What If Your Heel Pain Isn’t Plantar Fasciitis and What to Do About It

Stay the CourseNothing ruins a perfectly good runner like plantar fasciitis, the dreaded snake bite of the heel and arch of the foot. In essence, its nasty foot pain–particularly heel pain–that prevents us from running. Once it sets in, is one of the most menacing and stubborn conditions.

Ultrarunners seem particularly prone to heel and arch pain. Both uphill and downhill running stresses the foot: the ups stressing the soft tissues of the plantar arch, and the downhills providing ample pounding for the joints.

It’s okay to call your foot and heel pain plantar fasciitis–just like that Coke at the aid station that might be Pepsi or RC Cola. But be sure that you–and your doctor, PT, chiropractor, LMT or other healthcare helpers–are aware of all of the different sources of foot pain. Awareness is the first step in comprehensive treatment and fast recovery from the dreaded “PF” and its brethren.

Plantar Fasciitis, Defined

The plantar fascia is the thick connective tissue that runs from the base of the heel, to the bones of the forefoot. Collectively, with intrinsic foot and ankle muscles, it supports the arch of the foot and helps transfer energy from the forefoot to the rearfoot and ankle, and up the leg.

By definition, in a truly literal sense, fasciitis is an active inflammation of that tissue.

But is foot and heel pain always plantar fasciitis? In a clinical sense, one can only have fasciitis if an active inflammatory event is occurring. Since inflammation only lasts twenty days, indeed, not everyone with persistent foot pain truly has fasciitis.

Not all tissue paper is Kleenex. Not all lip balm is Chapstick. And so it goes, not all heel and arch pain is plantar fasciitis. But as Shakespeare once said, “Is foot pain by any other name, any less excruciating?”

However, to label all foot pain as plantar fasciitis possibly limits one’s ability to quickly and effectively recover from it. Below are some other, equally common causes of foot pain.

Foot Pain: Differential Diagnosis

There are a many possible sources of persistent heel pain and arch pain. Here are the most common I see, clinically:

Soft tissue sprains and strains. There are several major muscles, tendons, and ligaments that span from the heel and ankle to the toes. Besides the plantar fascia, there are several flexor tendons–of muscles originating on the lower leg–that course their way into the foot. Any number of these tissues can become strained under the load of road and trail running. A review of the Rules of Tissue Loading explains how a plantar surface tissue can become irritated.

However, since soft tissue tends to heal quickly given proper treatment, these causes tend to heal rapidly. Those with persistent heel pain and arch pain–who see me and other medical folks after weeks, months, and even years of pain–tend to have a pain generator of different origins:

Joint Pain. There are over two dozen joints in the foot and ankle complex. With the extreme stress of ultra trail running, these joints could become stiff, irritated, or both.

Joints–articulating surfaces of two bones–require but two things to be happy:

  • Full range of motion
  • Symmetrical, equal loading of surfaces

Seems simple, but running hard and long on uneven surfaces can strip a joint of those two things.

Range of motion loss. Joints get the bulk of their nutrition from range of motion. The vast majority of joints in the body are synovial: two bones surrounded by a leathery capsule filled with fluid. The cartilage surfaces receive very little blood flow. In order to receive nutrition, the joint must “lubricate” itself with the fluid of the joint, absorbing nutrients from the fluid along its surface–via regular, full range of motion.

When joints stop moving through their full range, elements of cartilage do not get this nutrition. The cartilage dries up. And it is replaced with bone. This, by definition is osteoarthritis. Preceding that, is pain.

Asymmetrical loading. Joints have the ability to move–sometimes small amounts in one plane; sometimes substantial amounts in many directions. But when running, joint surfaces are designed to be loaded so that the entire surface of one bone impacts flush against the other. This promotes maximum stability; it also ensures that cartilage receives a steady dose of hydration and nutrients.

Asymmetrical loading occurs as the result of abnormal running surfaces–uneven, rocky trails, or a cambered/slanted road–or with inefficient running mechanics.

And when a joint becomes unhappy, it causes pain. Typically, a painful joint will hurt at its precise point of irritation. But joints of the ankle and foot will frequently refer pain to adjacent areas, out the sides or beneath the point of irritation, at times mimicking soft tissue pain.

How can you tell if you have a soft tissue or joint issue? Below are some comparisons:

Soft Tissue Pain Characteristics

  • Succinct, reproducible, palpable tissue pain. Can you find the one spot that is tender?
  • Pain with active use: when you do a toe curl or use the muscle (absent weightbearing), does it hurt?
  • Pain with passive stretch: is pain produced when you bend back your foot and toes? (again, without weighbearing)
  • Pain with resisted testing: when flexing your foot and toes, is there pain?

Joint Pain Characteristics

  • Dull, diffuse pain: no discernible “tender spot.” Rather, it hops around and you can’t put your finger on it.
  • Pain with weightbearing through the joint.
  • Pain is worst in the morning, after prolonged weightbearing, or after resting, then bearing weight through the joint.
  • Non-weightbearing testing–actively flexing and passively stretching the foot–is pain-free.

If your symptoms align with the joint pain characteristics–and if your foot pain fails to respond to soft tissue plantar fascial treatment approaches–you likely have joint pain.

The three usual joint suspects–the talocrural, the subtalar, and the talonavicular–can all become painful and mimic plantar fascial pain. Each joint lies on the medial plantar surface of the foot, and each is prone to stiffness and asymmetrical loading during running.

Neutral foot - side view

Medial view of a foot and ankle model, identifying three common problems joints for runners.

