Hard Facts For Fast Plantar-Faciitis Recovery

Stay the CourseWhen treating an injury–running-related or not–the four fundamentals of healthy joints must be addressed:

  1. Full range of motion. Restore normal range of motion to joints, tendons, and muscles. Full mobility equals maximum blood and fluid flow in and out of tissues.
  2. Strong, supportive muscles. Restore normal muscle activation and strength, not only to the specific injury, but all around it.
  3. Be normal. Efficiency is everything. Most injuries are the product of too much (volume and intensity) on inefficient loading. Using joints, limbs, and systems in their maximum-efficient way is crucial to performance and recovery. Conversely, inefficiencies stress tissue. Even worse, pain tends to create compensation, which can perpetuate and even worsen inefficient loading. Efficiency is the most important but most frequently overlooked or glossed-over element of injury recovery.
  4. Don’t overdo it. All tissues have a limit of activity. Individual tissues, like an athlete, have an element of fitness. Sometimes they can handle enormous loads (like running a 100 miler), but very quickly that tissue tolerance can dissipate, and the same tissue can only handle a 10-minute walk. Just as a runner gradually ramping up mileage, knowing one’s specific tissue tolerance and not exceeding it is vital for improvement without a flare-up.

Successful and swift recovery from all injuries requires this comprehensive four-dimensional approach, and constant (if not obsessive) diligence toward all four elements throughout the rehabilitation process.

Why Running Injuries Don’t Get Better: The Halfway Approach

When a runner is injured, it is too common to address only one or two of those four. On one end, orthopedic professionals–usually a (non-runner) doctor–will prescribe absolute rest, then a gradual return to running. However, upon doing so, the runner’s injury pain returns. Why? Because both doctor and runner failed to address mobility, strength, and efficiency.

On the other end, diligent athletes and their fitness-minded physios will exhaustively exercise–stretching, strengthening, drilling, icing, elevating, compressing, and bracing–yet quite often, they, too, recover very slowly. Why? Because they neglected the other two elements.

They overdo it, with either one or more:

  • Running too much
  • Running or cross-training too intensely
  • Over-stretching or over-strengthening sensitive tissue
  • Doing too many non-running activities (usually including weight-bearing)

Along with overdoing it, the athlete and physio also tend to overlook efficiency. They fail to take a fine-tooth comb to all things gait–not only running, but also walking. Inefficiencies tend to cause injuries; pain-induced compensations tend to perpetuate or even worsen them.

As you can see, the hardest of the two elements is being normal (efficiency) and not overdoing it (tissue tolerance). The more efficient you are, the more sensitive tissue can handle; conversely, injured tissue has a very poor tolerance to inefficiency, including limping and compensation. Then, sensitive tissue requires some tissue loading, but not too much. Just how much loading is required is a ‘Goldilocks dilemma’–what’s too hot or cold, versus just right? Devising a progressive activity plan is as much art form as it is evidence-based protocol.

Plantar Fasciitis and the Four Fundamentals: Easier Said Than Done

Plantar fasciitis is one of the most common and persistent injuries affecting runners, particularly trail runners, who must negotiate challenging and punishing terrain. It has been written about so many times that while most runners know of scores of treatment techniques, few are able to quickly extricate.

Perhaps it is because those techniques address only strength and mobility, neglecting efficiency and activity?

Personally, I have had all sort of foot and ankle aches and pains, including several episodes that I would consider to be not plantar fasciitis, but other issues of muscles, tendons, and joints in the foot. But just recently, I have been lucky enough to experience true plantar-fasciitis injury for the first time. It fooled me, because I thought it was a simple tendon soreness, or some stiff foot and ankle joints. I was mistaken. My simple heel and arch soreness progressively worsened, and the classic medial base-of-the-heel pain appeared. It is sore to pressure, weight-bearing, and aches with too much activity.

Plantar-fascial strain, like the Achilles, can be difficult to heal because it is essential weight-bearing tissue with relatively poor blood flow. Once strained (or microscopically torn), it can be very painful and slow to heal.

