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The Truth About Plantar Fasciitis

We take a deeper look into one of running's most stubborn injuries.

Overuse injuries are the great equalizer, taking out the elite and weekend warrior alike. Most runners experience their share of injury, and although many of these conditions can be nagging, few are more so than plantar fasciitis.

But while plantar fasciitis is common—comprising 10 percent of all running injuries—its underlying cause is still a matter of debate and it remains very difficult to treat.

What experts agree on: plantar fasciitis is an irritation of the support system of the bottom of the foot, resulting in pain at the bottom of the heel and foot.

What they don’t agree on: whether or not the condition is the result of chronic inflammation as originally thought, or repetitive trauma that results in chromic degeneration or weakening of the tissue.

What’s important: a lasting fix requires more than just anti-inflammatories and ice. And while the underlying cause may seem unimportant to the average sufferer of plantar fascia injury, fixing the problem relies on determining the responsible process.

The First Round

For Sam Hudspath, an age group runner in Alexandria, Va., it all started with long days standing in hangars and flight lines as an Air Force officer. Add that to flat feet and hard military footwear and that’s a recipe for plantar fasciitis. At the time, Sam’s running program was about 20 miles a week but due to his schedule, he usually made these efforts intense to make up for less time on the roads. When the pain started, he tried to fix the problem by running slower and icing. He didn’t make any connection between the stresses of his daily work and the injury.

“I thought it was a running injury, period,” Sam says.

As with most sufferers of plantar fascia pain, Sam experienced the greatest discomfort in the morning and after runs.  A podiatrist dispensed orthotics and a night splint and advised him to stop running but did little to guide him on stretching, foot structure, or foot strengthening.

“The first phase of treatment should involve taking pressure off of the aggravated tissue. While orthotics can be helpful, I also recommend specific arch taping (Low-Dye) that can be worn throughout the day,” emphasizes Dr. Michael Fredericson, director of The Stanford Running Clinic.

According to a recent review article in the journal, Physical Medicine and Rehabilitation by Dr. Fredericson, the most effective treatment includes stretching of the calf and plantar fascia itself. The article goes on to recommend another common treatment—arch support—stating, “Good evidence exists that foot orthotics may be useful as a treatment for plantar fasciopathy.” In the research summarized by the article, arch support was most effective when combined with stretching.

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After visiting several podiatrists for repeated bouts of plantar fasciitis, Sam states, “I haven’t found them to be very forthright in prescribing physical therapy,” adding, “I definitely believe strong feet and ankles, as well as improving range of motion has a positive impact all the way up the kinetic chain.”

Although much of the research into the treatment of plantar fasciitis focuses on stretching, cortisone injections and orthotics, foot strengthening remains a largely unexplored topic.

One article that does address the subject, a 2013 study published in the British Journal of Sports Medicine, calls for increased use of “foot core” strengthening in the treatment of plantar fasciitis. The article concludes, “While temporary support (arch support) may be needed during the acute phase of an injury, it should be replaced as soon as possible with a strengthening program just as would be carried out for any other part of the body.”

The author of the article, Dr. Patrick McKeon, believes that strengthening the intrinsic muscles of the foot lessens the stress to the plantar fascia. “The plantar fascia has to passively stabilize the foot with every stride and strong foot muscles reduce that demand by adding an extra layer of support,” says Dr. McKeon.

For Sam, his first bout of plantar fasciitis seemed to go away on its own after about a year.  He doesn’t recall a specific treatment working better than another, or what he did to help it along.  But, like many, that wouldn’t be the first time that Sam had to deal with the problem.

That’s when what perhaps started as an inflammatory process became a chronic degenerative condition—one that could possibly be nipped in the bud before it becomes recurring.

“Stretching, particularly the plantar fascia, and foot strengthening play an important role in the prevention of future foot problems,” says Dr. Fredericson.

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Chronic Problems

After starting to take fitness and training more seriously, Sam started following a 20-week Greg McMillan training plan and earned a Boston Qualifier time at the Sugar Loaf Marathon in May 2014.  For cross-training, Sam bought an ElliptiGO and began seeking advice on how best to prevent injury. Dedicating more time to stretching and foot strengthening, Sam included more work with resistance bands, soft-tissue massage, balance and stretching. He started working with McMillan coach Jacob Puzey in October of last year, incorporating both ElliptiGO and deep water running into his training plans. These have helped Sam maintain his fitness after several setbacks on the road to full recovery.

Currently, Sam has been able to maintain 30 miles of running a week with a couple hours of cross-training. He still believes that working with a physical therapist will help him correct the muscle imbalances that are still present following his long history of foot problems.

For Sam, and other runners that battle plantar fasciitis, taking the time to implement all the components of successful treatment increases the odds that the problem won’t become chronic. Addressing both the mobility and stability of the foot will hopefully allow most to recover without any injections, surgeries or other invasive treatments.

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