Above shows a medial view of the foot, showing three main joints of the foot. The talus plays a role in all three: it is the go-between from the foot and leg bones.

From above, it forms the talocrural joint. The main motion for this joint is “up and down”–it allows the toe up/toe down action that occurs in the run stride.

This joint is prime to get stiff, especially with repetitive downhill running: rather than smoothly sliding and gliding, hard downhill trail running can cause jamming forces of the talus into the tibia and fibula. And when this joint gets stiff, it can refer pain in any direction around the talus–front or back of the ankle (mimicking both anterior tibialis tendonitis and Achilles tendonitis, respectively), or it can spit pain out the side–namely the medial ankle and arch.

Between the talus and the calcaneus–or heel bone–is the subtalar joint. It is designed to move in several axes, but its primary axis of motion is medial to lateral. This joint is of little consequence to the healthy, normal runner: minor motions occur depending on the gait cycle. However, deviations or inefficiencies–namely in the foot strike pattern–can cause significant pain emanating from the subtalar joint. Excessive lateral foot strike can cause stressful joint compression to the medial aspect of the joint–mimicking plantar fascial pain!

Neutral foot - rear view

Lastly is the talonavicular joint. This joint is the primary conduit from the fore and midfoot to the ankle and leg. The navicular bone is the “keystone” of the arch. Stiffness or irritation here can also cause significant arch pain.

The following are some illustrations of how mechanical forces can cause joint and soft tissue pain:

Foot and shoe position during pronation

Over-pronation, as shown with shoe and joint model.

Pronation + arch collapse - side

Medial view of a collapsed arch.

Excessive medial foot landing leads to over-stressing of the medial arch, or “arch collapse.” This stresses all tissues of the plantar surface and is the primary etiology of true plantar fascial pain.

Equally common, especially for faster trail runners, is excessive lateral foot strike:

Supination - shoe a foot - rear view

Excessive lateral foot strike/supination, as shown with a shoe and joint model.

Foot supination - rear view

Excessive lateral striking significantly compresses the medial joint surface of the subtalar joint. This compression accounts for a large percentage of non-plantar fascial foot pain cases. It refers pain at its site, but also farther down into the arch and along the heel bone.

Too much lateral strike can also cause plantar fascial torqueing: the heel rotating to the right (in the above picture), but the forefoot rotates to the left as it contacts the ground – adding a twisting force to the fascia.

Nerve pain. Perhaps the most unrecognized and overlooked factor in heel and foot pain is nerve pain. The peripheral nerves of the ankle and foot originate in the brain, course through the spine, exit the low back and pelvis, and must course–fluidly–through the soft tissues of the entire leg.

Repetitive impact forces from running–often combined with compromised spine posture from running all day (or, in our normal lives, sitting)–can cause these nerves to develop “hitches.” This is a concept called nerve tension.

Nerve tension accumulates in the spine and legs with age, injury history, and running volume. When nerves lose mobility, they begin to create pain–often very similar to soft tissue or joint pain, including plantar foot pain.

And because the same repetitive or excessive impact forces that create joint and soft tissue pain also create nerve tension, it is very common for a runner to present with both joint/soft tissue and nerve pain overlay at the same time.

Almost every runner (and most other folks) has some degree of nerve tension. Here’s a test:

Sit with your back against a chair, head and shoulders upright. Extend your knees straight, with toes up. Note the degree of “stretch” in the back of your legs. Then, slump your head and shoulders. Any increase in stretch sensation is nerve tension from tensing the nerve at the head and neck.

Nerve Pain Characteristics

  • Pain at rest–the hallmark sign of nerve pain overlay: do you have any symptoms in your foot when at rest, namely sitting (specifically, with prolonged sitting, long after you’ve stood on it)?
  • Symptoms described as burning, buzzing, or dull aching.
  • Other symptoms higher up the leg, specifically: lumbar, buttock, posterior thigh, calf or shin pain.

Very often, a runner who applies soft tissue or joint treatment concepts will get partially better, but fail to fully recover because they fail to address the nerve tension component.

Runners and clinicians, alike, need to recognize the existence of nerve tension and treat it concurrent with any soft tissue or joint irritation.

Treatment Approaches

Please discuss any of the following treatment approaches with your doctor, physical therapist, or chiropractor before performing.

Soft tissue

These are straightforward because everyone who [thinks they have] PF does them:

  • Rest, ice, soft tissue mobilization, stretch, strengthen.

Real, actual soft tissue plantar pain will heal rapidly, given correct doses of the treatments above. Those who do not respond to that approach likely have a joint or nerve issue.

Joint pain

The two treatment approaches to joint pain in the foot include full restoration of joint range of motion and symmetrical loading.

Range of motion restoration

Ankle dorsiflexion. Normal ankle dorsiflexion is about 20-30 degrees beyond a 90-degree bend at the ankle. If you cannot stretch this far–or if you have symptoms in front, or anywhere around the ankle joint–your symptoms might be due to stiffness there. To mobilize a stiff talocrural joint, try the following:

Perform a standard calf stretch, with a few minor adjustments: be sure your stretch foot is perfectly straight ahead. Keep the foot flat, lean forward with a straight knee until full tension. Then, slowly bend the knee as much as possible without allowing the heel to rise. Slowly oscillate between bent and straight knee. This mobilizes the tibia and fibula over the talus, restoring motion to this joint.

wall stretch ankle straight

Wall ankle stretch – straight knee.

wall stretch - ankle bent

Wall ankle stretch: bent knee. Keep the heel as flat as possible.

