I am not sure how many other doctors get this question, but it’s a frequent one in my office. As a runner and triathlete who’s always racing, I am constantly experiencing the same aches and pains as many of my patients, so I can relate to the frustration. With racing season upon us, it’s not surprising that I have been asked this question a number of times already this week regarding plantar fasciitis.
Plantar fasciitis is a painful and often debilitating injury for athletes. The textbook morning pain or pulling sensation at the inside aspect of the heel bone, can sideline the best of them and is quite common in our very active running community.
The plantar fascia is a strong band of fibrous tissue that originates from the heel bone and runs distal to the heads of the metatarsals. The muscle has a medial, central and lateral band. Most cases of plantar fascia involve the medial band at either its insertion spot on the heel bone or just under the arch.
Sometimes there is a bone spur associated with plantar fasciitis, which often is a result of the fascia inflammation and tightness rather than the primary source of the pain. Common factors that contribute to plantar fasciitis are flat or hyper-pronated feet, high arches, overuse, poor shoe gear selection, tight calf muscles, or running too much, too soon, too frequent, or over too many hills. The most common scenario I see in the office usually involves a runner that relates heel pain with morning muscle stiffness that loosens up, but then becomes increasingly more painful as the day goes on.
So inevitably the “what would you do, doc” question arises. I have learned over the years that while rest is important, so are many of the available conservative adjunct therapies. There is no doubt that injured tissue needs time to heal, especially when it comes to the fascia. The length of time someone needs to heal varies anywhere from one to six weeks, and sometimes longer. However, I have found addressing a few common denominators at the outset through preventative techniques always improves outcome and shortens the recovery time.
First, staying consistent with cross training is important to maintain fitness, as well as strength and flexibility (and sanity). It’s no surprise, that as a triathlete, I recommend cycling and swimming as excellent cross training modalities. I am often asked about the elliptical or Stairmaster for cross training purposes, but I am not thrilled with them, as they both tend to put additional stress on the fascia, thereby delaying healing.
Second, addressing muscle tightness in the calf is important, as studies have shown a direct link between calf tightness and plantar fasciitis. Studies have also shown weakness in the flexor digitorum brevis, an intrinsic muscle in the foot, to be another important contributing factor to plantar fasciitis.
Simply picking up marbles or a washcloth with the toes and feet can address these muscles pretty specifically. Weakness in the core can also alter your stride, transforming your muscle mechanics negatively and facilitating the onset of plantar fasciitis. Working with a good therapist or trainer can help identify muscle weakness and imbalances to set you straight (no pun intended)!
Another way to help strengthen and stretch these muscles is through yoga. There is no doubt that a good Vinyasa practice can help build strength, flexibility, balance and proprioception, all of which can improve one’s running abilities. So runners get used to the ohms and namastes!
Third, have your foot type evaluated closely by a medical professional with a gait analysis. A gait analysis will go far beyond just evaluating whether or not an athlete pronates, supinates or has a neutral foot type, but rather will take the whole body into account. Gait analysis plays a very important part in evaluating a runner’s propensities towards injuries, and facilitating a quicker recovery from them, as fallen arches or runners who over-pronate may be stressing their fascia more.
If you suffer from any of these issues, purchasing a stability shoe or custom arch support will drastically improve your discomfort. I personally run with custom orthotics. They offer my flat feet the proper support needed so I can avoid relying solely on a running shoe for support and cushioning. High arch feet will also benefit from proper support, but also requires a shoe with additional cushioning so it does not leave the fascia under greater tension. If you haven’t had a gait exam, get one done. Understanding your body’s mechanics is a valuable tool!
But what if these conservative and preventative techniques don’t alleviate the pain?
First, speak with your doctor regarding a cortisone injection. When it comes to a cortisone injection many athletes are apprehensive, and understandably so. While it is not my first course of treatment, and I actually prefer to see a patient fail at least four to six weeks of conservative therapy before resorting to an injection, athletes can benefit greatly from cortisone injections when given at the right time.
