-inflammatories don't work.

Also, it should go without saying the thick band of tissue they refer to in this definition is the plantar fascia. You know, the structure plantar fasciitis is named after. 

So what is it?

Anatomy of the Plantar Fascia

The plantar fascia is a strong band of fascial tissue on the sole of the foot that forms a strong linkage between the heel and the toes [4]. 

It has three bands, the main band being the central band. [3] This central band is sometimes quoted as being a continuation of the gastroc. However, some studies have shown the central band develops independently of the Achilles in adults as a separate structure. [4] Honestly, the whole plantar fascia as a continuation of the Achilles is still pretty up in the air.

Characteristics of the Plantar Fascia

• Fascial tissue is not muscle. It can not contract, and it doesn't stretch well. Think of fascial tissue as a rope versus a muscle is like a rubber band.
• The plantar fascia can change its composition based on external demands, thickening to high stress and becoming thinner without use. [5]
• The plantar fascia has nerve endings. The nerve endings are capable of sending pain signals to your brain. They are the reason plantar fasciitis hurts. [6]
• The plantar fascia has poor blood supply where it attaches to the heel, making the area prone to breakdown. The reason plantar fasciitis occurs at its attachment point at the heel. [7]

What is the function of the plantar fascia?

So we've identified where the plantar fascia is and some of its unique characteristics, but how exactly does it function to help us? 

The plantar fascia is a unique structure in its function. 

It has two main ones: 

1. Act as a supporting structure for your toes during propulsion 
2. Act as a truss on a bridge when you land to absorb energy

In the anatomy world, we refer to the plantar fascia's ability to absorb and generate force as the windlass mechanism. I think it's named after a type of winch on a ship.

Please don't quote me on that. I'm a PT, not a captain. 

But here's how it works... 

It's crucial to understand where the plantar fascia is to grasp the windless effect of the plantar fascia.  

So I'll repeat it again. 

The plantar fascia starts at the heel. Then runs along the bottom of your foot and hooks around the base of your toes. Finally, attaching to the bottom of your toes. 

When you land while running, your toes are flat. Your foot with flat toes allows more slack of the plantar fascia. This allows more give for the plantar fascia to stretch, causing the arch to flatten. This allows the plantar fascia to absorb your body weight.

On the other hand, just before you take your next step, your toes are extended upward. Your toes stretched upward cause the plantar fascia to get pulled around the base of your toes and tighten, creating a higher arch. This mechanism creates tension on the plantar fascia and propels you forward. 

How can you tell if you have Plantar Fasciitis

Obviously, getting your foot checked out by your doctor is important. But I get it, waits to see someone are long, co-pays are rising, and if you can figure it out yourself, why not?

The main things you need to be looking for: [8]

• Pain in the heel or bottom of your foot while taking your first steps in the morning or after prolonged sitting 
• Pain with the windlass test (see picture for explanation)
• Pain when you press on the middle part of your heel

How does plantar fasciitis develop?

Now that you understand the anatomy and the function of the plantar fascia, you can understand how plantar fasciitis develops.

When we run, around two to three times our body weight is absorbed with every step. The plantar fascia is a primary absorber of this energy. 

For this force to be absorbed, the foot rapidly flattens while you land, causing the plantar fascia to stretch. However, the plantar fascia does not stretch well because of its makeup (remember, it's like a rope). The inability of the plantar fascia to stretch causes a lot of tension at the heel bone. 

With an adequately flexible plantar fascia, strong intrinsic foot muscles, and a robust heel bone, you can handle the tension produced by the plantar fascia while running. However, weakness in any of these areas can lead to too much tension, irritating your heel. 

Once there is irritation, a slippery slope begins.  

Due to the poor blood supply to this area, the body has difficulty shuttling the proper amount of nutrients required for healing, and the area progressively becomes more irritated. The pain nerves we mentioned in the plantar fascia sense this irritation, and you begin to experience pain. 

And now you have plantar fasciitis. 

Without addressing it, the more you run, the worse the plantar fasciitis becomes. It may start as pain in the heel upon your first steps after sleeping and progress to constant pain along the bottom of the foot while walking. The more intense the symptoms are, and the longer they have been going on, the worse the plantar fasciitis is. 

Who is at higher risk of Plantar Fasciitis

When we talk about risk factors, there are two main types:

• Intrinsic Risk Factors - Risk factors that are a physical aspect of your body
• Extrinsic Risk Factors - Risk factors controlled by outside sources 

Risk factors are crucial because they can give clues about why the injury might be happening. Subsequently, they can tell you things you may need to work on or change to treat your plantar fasciitis. [3]

Treating Plantar Fasciitis

The good news is a majority of plantar fasciitis injuries resolve without the need for surgery or injections. [9]

The tricky thing about treating plantar fasciitis is figuring out what is causing it. Basically, you need to look at the risk factors and address all of those you possess. 