Subtalar inversion and eversion. A normal heel bone should be able to “wiggle” about 10-20 degrees side to side. To self-test, cross your ankle over opposite knee. Grasping hold of your ankle with one hand, drive firmly downward with your opposite hand on the inside of your heel bone. Can you move it, at all? If not, and you have heel and arch pain on the bottom/medial side of your foot, your symptoms may be coming from stiff subtalar joint.

To self-mobilize, perform the maneuver described above with firm, slow, on-and-off downward pressure. The degree of motion will be slight, but the potential for pain relief is substantial when motion is restored here.

subtalar mobility

The author applying a straight-downward pressure to the heel bone, stabilizing at the ankle. A normal heel will “wiggle” a few millimeters in both up and down directions.

Midfoot arch. A normal midfoot will have some degree of give, both to the hands and when standing on it. In standing, a normally mobile foot should “sink” a few millimeters to the floor.

Shoe orthotics are intended for those who are hypermobile in their arch: their arch joints are excessively flexible, and the arch “collapses” (typically defined as one centimeter or more) in weightbearing.

However, far more often than not, runners have hypomobile arches–they simply don’t move enough. These folks typically respond poorly to orthotics (often with no improvement, and sometimes they worsen pain).

A hypomobile, stiff arch will benefit from self-mobilization. If you have symptoms that originate farther down the foot, near the apex of the arch–and your foot lacks any give in standing–try the following mobilization:

Stand with stiff foot down. Place your opposite heel directly on top of the stiffest area–typically the navicular bone, which lies directly in front of the tibia-fibula complex. Gently, then progressive bear down with substantial weight onto the navicular. This may seem scary–test it first. A stiff navicular will give very little, even with full pressure. Pain usually comes from skin compression. “Stomp” on and off 10-20 times. Perform before and after running, and/or in the morning, when stiff joints tend to be stiffest.

midfoot mobility

The author, performing a mid-foot self-mobilization in standing. Try with soft-heeled shoes on, if too sore with direct skin contact.

Joint Loading Factors

Loading the joint equally is vital to joint happiness. Orthotics can be helpful for those with hypermobile feet, as they can prevent arch collapse. They are also helpful for slower runners with shorter stride lengths. A short stride tends to include excessive vertical forces (up and down motion). This vertical loading bears down on the medial arch–beyond the capability of muscles, tendons, and the plantar fascia to support it. An orthotic can aid in sustaining the arch. But ultimately, an efficient stride that emphasizes normal hip mobility with greater forward momentum is most important in preventing arch collapse.

Other important factors for symmetrical, low-stress loading include the position and angle of foot strike. The foot should always land as close to directly beneath one’s center of mass as possible. A foot that strikes in front, tends to strike:

  • On the heel;
  • On the outside edge of the foot (heel or midfoot); or
  • On the mid or forefoot, laterally-biased.

A heel strike creates considerable stiffness through the talocrural and subtalar joints. A lateral strike might cause asymmetrical loading of the subtalar joint, and/or a twisting, torqueing force through the midfoot and plantar fascia (see photo above). A midfoot or forefoot strike–significantly ahead of the body–will stress out those joints or strain the plantar fascia.

The most simple, sustainable and important way to correct a foot strike issue is addressing it proximally with:

  • Proper forward trunk engagement, and
  • Moving the hips such that the foot is “pulled” beneath the body

After ensuring proper foot placement beneath the trunk, shoot for a whole-foot strike, where all elements of the foot are absorbing and sharing impact forces.

Nerve Pain Treatment

To treat nerve tension, refer to the test above, except make one slight adjustment:

Sit in a chair, slumped forward. Slowly extend the affected leg with toes up. As the foot and lower leg rise, slowly extend your head at the same speed. The degree of stretch should be significantly less, but still present. Hold one second, then slowly lower. This is referred to as a “nerve floss” exercise: the head gives the nerve slack that is taken by the foot, and vice versa. Repeat ten to twenty times, and perform three to four times a day, especially before and after running. Here is a video link for the exercise.

Call for Comments (from Bryon)

  • Have you suffered from heel pain, plantar fasciitis, or other foot pain?
  • How did you heal your plantar fasciitis, heel pain, or other foot pain?
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 160 comments

  1. Mic

    This is very useful information.

    I notice that badly cut single track trails can lead to overpronation or oversupination. Imagine "fisherman" trails near a lake or fireroad trails that come down a mountain at a slant and for miles. I find that running on these type of trails leads to some pain in my feet. These type of trails are utility trails, just used for a purpose and for a "short" time, i.e. access to a fire/stop the fire or to go fishing for a few hours.

    I think mountain bike trails are some of the best out there. They are mostly constructed using a McLoad Tool. Trail runners are great with removing blow downs with chainsaws and maybe we can incorporate trail work days that include McLoed Tools.

  2. OOJ


    Thanks for the comment. I agree 100% – narrow trails + a slower "trail pace" can definitely create a "compenstatory lateral strike" due to having a narrow stride WIDTH, plus the difficultly of opening up the stride!

  3. Ron

    I agree that soft tissue injuries can be very hard to diagnose. I went to Physical Therapy for weeks with no improvement for my "PF". Turns out the diagnosis was incorrect and after an MRI, it was determined to be a plantar fibroma. Had cryosurgery done on it last week and the pain seems to be dissipating.

  4. Brett Rivers

    These "Stay the Course" articles continue to be super informative. The photos and captions also really help, thanks for spending the time to add those!

  5. MJackson

    Great material here, OOJ. "PF" is something that has nagged me on and off for several years. I really like the details in your explanations. It is helpful to see how various parts of our anatomy can have similar affects. Good to see the whole picture!