As with every injury, it was a terrific learning opportunity and application of the four fundamentals. For plantar-fasciitis treatment, tools and strategies abound for mobility and strengthening. But what about efficiency and tissue tolerance? Once again, I return to a clinical pearl gleaned from my boss and mentor, Jeff Giulietti, “No limping allowed! Be normal until it is sore, then rest.” It seems simple, but this concept is extremely challenging. What is normal? What constitutes limping or compensation?

Normal, efficient walking and running utilizes the whole foot, from heel to toe, and from outside to inside. For walking, especially, a heel-to-toe gait is vitally important. That rocker allows for normal walking forces to disperse along the entire foot–as opposed to a toe-walker or forefoot runner where the forces are concentrated on the front of the foot, adding greater stress to the plantar fascia.

But if you ask anyone with serious plantar-fascial pain, they’ll be quick to tell you:

  • It’s very painful on the medial heel and arch
  • Putting direct weight on that area is both painful and frightful (“Walking directly on it will make it worse… right?”)

Therefore, they will consciously or unconsciously avoid weight-bearing in that area, either through toe-walking and/or excessively lateral striking–both with walking and running.

But what strategy, normal or forward/lateral, actually stresses the fascia greater? First off, excessive lateral striking to avoid a medial pain makes sense, but as discussed in the previous foot pain article, excessive lateral striking adds energy to the system. The foot collapses from a greater height, while adding greater twisting stress to the plantar fascia, as the forefoot eventually slams to the ground, twisting the fascia along the way:

Excessive lateral footstrike diagram 600px

A photo illustration from the first plantar-foot pain article indicating how an excessive lateral strike creates more impact stress.

To consider heel-versus-toe striking, I had to dig into some classical physics. Torque is the cross product of a force times the length of the lever arm. So the resultant rotatory energy is greater with a longer lever. If you’ve ever used a wrench, this is easy to understand. The longer the wrench, the easier it is to turn a bolt.

With the foot, the injury site for the plantar fascia is its insertion at the heel. So it stands to reason, that the more force applied farther away from the heel–with the fascia as the lever–the more stressful force is applied to the injured fascia! This is illustrated below:

PF.Web.Md.1

Model of the foot with plantar fascia. Fascial length and lever arm is indicated in red, with distance d. Image courtesy of WebMd.com, amended by Joe Uhan.

As you can see, with a forefoot strike, the lever arm (red) is long:

Fascial loading with a forefoot (walk or run) strike. Note the long distance of the red lever with a forefoot strike, in relation to the heel bone, where the facia inserts – and the typical location of the strain. (Picture courtesy of WebMd.com, amended by Joe Uhan)

Fascial loading with a forefoot (walk or run) strike. Note the long distance of the red lever with a forefoot strike, in relation to the heel bone, where the fascia inserts–and the typical location of the strain. Image courtesy of WebMd.com, amended by Joe Uhan.

But with a heel strike, the force arm is much shorter, at least five times less:

PF.Web.Md.3.rearfoot

Fascial loading with a rearfoot strike. The length of the red lever with a heel strike, is far shorter, resulting in significantly less torque applied to the sensitive insertion point. Image courtesy of WebMd.com, amended by Joe Uhan.

So even though it may be tender to step directly on the sensitive insertion, the avoidance forefoot strike places as much as five times greater load to the fascial insertion point!

This may still be difficult to grasp: How can walking directly on the tender heel be less stressful than avoiding it on the forefoot? The answer is another question: What is more stressful to a strained rubber band, stretching it lightly or to its maximum?

Step on It… Then Rest! Tackling Plantar Faciitis Head-On

The best overall strategy for healing plantar fasciitis is truly a four-dimensional approach. To review:

Full range of motion. Massage and stretch the fascia and surrounding tissues, without overdoing it. (Of note, most braces and overnight socks vastly overdo the degree of stretch. Morning tightness is usually due to over-stretching and stressing the fascia the day before.)

Strong, supportive muscles. Strengthen all muscles of the feet and calves.

