Column 42, July 2011

Plantar Fasciitis

It wasn’t until I returned to NZ after my devastating DNF at the London Marathon in 2004 – where I was aiming to qualify for the Athens Olympics – did I hear the term ‘Plantar Fasciitis’. I had noticed a tightness and pain in my foot leading into the race, but never did I think this would cause me to pull out after tearing it at the half way mark. I’ve since read that it’s the most common complaint (ahead of knee pain) in runners.

The plantar fascia is a long band of fibers that attaches at the bottom of the heel bone and extends to the base of the toes. It is made of collagen, a rigid protein that is not very stretchy. Pain occurs when these tissues become irritated or inflamed – ‘fasciitis’ - or when small spurs begin to grow on the heel bone itself.

It can present as a deep ache, stabbing pain or ‘pulling’ feeling under the foot, or a bruised-like feeling in the heel. Morning stiffness and pain are common as the foot tries to heal itself in a contracted position overnight.

Contributing factors

Poor foot structure - flat feet, high arches
Weak arches
Tight achilles
Weight gain
Excessive pronation
Sudden increase in mileage
Commencement of speed work or a change to hard running surfaces
Wearing heels all day then switching to running shoes
Inappropriate running shoes

Plantar fasciitis can be a persisting problem which gets worse and more difficult to treat the longer it’s present, so it’s important to start treatment at the first signs of soreness.

Primary first-aid

Massage - by rolling a golf ball or cricket ball under the foot
Ice - for 10 mins after massaging, and repeat several times throughout the day.

Tip: Massage and icing can be combined by rolling the foot over a small plastic coke bottle that has been filled with water and frozen, or a frozen golf ball.

Anti-inflammatory gels – such as ‘Voltaren Emugel’ can be beneficial
Oral anti-inflammatories - such as Ibuprofen help reduce inflammation and pain but may cause stomach ulcers if used excessively.
Supportive everyday shoes – when the plantar fascia is inflamed it’s important to take the load off the area when not exercising by wearing shoes with decent arch-support. Birkenstock and Merrell are great choices. Formthotics (available in pharmacies) can be used in many closed in shoes and moulded to the wearers natural foot form. Avoid wearing high heels.

Treatment options for on-going pain

If pain persists for more than 3 weeks, see a sports podiatrist or sports doctor.

Treatment options include;

Night splints – The ‘Strassburg sock’ is a soft night splint available at some sports podiatrists which in one study was scientifically shown to treat plantar fasciitis in 97.8% of participants. It works by preventing muscular contracture and swelling in both the achilles and plantar fascia that occurs when the foot is pointed during sleep. I personally found it had a huge effect on my recovery.
Taping can be used to temporarily reduce the load on the plantar fascia.
Orthotics –may be recommended in some cases, although preventative measures are usually more helpful long-term.
Dry needling - claims to stimulate the healing response by cause injury to a localized area.
Cortisone – an injectable anti-inflammatory - can relieve the pain for a period of time, but because it masks pain symptoms time off running and a gradual return are required to avoid further tissue damage.
Shock-wave therapy (SWT) - is ACC funded in NZ if supplied by Kompass Ortho- shock, otherwise it is very expensive. It works by stimulating the regeneration process. A 2007 NZ study showed it to significantly improve symptoms; however an eccentric loading regime to strengthen the calves had a similar response. As with cortisone I would consider this method a temporary fix.
Surgery – which involves severing the attachment of the plantar fascia to the heel or removing the heel spur, is a last resort. Many foot specialists are reluctant to perform surgery, concerned that it will cause more problems than it will fix.

Prevention – The key to long-term success

Strengthening exercises

Soleus strength exercise – starting with toes on the edge of a block, and knees bent, take one foot off and lower the weight bearing heel to the count of 3, then push up quickly high onto the toes with both legs. Do three sets of 15 repetitions per leg at least 3 times per week.
Arch strengthening – any exercise requiring you to balance on one leg in barefeet or minimalist shoes will strengthen the arch. For example one-legged squats and many yoga poses. Alternatively place a 330g can at the end of a towel. Sit on the floor with your heel on the other towel end and grip the towel with your toes, bunching it up and pulling the can all the way to you.
‘Barefoot’ running - running in ‘shoes with minimal arch support (eg Nike Free) or barefoot can help to strengthen the plantar fascia. This transition from supportive shoes needs to be made gradually however, building up to 2-3 easy sub 30 min runs per week maximum.

Stretches

A great stretch that gets both the achilles and plantar fascia in one go is to place your foot up against a wall/post with the heel close to the wall. Bend the knee and push it towards the wall.
Starting in the position shown in the image lean your upper body weight onto the thigh to stretch the soleus and achilles. Place your hands in the floor in front then slowly bring the heel off the ground and the knee towards the floor to stretch the plantar.

Other prevention options

Regular massage - either from a sports massage therapist or the gold ball approach.
Wear suitable running shoes – consult a specialist running store, and replace worn shoes appropriately.
Increase mileage gradually – no more than 10% per week.
Run on soft surfaces as much as possible.
Ease into speed work gradually.
Avoid high heels, or run in the morning rather than after wearing high heels throughout the day.

Here’s to pain free feet!

Marnie Oberer