  6. Jason

    GREAT article. I've been suffering for years. I feel terrible after sleep and coming down the stairs in the morning. Crippling foot pain. It gradually subsides until I feel mostly fine, although walking around barefoot on our slipery hardwood floor feels not so great. Really never affected my running too much, only occasionaly do I even feel it. Rest doesn't seem to help, infact, it almost seems worse after time off (perhaps a year off would help, but I'm talking about a week in this case). Sitting in a chair causes pain upon standing (office job sucks).

    Footwear seems to make a difference. Obviously barefoot would be the way we were designed to move, but that option is out if you really want to move fast over rough terrain for hours.

    Hoka's are nice for the plush ride, and seem to help in that regard, but the wide platform causes excessive pronation (for me) on narrow trails, and the soft foam exaggerates that as it's easier to compress the inside edge of the sole. That pronation causes pain, and seems to bother a touchy knee (knee cap not tracking right?).

    I like the Montrail Badrocks for stability and toe box room, but notice the decreased cushion. Knee and ankle feel better, heel hurts more!

    Dumb question: Is there a good way to select a health care professional? Most seem to have two answers: Orthotics, or stop running ('running is hard on your joints'). NO! I need a therapist who IS a runner! It would be nice if there was a good sounding board for runners in various areas to ask/recommend therapists. Right now it seems to be totally trial and error, and I think most people just blow it off and run.

    1. Joe Uhan


      Thanks for the comment – sorry to hear of your ails!

      Feet: chronic foot pain could involve elements of all three issues: soft tissues (ROM, strength), joint mobility, and perhaps some nerve overlay (possibly). But it sounds like this is a foot strike issue. I would say the wide platform of the Hokas might not cause the pronation – it only brings the pronation issue to your attention.

      Selecting HC folks: GOOD question. Here are some recommendations:

      – Word of mouth. Who is everyone else seeing? And more importantly, what do they do? Do they take a big picture approach? Are their interventions grounded in either research or solid clinical reasoning (e.g. no snake-oil salesmen)? More importantly, can they look at your running? MOST importantly: can they help you effectively change it (without making you mental)?

      – Professional affiliations. For PTs, who typically are most experienced in movement, and have the time to devote to you, I favor two different professional affiliations in physical therapy: the North American Institute of Orthopedic Manual Therapists (NAIOMT), and the Certified Functional Manual Therapists of the Institute of Physical Art (CFMT).

      These groups offer credentialed certifications involving years of training in hands-on techniques – not only to "move stuff" but also to retrain. If you're devoid of any recommendations, seeking out one of these folks in your area is a safe bet.

      NAIOMT: http://www.naiomt.com/index.cfm?fuseaction=page.viewPage&pageID=770
      CFMT/IPA: http://www.instituteofphysicalart.com/ipa/referra

      Good luck!

  7. olga

    Joe, thanks so much, your articles are the best addition to iRunfar, even if don't generate much comments. Most useful for us all.

      1. olga

        Totally, I am working start/middle/finish AS, you'll hear lots of screaming in the morning too! But, speaking of the issue at hand, had it backwards: stress fracture and early running on it lead to PF, not tending to it lead to Plantar Tear! Then misplaced cuboid, nerves bundled into scar tissues – and a year and half later I am still often in pain on that foot. So, from personal (bad) experience I highly recommend to everyone to treat the injury – and the underlining issue – ASAP and fully!

  8. Scott F. Handley

    Then there's also bursa issues. My arches are ok, just have heel (right), pain on sides & back of heel. With overuse it sometimes transcends up the lwr. achillies a few inches.

  9. Elena Makovskaya

    Great article! Not only i had this problen myself back in spring (hope it never comes back!) but I also sent this ling to my non-running co-worker who is also suffering from PF. Question: what do you think of cortizone shots to treat PF and other soft tissue problems? I had one and it seemed to help, but I heard all sorts of opioons on that topic.. Thank you!

    1. Joe Uhan


      Thanks for the comment.

      Cortizone injections: GREAT "fire extinguishers": they put out the inflammatory fire (if there is one). But as my saying goes, "A Joint Problem* needs a Joint Solution".

      (*…or nerve)

      A cortizone injection will not mobilize a joint. It also won't properly align the joint or change your running stride. The most important job of the runner + healthcare helper, then, is to be sure that, once the "fire is out", that it does not re-ignite".

      1. Joe Uhan

        …if it IS soft tissue, the shot will help, but only temporarily unless the conditions that caused the irritation are changed (training factors, stride, etc).

        If it is joint, it will help, but be less effective unless inflammation is present. If it is nerve – it is less likely to help at all.

        1. Elena Makovskaya

          Thank you so much for your response!!! The shot helped me – in less than a week the pain was gone completely. I am lucky and my doctor is a competitive marathon runner himself and he immediately told me what the problem was: too many miles on roads at too hard of a pace.. And the shoes that I didn't change in 2 years.. So, now I am trying to do exactly what you say here – change the conditions that originally lead to the problem: fewer road races, more quality in training and better shoes.. So far so good.. Hope it stays that way. Thank you again!! Hopefully see you in Bandera in Jan.