Be normal. Address both walking and running efficiency. Walk and run heel-to-toe. Or at the very least, to ensure you’re not unknowingly over-stressing the fascia, make sure you’re employing a relaxed, midfoot run technique! Run whole foot, and avoid excess lateral striking. In the big picture, be sure you’re not running asymmetrically, overloading one leg, as identified in a previous article.

Here’s another big issue: Relax! Protective tension can play a major role in perpetuation of pain and dysfunction. Runners will commonly–yet unconsciously–keep their foot stiff with walking and running as a way to protect the sensitive tissue from stretching. This short-term strategy may be helpful in the acute stage to limit over-stretching. But over time, keeping the foot rigidly tensed during gait is akin to driving the car with the parking brake on. It needs to be free to move!

A healthy foot should be relaxed but athletic–flexing and extending as part of the walk and run cycle. When returning to running, err on the side of being too relaxed, letting the foot feel floppy–so long as you strongly push-off behind, a la Elite Feet!

Don’t overdo it. Walk and run with max efficiency for as long as you can, then rest. This means stopping at or just before the moment the heel begins to ache. Achiness during or after running, including just walking and standing around, indicates the tissue needs rest. Getting off your feet for as little as five to 10 minutes may be enough to allow you to bear weight again. Avoid flare-ups, which include any activity resulting in more significant pain or swelling. This means you’ve vastly overdone it, irritated the tissue, and possibly reversed healing.

There are some taping techniques–such as the Low-Dye Technique–that can help unload the sensitive fascia. A cursory search of this term online will yield some how-to articles and videos, but this technique is best reserved for a skilled medical professional.

***

Every day and each run is a learning experience, and the art form behind successful training and racing is the same as healing: the balanced recipe of the right ingredients in the right quantities. Let pain be thy guide, but above all else, be normal and efficient as long as you can, then rest! Then, the next day, do just a little more.

Joe Uhan

is a physical therapist, coach, and ultrarunner in Eugene, Oregon. He is a Minnesota native and has been a competitive runner for over 20 years. He has a Master's Degree in Kinesiology, a Doctorate in Physical Therapy, and is a USATF Level II Certified Coach. Joe ran his first ultra at Autumn Leaves 50 Mile in October 2010, was 4th place at the 2015 USATF 100K Trail Championships (and 3rd in 2012), second at the 2014 Waldo 100K, and finished M9 at the 2012 Western States 100. Joe owns and operates Uhan Performance Physiotherapy in Eugene, Oregon, and offers online coaching and running analysis at uhanperformance.com.

There are 14 comments

  1. Shane

    Thanks Joe, that was very helpful. I am recovering from a bad bout of PF. The point you made about not limping is very important. There are many stimuli to change your way of walking but few to return to normal after the pain has gone. I found that I had to force myself to walk/run as normally as possible even if this was painful. Alexander Technique gives a good template for checking that everytihng has returned to normal/efficient after an injury. Regards, Shane

  2. Lisa

    Fantastic write-up! I also think it’s important to take action as soon as possible; I recently read a study, conducted via survey of hundreds of NHS physios and podiatrists in the UK, regarding the challenging nature of successfully treating plantar fasciitis. A huge number of these professionals cited late referrals as a confounding factor to addressing PF. Once it goes chronic, it seems to be a whole different animal!

    Having dealt with PF a handful of times, I can attest that the sooner I take a step back and address it head-on, the quicker I recover. This article gives me tons more food for thought.

  3. Brian

    Very timely article for me! Just got back from holidays in warm, sunny Arizona, and of course I overdid the training. The day we left I got a sharp pain on the inside of my heel. I’ve never had that before.

    I’ll definitely be using these guidelines for my recovery. Thankfully I’m not missing out on any great runs as it’s 3 degrees (f) and icy out here in Iowa.

