Having experienced a long-term (though fairly low-grade) case of plantar fasciitis myself a few years ago, I’m always curious when I see reports of potentially effective treatment protocols for the condition. As such, I though I’d dig a bit more into this study.

The full text is not available for free (I received a copy from the author), but the lead author wrote up a nice summary of what they did on RunningPhysio.com. Basically, they took 48 patients with diagnosed plantar fasciitis and randomized them into either a plantar-specific stretching regimen or a high load strength training regimen for the foot (all subjects also received gel heel inserts).

Here’s the description of the stretching regimen (via Michael Rathleff on RunningPhysio):

“Patients were instructed to perform this exercise whilst sitting by crossing the affected leg over the contralateral leg (Figure 1). Then, while using the hand on the affected side, they were instructed to place the fingers across the base of the toes on the bottom of the foot (distal to the metatarsophalangeal joints) and pull the toes back toward the shin until they felt a stretch in the arch of the foot. They were instructed to palpate the plantar fascia during stretching to ensure tension in the plantar fascia. As in Digiovanni, patients were instructed to perform the stretch 10 times, for 10 seconds, three times per day [10].”

The above-described plantar fascia stretching regimen was used in a previous study (DiGiovanni et al., 2003) and was found to provide superior results to an Achilles tendon stretching regimen.

Here’s the description of the strengthening regimen (via Michael Rathleff on RunningPhysio):

“High-load strength training consisted of unilateral heel-raises with a towel inserted under the toes to further activate the windlass-mechanism (Figure 2). The towel was individualised, ensuring that the patients had their toes maximally dorsal flexed at the top of the heel-rise. The patients were instructed to perform the exercises every second day for three months. Every heel-rise consisted of a three second concentric phase (going up) and a three second eccentric phase (coming down) with a 2 second isometric phase (pause at the top of the exercise). The high-load strength training was slowly progressed throughout the trial as previously reported by Kongsgaard et al. [11]. They started at 12 repetition maximum (RM) for three sets. After two weeks, they increased the load by using a backpack with books and reduced the number of repetitions to 10RM, simultaneously increasing the number of sets to four. After four weeks, they were instructed to perform 8RM and perform five sets. They were instructed to keep adding books to the backpack as they became stronger.”

And here is the summary of study outcomes that the lead study author wrote on RunningPhysio:

We used the Foot Function Index as our primary outcome after three months but also did follow-ups after 1,6 and 12 months. At our 3 months follow-up we saw that patients randomised to high load strength training had a 29 points lower Foot Function Index. This is far greater than the minimal relevant difference and suggests a superior effect of high-load strength training compared to plantar specific stretching. An important aspect is that we saw no difference between groups at 6 and 12 months indicating no superior long-term effect. However, if you ask patients to choose between two treatments that have similar long-term effect but one will give you a quicker reduction in pain, I am certain that all patients would choose the treatment, which provides them with the quickest reduction in pain.

This all sounds great – if you have plantar fasciitis and want to improve your symptoms, a foot strengthening routine like the one used in this study could provide relief more quickly than a stretching routine. There is some logic behind this finding as eccentric loading is commonly used to treat tendon injuries such as in Achilles tendinopathy. The idea is that if you strengthen the tissue, it becomes better capable of handling the loads placed on it.

As with any academic study, it’s always important to be open minded and critical. Such is the nature of science. Podiatrist Craig Payne recently wrote a critique of this study on his site Run Research Junkie, and it makes for interesting reading. He points out that the results are consistent with the approach he advocates for treating plantar fasciitis, and outlines a number of positives about the study. But he also points out a number of concerns. Of these, I’m only going to comment on one here, and that is the lack of a control group that did not receive either intervention (or the gel heel inserts).

As Craig points out in his critique it is not atypical for plantar fasciitis to simply improve on its own with time (sometimes an extended period of time). For example, I experienced symptoms with my case of PF for over a year, and though I did seek treatment I have no idea if my case resolved due to a specific intervention (e.g., I did a lot of calf foam rolling, Graston/ART, and some stretching) or if it simply resolved on its own (it actually improved during a summer when I was running a lot more miles than I had in quite awhile). Thus, without a control group in this study we can’t say for certain that stretching or strengthening exercises performed better than just letting the case of PF improve with time (it’s worth noting that studies looking at the effectiveness of stretching vs. controls for treating PF have given mixed results). Craig also points out that the intervention of the gel heel insert in both groups could have contributed to improvement, but again we cannot assess any influence of that compared to a group that did not receive a heel insert.