A cortisone injection will reduce inflammation and pain, which promotes healing. I have found in my own instance that I have benefited from them when given at the appropriate time. However, if you are going to opt for an injection after consultation with your doctor, make sure it is given utilizing ultrasound guidance for improved accuracy.
Another treatment I use on patients often (including myself) suffering from plantar fasciitis, is low pulse activation therapy, or what is commonly referred to as shockwave therapy. Studies have shown these low level shockwaves will produce enough controlled “trauma” to induce a cellular affect towards tissue healing. Shockwave therapy has also shown to increase local blood flow, which is critical in facilitating healing. Shockwave treatments typically take five minutes, cause little, if any, discomfort, and results are usually seen in three to five treatment sessions.
Doctors and physical therapists have also utilized Trans Electrical Nerve Stimulation (TENS) units over the years and have seen a good amount of success with them. Nerve stimulation not only mitigates inflammation, but it also provides analgesia, or pain relief. Using a TENS unit once a day for 30 minutes, five to seven days a week, can speed up healing and facilitate injured tissue repair. I usually have my patients follow this with 20 minutes of ice therapy. If you are looking for an easy ice therapy method check out ice-sox.com.
Platelet rich plasma therapy (PRP’s) is another widely used treatment by sports doctors and podiatrist for patients suffering from plantar fasciitis. In my practice, I have found it to be very useful and effective for conditions such as plantar fasciitis, Achilles tendonitis and lateral ankle sprains, strains, and instability. PRP allows you to target specific areas of soft tissue that need repair, by injecting platelets that contain growth factors that are responsible for cellular healing and repair.
These injections also increase the amount of local blood flow to the targeted area, which when combined with the growth factors, exponentially increases the body’s ability to heal and repair naturally. Again, if you opt for PRP therapy, make sure it is done utilizing ultrasound guidance.
Massage therapy: Prevention is certainly the best medicine and this is why I love massage therapy. Professional athletes, top age-groupers and weekend warriors alike can benefit greatly from the powers of massage. While there are a variety of techniques, a good deep tissue sports massage is all that’s needed. Sports massage can break up scar and fascia adhesions, remove unwanted cellular debris, relax and lengthen smooth muscle for quicker recovery and injury prevention. Isang Smith has been New York’s secret massage therapy weapon. An elite level runner herself, her hands are nothing short of miraculous. Relax and let someone up your recovery game.
Shoes as medicine is a term I like to use. If the right food keeps us healthy, the right shoe can keep us injury free. As mentioned above, know your foot type and running mechanics, but also know what shoe works best for you. Do you need more cushion on those long training runs? A lighter weight shoe for quicker turnover on your tempo and fartlek runs? Prone to one injury or another? I’ve always varied my shoes, and I feel most runners should too. To do this I’ve always relied on my own personal experience, shoe reviews, and the shoe doctor himself, Nyles Garrison at The Running Company in New York’s Time Warner Company. He’s another professional who walks the walk and talks the talk. We’ve spent countless hours discussing injury, training and shoes! It’s definitely worth your time.
Finally, an option of last resort that I will employ for my patients with chronic plantar fasciitis is the plantar fascia release. It is exactly what the name implies; however, it is releasing only a very small area of the plantar fascia that inserts onto the medial heel tubercle, also known as the “hot spot”. This mechanism essentially releases the area of the fascia under the greatest tension to alleviate pain. This procedure has great success. However, it should be utilized as an “option of last resort.”
With so many treatment options and algorithms available, athletes have a variety of options that can be tailored to them and the approach they want to take. I always emphasize quick diagnosis and appropriate treatment to get injuries under control fast. While plantar fasciitis is very common and most troubling, it does not have to sabotage your upcoming race season. Athletes should seek out doctors or sports care professionals who understand running mechanics and the importance of running on their life. It’s a relationship built for success.
Dan Geller, DPM
Sports Podiatry/Foot and Ankle Specialist
This story first appeared on hitthegroundrunning.me.