Foot Injury - Plantar Fasciitis - Running Injuries, Maintaining Health while Running - Injury and Health

Our feet perform several functions and are put under considerable strain. Hence it's no surprise they're susceptible to injury. Find out about Plantar Fasciitis, one of the most common injuries.

Hi and welcome to another dose of the Running Bug’s Sports Injury Bulletin. As a response to reader requests and enquiries, the next few instalments will focus on the causes and types of foot pain in runners.

When you are pounding out those miles on the road, sprinting down the track on the balls of your feet, or tackling rugged off-road terrain, do you ever consider the demands placed on your poor old feet?

As the single points of contact between the ground and your body mass (which can be increased seven-fold during running!), your feet must constantly adapt from flexible bases of support to rigid levers producing propulsive forces. Impressive! Over the next few months we will therefore give these essential body bits the attention they deserve.

There are numerous common foot problems, and also some more unusual foot problems, which can be experienced by runners and non-runners alike.

Of all the foot injuries Plantar Fasciitis is among the most common, especially in running athletes, and constitutes 10% of all running injuries (Kibler et al, 1991). Plantar Fasciitis will therefore be the focus of discussion in this edition of the bulletin.

What is the Plantar Fascia?

The plantar fascia is a thick connective tissue structure that stretches from your heel bone (calcaneous), to the ‘knuckles’ of your foot on the underside.

By covering this region under the foot it protects the small bones, joints, ligaments, and muscles on the underside from direct trauma and friction, it provides flexibility for shock absorption, and creates a ‘windlass’ mechanism to transform the foot into a rigid lever to propel you forwards during running and walking. I did say it was impressive!

Anatomy of the foot including the plantar fascia

What can cause injury in the plantar fascia?

The plantar fascia can become irritated when subjected to abnormal or excessive stresses, especially running. High arches, excessive pronation during load bearing (running!), and even flat feet all lead to excessive stress and overstretching of the plantar fascia.

These inherent biomechanical factors are then usually combined with some other factor, such as increased training loads, inadequate shoe support, reduced dorsiflexion (ability to pull foot towards shin), reduced extension of the big toe (seen with osteoarthritis or trauma), and running on hard surfaces.

Plantar fasciitis usually occurs in middle age, with obesity also being a predisposing factor. It may be precipitated by a change in footwear, so be warned when you spend your two-week summer holiday entirely in flip-flops then return to running.

The mechanism of injury is thought to be repetitive microtrauma through overloading of the long arch of the foot, particularly on the inner side of the under-foot. Local tears ensue and there will be inflammation in or around the fascia where it inserts into the heel bone (calcaneous) as shown below:

There may be a traction injury resulting from the small muscles within the foot (which attach to the plantar fascia) contracting and pulling on a stretched plantar fascia during the ‘push-off’ phase of running or walking.

Is my foot pain plantar fasciitis?

Other problems in this area include a heel spur and fat-pad syndrome.

The latter is characterised by direct pressure under the calcaneous (heel bone), and usually follows a fall on to the heel, or a long history of poor heel cushioning. A heel spur will often present itself like a case of plantar fasciitis and may need x-rays to distinguish the difference if treatment is not progressing.

The most classic symptom of plantar fasciitis is pain when weight bearing first thing in a morning, or after sitting for a long while. With continued walking (or running) the pain eases off, but returns with prolonged periods of standing.

Pain is usually felt at the inner aspect of the under-side of the heel, and in severe cases you may experience this pain even at rest.

Please do not wait until this point before you see a suitably experienced physiotherapist or doctor, as it may be months before you are able to enjoy pain free running again.

That sounds like my pain, what do I do?!

As with all my advice, treatment must include correction of the underlying cause. This usually entails stretching exercises for tight structures, adequate shoe support and orthotics if needed to correct an abnormal foot posture, changes to training surfaces, and proper conditioning to support your running demands.

Here are some potential treatments:

1) Inflammation - Anti-inflammatories such as ibuprofen may help to relieve pain and reduce the local inflammation.

As always please see your doctor before taking any medication. In severe cases, a specialist GP or trained physiotherapist may administer a cortisone injection. I would always go straight for the ice (without the whisky!) as a first port of call. Apply for up to 20 minutes every 2 hours.

2) Pain on walking - Mechanical off-loading of the inflamed structure will reduce your pain in the short term and allowfor adequate healing in the longer term.

Methods to off load the plantar fascia may include using a heel cup with strapping, strapping / taping across the long arch of the foot to take up the strain, and using heel lifts in your shoes to reduce the strain on the Achilles tendon and thereby the plantar fascia.

3) Tightness - To discard the heel lift early in rehabilitation, stretching of the calf muscles and the Achilles tendon should be started from the outset. As withall stretches hold for 15-30 seconds and repeat 4 to 5 times. Here's an example stretch:

Plantar Fascia Stretch Exercise

Stretching of the plantar fascia and mobilisation of the ‘knuckle’ of the big-toe should be performed with the ankle in dorsiflexion (foot pulled towards shin), and the big-toe extended upwards. This can be achieved by modifying the above exercise to bring the big-toe up against the edge of the bottom step and then flexing the knee forwards over the step.

Massage with a golf ball, rolling pin, or cold can of drink (beer?!) can provide relief and stretch out the plantar fascia.

Progressing rehabilitation

Once inflammation is under control and you are progressing with stretching exercises, then strength and conditioning exercises may commence.

Muscles to target are those that turn the sole of the foot inwards (inverters), and the small muscles in the foot. Try exercises such as picking marbles and rolled-towels up with your toes, or turning the sole of your foot in against resistance.

Please do not progress your training too quickly as overloading an inflamed plantar fascia can in some cases lead to a rupture. A Chartered Physiotherapist can guide you through your training and help you make a speedy return to your much beloved running.

Enjoy your running, and keep injury free!

Ross

Ross Clifford MCSP is a practising Physiotherapist with a specialist interest in sport and exercise Physiotherapy. He also holds a Sport and Exercise Science degree and has taught in the area of Sports Injuries and the Biological Sciences. He is a keen runner and cyclist.