Ask a PT: Is There an Actual Cure for Plantar Fasciitis?
Physical Therapist Dr. Marc Robinson answers your questions about running, chronic pain, injury prevention & training in our monthly column.
Question 1:
I’ve been diagnosed with Pes Anserine Bursitis. I am writing this after trying every stretch, exercise and rest that has been prescribed, and have even bought two new pair of shoes. Please, what can I do for my knee to feel normal again?! I have gone to see so many professionals (but no PT’s) and I have not seen improvement…please can you help me?!
— Tom, 34
San Diego
Answer: Dr. Marc Robinson
Hi Tom,
Thanks for your question. I can understand how you must feel. The Pes Anserine is the insertion point of the gracilis, sartorius and semitendinosus. Pes Anserine Bursitis occurs from inflammation of the bursa under the insertion of these tendons on the inside of the knee below the knee joint. Because I’ve seen pes anserine bursitis misdiagnosed many times, I wanted to share a quick review of what it is and what its symptoms include.
One study showed that the prevalence of pes anserine bursitis was 2.5 percent as detected by an MRI. It is interesting to note that only 2.5 percent of people with symptomatic knees actually had pes anserine bursitis. There is a possibility that the pain may be coming from the knee joint or the lower back. The medial meniscus and MCL should be ruled out as sources of pain. In addition, the lower back should be ruled out as it can refer pain to the inside of the knee due to complex nerve pathways. A physical therapist can help differentiate these potential sources of pain.
I can provide general recommendations under the assumption that you have pes anserine bursitis as diagnosed by a licensed physician. Tightness in the hamstrings can lead to excessive pulling at the insertion of the semitendinosus. Hamstrings tightness may be related to a literal shortening of the muscles; however, many times the feeling of tightness is related to another factor such as weakness of the core or glutes. The tightness experienced may be a symptom of excessive tone and overuse of the hamstrings as a compensation.
Strengthening the core, glutes and hamstrings can be beneficial to alleviate the feeling of tightness. If the hamstrings are contributing to the symptoms, then progressive loading of the hamstrings with concentric and eccentric exercises can help. In addition, the hamstrings can be stretched statically and dynamically.
In most cases of knee pain, hip strengthening is recommended. Exercises such as bridges, clams, fire hydrants, squats, hip hikes, and single leg exercises can help reduce stress to the knee and improve running performance. The dosage and specific progression of these exercises will vary depending on strength level and symptom response.
Another recommendation is to improve running mechanics. Poor running mechanics can lead to repetitive stresses to the knee. The improvement of running mechanics will help to reduce excessive stress to the knee allowing the injured tissues to heal.
As you can see, you have different options to recover from this injury and subtle changes in your recovery program can make a big difference. If the symptoms persist, try a one-on-one consult with a physical therapist.
Stay active,
Dr. Marc
Dr. Marc Robinson is a Physical Therapist in San Diego, CA who provides online physical therapy and virtual consultations for those who need on-demand help with injuries. His company, Evercore offers online injury prevention courses and fitness products to promote a pain-free, active life. They specialize in low back pain and helping their clients achieve health goals beyond what the traditional medical system can offer.
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Question 2
Aloha,
I’ve had plantar fasciitis for just over three months. It started from a rundown pair of Brooks, the cushion felt super hard during a run. The pain came almost immediately after the run. I dumped the shoes and have been going easy on it, spreading out runs further but the pain hasn’t disappeared, and sometimes it gets sharper the morning after a run and sometimes nothing, no pain.
The pain subsides after two or three days, [and by the] fifth day does result in less/no pain or pain. [This] seems to depend on the shoe I wear. I use some inserts specific to plantar fasciitis in my walking shoes, which do help the pain subside faster. I started toe raises and try to stretch my foot.
Is there an actual cure or am I going to have to learn how to live with it? And should I ice it? Is there a routine to do after a run that could help reduce the pain. Also [does] diet have any impact on the condition?
Thanks for any insights.
–Edward C.
Wailea, Maui
Answer: Dr. Marc Robinson
Hi Edward,
Thanks for your question. Pain on the bottom of the foot—usually by the heel—in the morning or after the first few steps in the morning is a common symptom with plantar fasciitis. Plantar fasciitis typically results from connective tissue in the bottom of the foot breaking down. It appears there was an initial onset of injury from running in the pair of worn-out Brooks. At that time, you may have overstressed the plantar fascia or muscles in the bottom of the foot leading to a disruption in the integrity of those soft tissues.
Time and progressive loading of those structures will usually help those tissues to strengthen and adapt as you return to their normal running volume and intensity. Initially, you may need to unload and reduce the amount running. Taping or using shoe inserts can help to protect and unload the plantar fascia as the tissue heals. The inserts seem to be helping you already. As the tissue gets stronger, you can gradually increase the volume and intensity of training.
In addition, calf stretching can help to reduce the strain on the plantar fascia. The calf muscles become the Achilles’ tendon and the Achilles’ tendon attaches to the plantar fascia. By stretching the gastrocnemius and soleus, you can reduce strain on the plantar fascia. In addition, calf stretching can help improve ankle mobility.
Research supports the use of manual therapy as an effective treatment for plantar fasciitis. In the clinic, I have found aggressive instrument-assisted soft tissue mobilization (IASTM) to be effective. This involves using a metal tool to scrape or massage the bottom of the foot near the location of pain to stimulate a positive change to the tissue.
As a home exercise program, I recommend that my clients roll the bottom of the foot on a tennis ball or frozen water bottle to replicate the effects of this treatment. Please note the frequency and intensity of self-mobilization is important and depends on the response of the tissue. You would not want to keep rolling out the bottom of your foot if the pain worsens.
The same principles apply to stretching the plantar fascia. Gentle or more aggressive stretching may be indicated depending on the length of the plantar fascia. Is it too long or too short? The plantar fascia may be overstretched already, in which case one may not want to stretch it out more. An assessment helps to clarify these variables in treatment.
Yes, you can overcome plantar fasciitis and return to pain-free running; however, it will be beneficial to continue self-care strategies to stay out of pain. Ice can be used if you want. Ice is not going to harm you if applied properly. Nutrition plays an important role in the healing process of any injury. It will be beneficial to stay hydrated and minimize the consumption of processed foods and refined sugars. Maintaining a healthy pattern of eating, minimizing weight gain, reducing stress, and getting adequate sleep will promote an optimal environment for healing.
To help prevent plantar fasciitis, I would recommend the following:
- Stretching the calves before and after running
- Strengthening the muscles of the foot with exercises like toe curls, arch lifts and calf raises
- Strengthening the gluteal muscles
- Wearing proper shoes
- Improving running mechanics
- Dosing exercise and running appropriately
In summary, plantar fasciitis is multifactorial. Weakness of the foot muscles, poor activation of foot muscles, excessive pronation of the foot, decreased ankle mobility, shoe wear (as you learned the hard way) contribute to plantar fasciitis. Self-care may be sufficient for you to return to pain-free running; however, you may want to consider an assessment by a physical therapist who can isolate your specific weaknesses and help you improve those areas for the best long-term outcomes.
Keep moving,
Dr. Marc
Dr. Marc Robinson is a Physical Therapist in San Diego, CA who provides online physical therapy and virtual consultations for those who need on-demand help with injuries. His company, Evercore offers online injury prevention courses and fitness products to promote a pain-free, active life. They specialize in low back pain and helping their clients achieve health goals beyond what the traditional medical system can offer.
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