    1. Joe Uhan

      This IS dedicated to AJW! As I posted on FB, I began to write this in the fall/winter of last year, but by then you'd moved up the ladder from foot to knee issues! Here's for next time. :)

  10. Trail Clown

    I was surprised when Iron Mike (Wardian) came down with mild PF this year, and then of course he got the stress fracture. I thought the man was invincible. But it just shows…if you stress the body and "go for it", noone is safe. I am not even half the runner Mike is, but when I trained for my first 100 miler, PF was the result. Too much pounding, too many hills, not enough rest. It was a real painful lesson. Thanks for another great article Olive Oil J…

  11. Elena Makovskaya

    btw.. my own PF experience lead to a stress fracture as well. I kept running through it for about a month and was compensating with my other foot ==> stress fracture in the other foot. Lesson for sure! :(

  12. Erin

    Great info, and the pictures are super helpful, but……as a yoga instructor (who also runs), I think it's important to include information about PREVENTION of things like PF, not just the typical American response of "what to do AFTER you get ailment X". Yoga practices often include foot exercises that can help PREVENT PF-type problems, and I would always recommend a yoga practice to supplement runners' regular mileage. (Heated Power Vinyasa, in particular, is uniquely suited to runners and their needs.)

    1. Joe Uhan

      Excellent point, Erin. I'm a huge proponent of Yoga for many reasons. Other comprehensive prevention things could include small amounts of barefoot jogging (even on the order of 1-2 minutes after a run, twice a week), or simply wearing different shoes. Because of my high volume of training, I will frequently roll my feet with a tennis ball in the morning, in addition to performing the ROM exercises listed above.

  13. eric hodge

    i often get problems in my knee that are more pronounced than the "other" problems i feel. these "other" problems, however, are consistently there and are most likely the issues that cause me to change my gait. these issues seem to relate to nerves, as it's slight pain that moves around (could be joint stuff too, i guess, based on what you wrote) and weakness in parts of my foot, with sensations that run into the ankle and up the calf. so it would seem my gait is off to begin with. can one run through these types of problems and solve them with better biomechanics? i'll certainly try. wish i knew what it was about my foot strike (etc) that was causing it though.

    regardless, great article (once again). very informative, through and clear.

    1. Joe Uhan

      For a runner with multi-joint issues and symptoms, I would look proximally to what is going on at the trunk/pelvis: are you strong and efficient in this area? If not, the rest of the leg might be lacking strength and stability, causing a myriad of issues that you describe.

      A thorough examination that includes gait analysis and strength/ROM through the trunk and pelvis would be helpful!

  14. MonkeyBoy

    Liquid Gold, OOJ.

    I wanted to say, having decreased range of motion/mobility in the ankle led to the only stress fracture I have ever had. The decrease in ROM, coupled with running on off camber trails with poor flexibility in my calves and hamstrings, led to a severe stress reaction/fracture in my heel. The pain felt like severe PF, without the arch tightness or locked up midfoot. I had the signs/symptoms for a couple of years leading up to this in the form of recurring achilles tendonitis.

    I do the wall stretch daily to work on my dorsiflexion and I struggle to keep it above 20 degrees. I also do a lot of work on keeping my posterior tibs healthy, as a tight joint puts additional stress upon them. My lesson? Don't let it get this bad before you address this issues. Great article!


  15. Nick A

    Great article, really enjoyable. I seem to be succumbing to PF, have a similar problem to one mentioned above where getting out of bed hurts like hell, but once I move around a bit it gets better. Strangely my knees are now causing me problems, I wonder if this could be linked to running style issues (think: the bells, the bells) caused by the sore feet?. I've started a routine of stretching, cross training and strength training in addition to running, hoping that will help? Cheers, Nick

    1. OOJ


      Stretch, x-train and strength can help bolster your tissue tolerance and increase the margin of error IF there are any gait issues. Stay tuned for next month when we go over some simple form drills that might help both your knees and feet.

  16. Derrick Kanashiro

    You didn't write about tendonitis in the ankle, like posterial tibial tendonitis or Achilles tendonitis. Any suggestions on causes and treatment for them?

  17. Mic

    Since the trunk and pelvis were mentioned, it reminds me of ab or core work. I recall a cross country friend in college, Div. 1A, always on the floor doing ab work. If you went to visit her – she'd slowly and casually make her way to the floor and socialize while doing crunches. It almost went unnoticed along with the fact that she always carried around a bag of food. She is diabetic and likely needed the food but also needed it for the calories, of course (@ 70 miles a week).

    I mention ab work because – although it may go without saying – among this crowd, ab work seems to free up my lower body to do as it pleases. I recall times of feeling heavy on my feet when I began ultras. My feet were having to run and balance all the while controlling my upper body. After much ab work, I find that my feet are sort of liberated to have fun and maneuver.

    There are definitely yoga poses for the abdominals – leg lifts and resting on forearms, etcs.

  18. Ran Pergamin

    Hi John,

    Your article came just in time !

    I have been dealing with a stubborn heel pain for several weeks now.

    It actually started as metatarsal & arch pain, that slowly settled in the heal..

    I caught it early, so its volume is not super high (though annoying when flared..) , but I stopped running, to get rid of it as fast as I can.

    Immediately, I suspected Plantar Fasciitis. The heel pain. Reading all the material online about it.

    I want to 4 different therapist, heard 4 different theories, and no relief. None really with expertise in dealing with something that is not of classic symptoms.

    I became skeptical & in "trust no one, but what works" mode

    I did the ice, stretching, roller, deep tissue massage, PT & complete rest from running, but the pain would not go away.

    Your article came just in time, cause, something along the way didn't match PF classic symptoms:

    1. I don't suffer morning first steps aches

    2. My pain is actually stronger while sitting/driving/rest, no during activity.

    3. Even during a period of 1 month when I wasn't running the pain would stay.

    4. The pain awakes also from long period of standing

    3 weeks ago I noticed that when I wear my Birkenstock sandals, it dramatically reduces the pain to a degree where it kind of disappears. (Still no running)

    I gradually started running again, 10-15min (barefoot or minimal) at a time, no one day after the other.