  4. Anonymous

    Hi Joe,

    Nice article, much appreciated.
    For the physics aspect of it, I believe you have some misinterpretation of the forces and torques. This in no way affects your conclusions mind you, just the way to arrive at them. So anyone who doesn’t give a *&^% about the physics, disregard the following :-)

    In your 3rd diagram where you show a (~80%) shortened moment arm, this can’t happen. Basically, torque only occurs if there exists a force at the ball of the foot, which is the only time that the ligament is put under tension (other than dorsiflexion).
    In a heel strike, a certain % of the vertical potential energy (‘bounce’) and horizontal kinetic energy of the runner is dumped into the heel, then, shortly thereafter, another % is dumped into the ball. Now, how these %s are shared is significant: if 80% (and it could be some other #) is dumped into the heel, then only 20% is loaded into the ball, and hence across the ligament. In this scenario you would get the exact benefit you described. On the other hand, if you just tap your heel down and immediately drop onto the ball loading in a 20%-80% sharing, then the ball gets loaded 80%, which yanks harder on the ligament. So it’s the details of the type of heel strike (or of the forefoot strike) that matters. Heel striking should not considered a binary yes or no, it all depends on what you load more.

    Then, of course,there’s the push-off phase, where you are loading the ball with all the potential energy required to reach your next high point of your stride (‘bounce’), as well as that required to recover any forward inertia lost in the prior footstrike (the ‘braking’). This does not depend on heel/forefoot striking except in so far as that relates to the amount of inertia lost on foot strike.

  5. Rob

    I’ve recently been increasing my mileage for the season and have had some pain in the heel. It’s not normally noticeable until the next day after a run and the pain is minimal, but still has me concerned.

    Does plantar-faciitis get gradually worse or is it something that blows up quickly? I’m guessing the answer will be that it varies on the individual but I’m hoping I can continue increasing mileage with out doing any further damage.

    1. OOJoeuhan

      Hey Rob,

      Thanks for the comment, and sorry to hear about your foot!

      It *does* tend to worse – even with backing off running a bit, usually because of Factor #3: “Be Normal”. If there’s an asymmetry or imbalance in your stride (that is overloading that foot), it won’t usually go away on its own.

      So address all 4 factors (stretch/massage, strength, rest to the point that “the next day” is LESS sore), but do your best to address any stride inefficiency, as well!

  6. ClownRunner

    “Plantar-fascial strain, like the Achilles, can be difficult to heal because it is essential weight-bearing tissue with relatively poor blood flow.”

    Yup, that’s the real problem–the lack of blood flow–and it’s why it should definitely be called Plantar Fasciosis (not Fasciitis).

    It’s not an “-..itis” because it’s not inflammation…it’s an “-…osis” because it’s basically dead tissue because of lack of blood flowing to the area. That’s why it takes 3-4 years for some people to heal it….glacially slow return of blood to the area…

  7. Jackie Swanson

    Great article. One thing missing is the question of footwear, since the right shoe plays such a key role in foot health and injury prevention. Options worth considering for all you trail runners are Treksta’s trail running offerings (Trekstausa.com), which offer the innovative NestFit system that reduces both foot pressure and muscle fatigue. That reduces the risk of injuries, like Plantar Fasciitis. We have many amazed users and followers in this regard. Here is info on Nestfit https://www.trekstausa.com/technology/nestfit
    Cheers, Jackie

  8. Ben Pine

    Great article.
    Really interesting what you say about heel striking too. When I first got PF I was given some orthotics I was told I would have to wear from then. With some reading I found that a more minimalist shoe may help instead, and for me it did – though it caused some calf problems along the way. I then learnt the value of some of your strength work to alleviate that and it is now largely manageable.
    From what you say though, a more minimalist approach shouldn’t help, though understand we’re all different etc ;)
    Ben

    1. Richard

      I was prescribed orthotics a few months ago and have seen no real improvement recently. They helped a lot with the pain at 1st but I seem to have plateaued as far as recovery goes. I would love to be rid of my orthotics. Was this your experience? Also, how long did it take you to get back to pre-PF conditions?

  9. Isobel

    So us heel strikers are back in fashion? I wonder if people who consciously try to alter their gait end up with PF more often. I was lucky to never have it and maybe running in Vibrams and minimalist shoes, as well as going barefoot at home helps prevent PF.

  10. John G

    Very helpful Joe, and IRFM. This is one of the best articles I’ve seen because of it is written from the perspective of a runner. I am now under the care of a DPT, and they seem to agree with your four key points, which is reassuring.

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