All we can really say with certainty from this study is that foot strengthening exercises provided quicker improvement in plantar fasciitis symptoms when compared to plantar stretching. It’s important to note that this does not preclude either of these interventions as potentially valuable tools in the treatment of plantar fasciitis. It’s also worth noting that plantar stretching is a commonly used/advocated approach to managing plantar fasciitis, so in that sense this study was comparing a new protocol to one that is commonly used. As such, the fact that strengthening led to quicker improvement in symptoms is a valuable finding. But I do agree with Craig in that the lack of a control group makes it difficult to discern the benefit of either protocol relative to doing nothing at all. A logical follow-up study would therefore be to compare foot strengthening exercises to a sham treatment or no treatment at all.

All of the above being said, the logic behind the strengthening approach does make sense to me and is, as mentioned, consistent with treatment protocols for some forms of tendinopathy. If my PF decided to return at some point it’s a treatment I would consider, but I would like to know a bit more about how it performs relative to a control.

Plantar aspects of foot, varying depths (superficial to deep) (Photo credit: Wikipedia)

I’ve been meaning to write this post for a long time. However, I’ve been holding off because I wanted to be sure that I have in fact won my battle with persistent heel pain. I’m finally at a point where I think my war with plantar fasciitis is officially over.

As a runner, I’ve been very lucky in that I have not succumbed to any significant running-related injuries. In fact, the only injury that kept me from running for more than a few days occurred as a result of running a second marathon in a month’s time in a new pair of racing flats (my first marathon in flats). I developed a case of peroneal tendonitis that stopped me cold on a few subsequent runs and sent me limping back to my house. Given the stupidity of my approach to that race, I deserved to get hurt, but even then I missed less than a week of running.

For the most part, my body seems to repair itself pretty quickly. Aches and pains pop up, and usually within a few days they go away. I’m usually good at listening to my body, and I’ve developed strategies for attacking aches that seem to be very effective for me (e.g., mixing up shoes). However, the one pain that appeared and simply did not want to go away began in late 2010.

I can’t remember exactly when my heel pain started, but I think it was shortly after the above-mentioned race in which I injured myself. I know that the pain was in full force in January 2011, and it lingered for well over a year. The symptoms pointed to a classic case of plantar fasciitis. Pain, sometimes intense, upon first waking up in the morning, just below my left heel. It hurt to put any kind of pressure on my heel for the first few steps after getting out of bed. After a bit of walking the pain would ease off, and on most days it would go away such that it wasn’t a big deal. Sometimes it would hurt on runs, most often not, and it was never bad enough to keep me from running (I didn’t miss a single day of running due to heel pain). I couldn’t find any pattern linking my footwear choices to the appearance of the pain, except that shoes with hard heels made it hurt when I walked (e.g., Merrell Trail Glove and Vibram Trek Sport), and I recall one memorably painful run in the Saucony Guide 5 (talk about shoes that have little in common!).

Until summer 2011, the pain was isolated to my left foot. That summer I ran a 5K in Vibram Fivefingers just to see how fast I could go in a barefoot-style shoe, and though the race went well, I strained the insertion of my abductor hallucis muscle on the inner side of my right heel. The insertion was tender, and not long after that pain appeared underneath my right heel as well. I had what I self-diagnosed to be bilateral plantar fasciitis (I may or may not have had a bit of assistance from Dr. Google, perhaps you know him?).

I was never particularly aggressive in trying to treat the pain, mainly because it was never much more than a first-thing-in-the-morning nuisance. A bit of calf stretching, both straight legged and bent-knee to target the soleus muscle, seemed to do the trick. Being in zero drop shoes at work all day seemed to keep things loose and stretched out (particularly my calves), which I think helped prevent progression to a more severe case, and on most days I’d forget that I even had a problem. But the pain was still there every morning, both under the heels on each side and at the abductor hallucis insertion on the right side. By early 2012 I realized that when something painful lingers for over a year, it might be worth getting it checked out (yes, I am sometimes stubborn). My wife had been seeing a chiropractor friend (Brett Coapland of Performance Health Spine and Sport Therapy) who specializes in treating athletes (she’s had nagging hip issues since the birth of our daughter), and I decided to let him have a go at fixing my feet.