    The runs feel amazingly well (I never had the heel pain during activity).

    After each run, 2-3hrs after a 10-15min run the pain would come back. I would do the roller, ice , stretch & the next morning usually my feet would actually be better with little ache, if at all (again still walking Birkenstock).

    The last PT I went to claimed that the pain comes from my back (weak core muscles), and that I have no real PF.. Which I wanted to believe, but have been to skeptical about theories.. I started working on those core muscles but that will obviously take a while..

    Than I read your article, about the nerve tension.. Any my symptoms kind of jumped out… WOW, could it be that my pain is indeed not really PF, but actually something different ?

    My problems is the lack of Professional Therapist to point me in the right healing direction, and guidance on running/not running thingy.

    I have decided now to stop running again, cause I don't want to take two steps back on the healing process with further inflammation, however, I am still feeling in the dark, as to whereas what healing process I should follow, when to come back running & how, and what is actually the source of my pain..

    Should my pain be neural tension, how fast , doing the excersie, would I feel a difference ?

    Are these symptoms "easier" than PF to treat / heal ?

    Any other therapy you would recommend for the symptoms I mentioned ?

    Any guidance / thoughts is highly appreciated.



  19. OOJ

    Excellent point. Next month's column will be "Part II" on gait mechanics, where I'll be doing a compare/contrast of two major "schools" of gait training – Chi Running and the Pose Method – along with my clinical training. All three elements strongly emphasis proximal (core/trunk/pelvis) initiation and control in running.

  20. OOJ


    Sorry to hear about your struggles – but a familiar tale for many folks.

    A nerve origin of your pain is possible, especially with the pain at rest and/or with prolonged weight-bearing.

    For all exercises – and the nerve stretching *especially* – I recommend you run them by a professional first. But with initiation of nerve "mobility", your symptoms can rapidly diminish.

    BUT: the real question is, how do you keep them from coming back? What are you doing (running, not running) to accumulate nerve tension? Ultimately that question must be addressed.

    Refer to my post above about choosing a healthcare person. Anyone from either the NAIOMT or CFMT lists will be very knowledgeable about these concepts.

    Good luck!

    1. Ran

      Thanks Joe.

      Sadly, I am based out of Israel, and the amount of "real" running proffesionals therapist is to be counted on less than one hand, and even I not sure I can point who they are…

      So right now I am struggling with whatever makes me better.

      I 100% agree with you, I want the root cause, not put down the fire only.. That's the hard one to nail.

      I am actually considering to take advanteage of a business trip to UK or USA, and go to a good running clinic to get my walking/running/standing gate sorted..

      I hope to have good news in the near future…

      BTW a though, do you think remote video thearapy / analysis is something that could work.. I know as a therapist when you cannot touch the patient, it takes siginficant % of the treatment. My thought is whether you (or therapist like you), could analyze a runner / person (myself ?) diags via remote video / voice session or something in that area.. I that was doable, I think it would open the door for so many poor people suffering like me to get proper advise… Think about it, and if you have experimental thoughts, I am open to experiment :-)



      1. Ron

        You should get an MRI which is the only way to accurately diagnose what you have. Otherwise you may spend months on therapies that will not help. I had an MRI done and once the problem was pinpointed (plantar fibroma), I was then able to take quick and precise actions to mitigate the pain. Good luck and I hope you can work it out.

        1. OOJ


          MRIs and other diagnostics can be helpful as part of a comprehensive clinical examination. In your case, finding a tissue anomoly was important. But in sports medicine, this sort of finding is *extraordinarly rare*.

          The truth is, MRIs are extremely over-used and, more often than not, lead people down paths that result in excessive medical procedures. And doctors, themselves, are beginning to see this:


          Some other interesting research with MRIs:

          – 50% of all people over the age of 30 will have a positive finding (disc bulge) with a lumbar MRI. Asymptomatic..

          – 50% of all people over the age of 50 will have a positive finding for a rotator cuff tear in the shoulder. Asymptomatic.

          For sports medicine issues, only when a comprehensive clinical exam *including* a thorough motor control/gait assessment**, is an MRI indicated.

          (**OR the presence of "red flag findings": http://www.bboyscience.com/medical-red-flags/)

      2. OOJ


        Remote gait analysis is possible, but because of your background (with possible nerve/lumbar contributor), you would be best served to see a healthcare professional who will do a comprehensive exam — the whole leg, the pelvis and back, as well as gait.

        To *only* look at gait might be missing a vital part of your issue.

        Keep searching for a quality, versatile sports med professional – I'm sure there are many in Israel! Ask around, do some homework! And definitely, if your symptoms worsen, seek out an MD to be sure there might not be a more serious back is going on.

        1. Ran Pergamin

          Thanks Joe.

          I am still on the hunt, but this search is expensive.

          I have not met yet a true proffesional, who as you well written, will look at the big picture, look at my running, walking, standing, examine my body posture & identify the problems..

          Every PT I went to were way too confident that they "know" the source of the problem from a 5-15min check.. So you understand how pro, that can be..

  21. OOJ

    Clarify: only when a comprehensive clinical exam is PERFORMED (including movement/gait assessment) and NO improvement is made, is further diagnostic testing indicated – unless there is a presence of a medical red flag.

  22. monica ochs

    Great article! I had self diagnosed PF and learned about a month later it was a calcaneus fracture. These injuries require different care so lesson here is to have it looked at by someone other than self!