If you have a flat arch, you need to strengthen your foot's intrinsic muscles or maybe wear orthotics. Someone with a high arch may need to stretch their plantar fascia. It could also benefit to take a look at your training schedule. You may be ramping up too quickly or running too often and need to make adjustments. If you have high body weight, you may benefit from trying to shed some pounds via cross-training before you take up running again. 

Often, it is a combination of risk factors that sum up as a whole. Identify the ones you have and work on all of them. A good program for treating plantar fasciitis will use a combination of methods. 

It's like shooting spit wads at the ceiling in high school. Eventually, something will stick. 

But let's get into some treatment options. The good ones that don't require injections or surgery.

Stretching: Research has proven a tight plantar fascia and tight calf muscles put you at risk for plantar fasciitis. So why not stretch them? Plantar fascia and gastroc/soleus specific stretching have been proven to provide relief for plantar fasciitis. [10]

I've found stretching the plantar fascia is particularly helpful for those who have high arches. Some tell tale signs of a high arch are you are a "loud stepper" when you are barefoot, have calluses on the outside of your feet, or have wear on the outside of your shoes. 

Foot Intrinsic Strengthening: In 2014, a study by Latey et al. found a link between weak foot intrinsic muscles and plantar fascia pain. Therefore it would make sense to strengthen the foot intrinsics. [11] 

Intrinsic foot strengthening makes sense when you think about it from an anatomical standpoint. The plantar fascia and the intrinsic foot muscles help make up the foot's arch. Plantar fasciitis can be caused by too much flattening of the arch, irritating the heel from excess tension. By strengthening and activating the arch's intrinsic foot muscles, we can cause less flattening of the arch. Leading to less tension at the heel, ultimately getting you out of pain.  

Hip Strengthening:  Your hips play a huge role in the stability of your legs, particularly your knees and feet. We will focus on how the hips affect your feet. After all this is an article about plantar fasciitis. 

Strengthening the hips can help lift the arch and activate your foot's intrinsic muscles. If you're skeptical, go ahead and take off your shoes and socks and stand up. Note how far your arches are off the ground. Now, while standing, I want you to contract your glute muscles and look back down at your feet. You should notice your arches are now lifted higher off the ground. 

Someone who has flat feet will notice more of a change with this exercise but strong and active glutes are just as important for someone with high arches. High arches doesn't get you out of hip strengthening sorry. 

Lee and colleagues had a patient with plantar fasciitis perform hip strengthening for three months. With pressure sensors, they tracked the weight distribution of her foot. Check out the results. 

As you can see, over time, her pressure begins to shift from the inside of her foot to the outside. This is because she is gaining more support from the intrinsic foot muscles. More support on the intrinsic foot muscles means less demand on the plantar fascia. [12]

 Heel pads: Heel pads are a tool that can provide immediate relief from your plantar fasciitis. They work to alleviate pressure on the sensitive heel. While many who suffer from plantar fasciitis see less pain in the short term, heel pads don't seem to have great long-term effects. 

Think of heel pads as a band aide. Heel pads will help your pain but won't fix the problem. Think about it, if you have plantar fasciitis from weak or inactive glutes, inserting a heel pad will not make your glutes stronger.

I do like heel pads as an aide to help you treat your plantar fasciitis. They help you get out of pain quickly, allowing you to tolerate more activity. When you can do more, you can better work on weaknesses and actively recover faster. [13]

Taping: Anti-pronation taping can also provide immediate pain reduction. [14] You can check out this video to learn how to tape yourself. It is easier to have someone else tape you but completely doable by yourself. 

Anti-pronation taping works because it aims to unload the plantar fascia by lifting the arch. 

Foot Inserts: Either over the counter or custom fabricated foot inserts can work to support the foot's arch and cushion the heel. The research has shown foot inserts can reduce pain and improve function, particularly for those who respond to tapping. [15] 

I want to add custom foot inserts are expensive. If you do not have custom inserts, don't feel like you have to go out and buy a pair. The inserts you get from the shelf are just as effective as custom-made ones. [16] 

Factors you will want to consider are the rigidity of the insert, your arch height, the heel cup design, and the length of the orthotic.

I encourage you to read this article I wrote up here on choosing the best insert for your foot.

Night Splints: Wearing night splints has proven to be an effective method for treating your plantar fasciitis, especially for those with pain during their first steps in the morning. 

The hardest thing about night splints is they are uncomfortable to wear. They make what's called posterior and anterior night splints. Landorf and Menz found anterior night splints were more comfortable, with fewer reports of sleep disturbance. [19] Studies have shown relief when using night splints. [20]

There are many different types, and not all are built equally, so check out my guide here on the best night splints for plantar fasciitis. I will talk you through how to choose a pair. 

Anyways, hope you guys enjoyed and got something out of this. 

Until next time, 

Joe