An Unconventional Way to Treat Plantar Fasciitis
You’ve just been diagnosed with one of the most frustrating running injuries: plantar fasciitis. Conventional wisdom is to stop running. The good news is that under many circumstances that advice is wrong. While you may not be able to continue at your current intensity, you can often continue to run while treating your plantar fasciitis. That’s because, paradoxically, stressing the tissue (or what I call “loading”) is actually the pathway to healing this condition. Very rarely does totally shutting it down help plantar fasciitis.
Emerging evidence shows that stress is required to stimulate the healing process of the plantar fascia (PF). For example, consider a study by Michael Rathleff, PhD out of the Orthopaedic Surgery Research Unit of Aalborg University Hospital in Denmark. For the study, Rathleff and colleagues tested a high load strength program for the plantar fascia. When compared against standard treatment protocols, they found that the strength program significantly out preformed typical care—stretching and shoe inserts—at a three month follow up. (The strength group performed single leg heel raises with a towel inserted under the toes, which you'll learn more about below.)
Why does loading help? No different than how in order to build your leg muscles for running you need to challenge your legs in workouts, you also need to “challenge” your plantar fascia for it to repair, regenerate, and become stronger.
Now, obviously, we’ll need to change something. After all, what you're currently doing is making your foot hurt! Your goal is to find a level of stress—through running and targeted exercises—that stimulates the healing of your PF but does not make it worse. The best way to find that level is to use pain as your guide:
0-3 (Green Zone): During your runs, you are aware of your plantar fascia, and you may be feeling minor discomfort near your heel.
4-6 (Yellow Zone): Your heel hurts enough that you are changing your gait; you feel it on every step; it is significantly painful first thing in the morning; and/or it is significantly painful when you begin to run.
7-10 (Red Zone): Every step is excruciating; you know you shouldn’t be forcing yourself to run. Don’t lie to yourself.
Note: Shooting For The Sweet-Spot: It is important to understand that if the symptoms are slightly worse for a few hoursafter doing the targeted exercises (or after running), that may be OK. If the symptoms are present into the following day, however, you’ve done too much. You are trying to stay in the “sweet-spot” zone of stress. Too much and you aggravate the injury, not enough and you aren’t helping the injury heal. For more on this idea read: Load for healing.
In the treatment approach that follows, your goal is to stay in the sweet spot, which generally means between 0 and 3, or in the green zone. If your symptoms are above 0-3, you are in either the yellow zone or red zone and you will need to make modifications, described below. Now that we’re on the same page about what the “right” level of stress is, let’s discuss how to go about applying it.
If your pain is currently 6 or above, you are in the red!
Too many stubborn endurance athletes have forced themselves to run through this kind of bad pain, only to end up sidelined for a prolonged period of time. Better to take a week or two off now than six months off later.
- Stop running. Unfortunately, if your pain is this bad, you will likely need some time away from running to get the symptoms under control. In general, I usually wait until my patients are back in the 0-3 pain range with daily activities before re-introducing running. Don’t be discouraged, this usually doesn’t take long.
- Attempt the exercises outlined below and try to find the “sweet-spot” zone of stress. In these more acute cases, doing the isometric exercises and taping tend to be the most effective early on. (See the videos below.)
If your pain is 4-5 you are in the yellow and will need to modify your running.
- Modify your running. Each case is individual but start by reducing the duration and intensity. Also, avoid uphill running, as that will add too much stress to your plantar fascia. You may also need to reduce the overall frequency with which you run to allow for the plantar fascia to recover and adapt between runs.
- Perform the exercises below, assuming you can find the “sweet-spot” amount of stress.
If your pain is 0-3
- You may need to modify your running. Start by cutting your overall duration and avoid uphill running.
- Perform the exercises below, assuming you can find the “sweet spot."
Banded Toe Strength - strengthening the muscles which support the plantar fascia is vital to the recovery process. This can be a very early phase exercise.
The band is resisting the lesser 4 toes while the big toe stays in contact with the ground.
Sets: 3 Reps: 15
Isometric Calf Raise - isometric just means there is no movement while you are contracting the muscle and you just hold the contraction. When symptoms are acute this may be a good place to start. Often times the pain will improve after doing the isometric exercise.
Tip: To increase the stress to the plantar fascia, roll up a towel and place it under your toes as done in the video below.
Sets: 2 Reps: 10 holding each for 10 seconds
Plantar Fascia Heel Raises - This is the exercise from the research study referenced above.
The towel elevating the toes places more tension into the plantar fascia. This is a mainstay in the rehab process for this injury. Do this if you can stay in the sweet spot while preforming this exercise.
Sets: 3 Reps: 15
Remember you're ultimately shooting for the "sweet spot"
Rolling - keeping your foot loose throughout the recovery process is important and should help reduce pain and improve the function of your foot. You can attempt this at any stage.
Taping - Applying this taping application protects the plantar fascia at the bottom of the heel by gathering the heel's natural fat pad for increased cushioning. At first this may feel VERY tight but the tape will loosen up after walking around. The tape I use is Luekotape P, which is a rigid athletic tape. Taping your heel daily for a period of time can help reduce the irritation and sensativity of the plantar fascia.
It is important to note that these are general recommendations and nothing replaces a skilled and trusted professional’s hands on your foot. Also, this is one aspect in a holistic approach to your injury and there are likely other things that will be helpful.
Rarely do you need to completely rest plantar fasciitis for extended periods of time. On the other hand, continuing to do the same training that lead to the injury is also unlikely to work. The important take away is that load plays a vital role in healing. Finding the sweet spot of loading, both in running and targeted exercise, can be the difference between healing and not healing. This is often the most important conversation I have when I see patients who have struggled with PF. Too often people either completely shut down running, or, they do the opposite: they just plow through training expecting something to change without making any adjustments. The answer often lies in finding a middle ground.
Hopefully this article has helped to give you some direction and actions to begin the healing process.