  23. Runnerjen

    Yes, I have the same thing. Taking a break right now and hoping the heel bursitis (both heels) will calm down. I'd love to have treatment plan for this! I also get that "buzzing" in the side of my right achilles when resting. Weird.

  24. OOJ

    The heel bursa, like any other bursa, is a passive structure. The question is, what is irritating the bursa? The tendon/muscle that runs over it? The joint it sits beside? Or the impact forces around the adjacent bone?

    Runnerjen – "buzzing at rest" is not an orthopedic tissue sign. Refer to the section on nerve symptom origin.

  25. Dave

    Interesting… I had surgery for a bone spur on the back of my right heel in April (with a follow up for a post-surgical infection in May). I've never had plantar fascitis nor knee pain in 30+ years of running. Yet… this really sidelined me. Turns out the bone spur was right at the insertion point of the Achilles tendon – so the tendon needed to be detached as well. With the infection after, I had 10 weeks of total immobility.

    Anyway… I'm on the road to recovery – but I did want to say to those who indicate "the best way to find out is via an MRI". I disagree that that is the case for all. For me, the x-ray diagnosed the bone spur. A "diagnostic ultrasound" on the Achilles showed the corresponding tendon damage. Never had an MRI – but clearly needed the surgery and (despite the infection) ended up successful.

    I think it great that Joe doesn't assume all issues are PF – and talks about other issues. I overpronate – don't know if the injury was chicken or egg – but recognize that accurate individual diagnosis is critical.

  26. Anonymous

    Question: Say you're sure you're dealing with soft tissue damage in the arch. You decide to stop running completely. You're article states soft tissue will heal rapidly. How rapidly? Most are familiar with how quickly muscle can heal, but fascia does not have the same blood flow. Also, daily, routine walking around I suspect can slow the healing process.

    For a runner with moderate case of PF, who completely stops running, walks around during the day, x-trains, stretches, ices and massages, what is a ballpark estimate for how long before one can be sure the tissue has significantly healed? I realize it depends on the individual case, but I'm just looking for a rough estimate.

    Thanks and AWESOME article.

    1. OOJ

      "Rapid" is relative. An acute strain of tendon tissue will heal in 3-4 weeks, but "rapidly improve" within days. Muscle is much faster.

      However, the scenario you describe – "only soft tissue damage" – is extremely rare. Injuries are typically "conspiracies" of several factors – joint, soft tissue, motor control – such that you have to address them all.

      But when you do address them all, an otherwise young[er] (<40yo), healthy runner with a mild/moderate plantar strain that I see in clinic will typically be able to return to running 100% in a month.

  27. TCJ

    I've had many right ankle inversion sprains from my days as a soccer player. The ligaments are very loose now. When I run, this foot noticeably over-supinates. I keep getting plantar fasciitis only in this foot – I let it heal, but it comes back when I start training hard. I think it could be the torquing of the plantar, as shown in your picture. It's also difficult to do stretching/range of motion exercises with this ankle because something pinches in the front of the ankle when I stretch. The ankle feels stiff.

    If I was to come see you as a patient, what would you recommend? I'm thinking of going to see a PT, but I don't have much money to spend…

    Thank you.

  28. Madi

    Interested to hear your view on this one, suffering similar problem of left foot noticeably over-supinating, ankle stifness with pinch felt inner/front upon stretching (has improved with ankle mobility exercises) and chronic heel pain (7-8 months now). History of ankle sprains on this side. Had nerve pain on this side (calcaneous & up inside of ankle) which has improved 90% so far with nerve "stretches" as described in the article. Heel pain still present but not just in morning or after periods of rest – pain also when foot is up.

    Look forward to hearing your comments as sounds similar to above complaints.


    1. OOJ


      You *could* have the same issue, but there could be a lot of other things going on as well (with respect to where your foot is landing – how far out front vs beneath you).

      Unfortunately, pain of any chronicity (with a history going back even farther) isn't easy to fix – and likely won't remedy 100% without a thorough evaluation and several treatments. However, I'm glad to hear you're 90% better!

  29. OOJ


    Thanks for the post – sorry for the delayed response.

    Chronic lateral striking might actually be an issue up high. Folks who don't push off with their hips well tend to have a "narrow stride": When we push off, the hip extends and abducts (think ice skating, rollerblading, or skate skiing), which ensures that the "landing foot" in front lands slightly "wide".

    A deficient push off can result in a narrow width, which results in a compensatory lateral foot strike and the torquing you alluded to. A good PT or gait analyst will be able to determine if this is the case, based both on a "table exam" and a running assessment.

    1. OOJ


      Thanks for the comment. The term fasciosis is dervied from "fascia" + "osis" — or a state of being diseased or disordered.

      This term is gaining traction because, as mentioed in the "Defined" section above, "-itis" means inflammation, which can technically only last 20 days. Indeed tissue biopsies performed on chronic "PF" patients revealed the complete absence of any inflammatory compounds.

      So they called it "-osis"…simply because it wasn't "-itis". In essence it replaced an incorrect designation with a wider, non-specific designation of -osis.

      Perpetual tissue "-osis" may easily occur with perpetual mal-loading. Is it the shoes? Maybe (as many folks are placed into aggressive orthoses or motion-controlled shoes, which creates increased mal-loading of the rear/midfoot joints). Or it could simply be perpetual mal-loading of the joints and tissue.

      Is it really a blood flow issue causing tissue death? Could be (but testing this theory would be very difficult: are tissue biopsies showing dead, decayed tissue in these patient?). A more plausible explanation is asymmetrical loading and chronic tissue strain (AND joint irritation, referred) as theorized above.

  30. Dave Kelly

    Joe – great article, I've been experiencing an ache in my right heel for a little while which would just come and go. It's worsened as of late and I suspect that running in a pair of neutral Brooks that had probably done more than their recommended mileage may have contributed (who knows?). I estimate that I was running in the Brooks for approx 7-8 months and reckon I probably did 600 miles. I've changed running shoes now, as it was high time. I'm hoping that the increase in support will help. What support should I use when I'm not in running shoes. I'm easing off training slightly, I find that first thing in the morning the ache is directly from calcaneous – I don't feel any discomfort in my arches. After a few steps the ache lessens and during a run it lessens too. I don't impact much on my heel when I run as I sort of run as more of a forefoot or mid foot runner. I mostly run on paths or asphalt. My mileage is currently 25-30 miles per week. Not entirely sure if this is is PF or not – I suspect it is, I'm hoping it has been caught early enough. What else can I do? For the record I have a history of tight calves, I assume this could be a contributory factor.

    1. OOJ


      Thanks for the post.

      Without seeing you in person, it's difficult to make recommendations with any merit. BUT:

      – Posterior heel pain

      – Tight calves

      – Pain in the morning that goes away

      I suspect this is either true PF or the joint issue (as discussed above). AND, based on that collective of symptoms, I suspect you're a "braker": landing with the foot in front of the center of mass. This COULD explain the heel pain plus the tight calves (which COULD be over-used to help with braking).

      That said, shoe selection means relatively little: a foot landing in front of the body = stress.

      Try this drill (video 1): http://runningwellct.wordpress.com/drills-videos/

      The emphasis should be on a straight up-and-down leg action + the forward lean demonstrated.

      The results will be gradual – improved foot strike should result in gradually less heel pain. IF that is the issue.

      1. Dave Kelly

        Thanks OOJ

        and thank you for the comments and drills. Sounds like I possibly need to alter my gait then, that could take a while. I'm going to see a sports PT later today for deep tissue massage (calves) and mobility work. I was interested in what you said about 'braking'. I'm supposed to be doing a half marathon in about ten days, is it wise to run with PF. Yesterday during a run my foot felt a little sore initially but felt ok as the run progressed. I only ran 5 miles but it was at Tempo Run pace. I felt like I could have carried on but then a couple of hours later my heel started to ache and then it was pretty sore first thing this morning. I'm looking on the web for some good PF stretches and will do those daily.

        1. OOJ


          Glad to be of help.

          The #1 job of physical therapists (in my opinion) is to be "pain managers" – help progress your recovery – in the same way a coach would progress your training. Speak with your PT about what he/she thinks about your half-marathon, and how it would affect your condition.

          Good luck!

  31. twenty_over

    Interesting article and comments, I had a release done to my right foot on Dec. 13 and was just browsing the web for info. It is now 23 days later and I still have heel pain, I’m just hoping that it’s still too early to tell if surgery will help or not.

    After about two years of heel pain the podiatrist suggested I get another opinion so I went to an orthopedic surgeon. The surgeon gave me x-rays, a bone scan, and then an MRI; he concluded that pain was due to pf. The heel of the bone scan was illuminated quite a bit, right where the pain is.

    I’ve worked in an auto factory for the last 25 years and do a lot of walking on concrete floors so maybe that’s the cause. Last summer I could not even cut my grass and it kept me from doing the activities I like to do so I opted for the surgery.

    Thanks for letting me vent…

    Good luck to all with such a problem…

    I enclosed a link to a picture, hope it works and that no one minds.

    [broken link removed]

  32. diane

    thanks for this info. i started having heel pain after a 10 miler in the snow with my yaks on. that was 3 weeks ago, and my heel is still hurting even after not running (I am cross training). its 2 days until race day and I'm almost dreading it. ugg! by the way, I really liked the diagrams!

  33. Monica

    I have had lowered leg and foot pain for. 6 months now. . Have had emg… Tested for blood clots and veins ok . Had a mylegram and praying I get a answer. Before this horrible pain… I worked out three times a wk. in so much pain I can't do anything

    1. OOJ


      Thanks for the comment, and sorry for your troubles!

      Be sure your doctor/"medical team" look at the following, and answer the following questions:

      – Lumbar spine (any low back pain?)

      – Lower leg arterial flow/atherosclerosis (e.g. narrowing of leg arteries) – do your symptoms come on, or worsen, at a very specific time during running/activity?

      Good luck!

  34. Monica

    Ihad back surgery 10 years ago… My orthopedic surgeon ordered MRI with dye. He said leg and foot pain wasn't coming from my back . Had Doppler artery test and testing on veins.. All normal. Emg was normal! I do have more pain when being active. My feet and ankles hurt ( they did ex rays of legs.. No shin splints). When this first started about two years ago , it felt like I was walking on rocks. Bought the pads for shoes and it would be ok for several months then pain again and would change pads and ok again ( I thought it was just from bouncing. Around on boards at exercise class. Both feet hurt, but the left is worse ( I do have plantar fibroma in both feet… The one under left foot is fairly large.. I hurt in heel area and lower legs. Lower back hurts at times ( because lack of exercise ). I've gained 13lbs because I can't exercise with this pain My left buttocks hurts terribly ( have to put a pillow under it) my legs and butt hurts worse when I sit . I saw a podiatrist in the very beginning and he said that the plantar fibroma wouldn't be causing my lower legs to hurt…. But with all my research I found out that is not true . I will get results of my mylegram Tuesday and pray its nothing serious , but at the same time hoping I get an answer . I have tried remain possitive, but I'm so tired !! Very tired !! Thanks for listening

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