Brett has great manual therapy skills, and he did some active release work and Graston on my feet and calves. He also did a bit of dry needling – not sure if it helped, but it sure felt interesting. He also gave me some exercises and stretches to loosen up my posterior chain – my hamstrings and calves were wickedly tight after years of neglect. We talked a lot about trigger points (I had some really tender spots in my lower legs), and he had me doing regular foam rolling of my calves, particularly my soleus in the lower calf.

The first foam rolling sessions were intensely painful, even worse-so when I used the Rumble Roller, which may as well be a medieval torture device! I remember on one occasion my 2yo son taking the roller away and putting it out in the hall because I was screaming out while rolling my legs. In addition to stretching my hams and calves, I also regularly worked my foot over a rubber bouncy ball (stolen from my kids – they’re a great source of improvised self-therapy devices) and a Foot Rubz ball.

Over the following weeks I noticed my hamstring mobility improving – I actually reached a point where I could touch my toes with locked knees – never been able to do that in my life! Un-weighted, stiff-legged deadlifts in front of a wall seemed to really help stretch out my hams. Foam rolling got progressively less painful, and I became a strong believer that it does actually accomplish something beneficial – it seemed to really work away some of the angry spots in my calves. It’s really hard to say for sure, but the heel pain did seem to subside a bit as I headed into Spring 2012.

Another thing worth mentioning is that in January of this year I started taking Taekwondo classes with my kids. Taekwondo is great for improving flexibility and strengthening the feet and legs. It’s also great for improving balance. We always practice barefoot, and much of the class involves standing on one foot. Again, I don’t know if this helped, but it’s a factor worth mentioning. I also played around a bit with using Therabands for foot strengthening, as well as an AFX Foot Strengthener, which is an interesting device. I’m really lousy when it comes to following through on home strength work though, and given that Taekwondo was a scheduled class twice per week, that was my most consistent outlet for strengthening exercise.

Move the calendar forward to July 2012, and I embarked on the two most intense months of running I have ever undertaken (monthly mileage PR’s in both July and August). And, rather surprisingly, my increase in mileage coincided with a complete cessation of my foot pain. My feet still felt a bit tight when I first woke up (and they still do), but no pain to speak of, and nothing at all during the day or on runs. The lingering pain at the insertion of my right abductor hallucis muscle disappeared as well.Three months later and that’s where I am now – pain free and still not quite sure how I got here.

Lots of people will claim to have the answer to curing plantar fasciitis. I will make no such claim. All I can say is that the diminishment and ultimate cessation of my pain seemed to coincide with three things – starting Taekwondo in January, being treated by Brett and following his advice in the winter through early Spring (mostly for calf work after the initial few appointments), and ramping up my mileage from Spring into summer (2011 was a low for me running-wise – many weeks with only 10-15 miles max). I don’t know which of these factors, if any, was most important in fixing me (or if all played a role), but let me wildly speculate for a minute (this is, after all, a blog and not a medical journal, so I’m allowed to wave my hands around a bit here).

Here’s what I think happened. I started running minimalist in 2009. As it does for most people, moving to low drop shoes, particularly zero drop, non-cushioned shoes, resulted in a lot of initial calf soreness for me. I had sore calves for a long time, and I never did anything to take care of them. No stretching, no foam rolling, nothing. I think that as I accumulated more and more miles in flat shoes my calves got progressively tighter and tighter. Then, I ran a hard marathon training cycle in late 2010, with two hard-effort marathons in late 2010. I think the progressive battering of my calves for over a year combined with those races (and the preceding intense training) may have triggered the pain in my feet. I continued to do nothing to take care of my legs through 2011 (short of being in flat shoes all day to keep my calves from shortening up), and my mileage diminished considerably so there was less positive stimulus for repair. The pain lingered.

As I moved into 2012 I began doing intensive strengthening and flexibility work on my feet and legs in Taekwondo, then added to that by seeing my chiropractor and following his treatment plan. The calf foam rolling worked wonders, and continued flexibility work helped as well. As my calves loosened up, they pulled up less on my calcaneus on each side and eased some of the strain on the plantar fascia below (the tissues are all interconnected). My calves no longer seem to get sore when I run zero drop now, so that is an added bonus. Then, as I increased my mileage I kept a good positive repair stimulus going and kept the blood flowing well to the damaged regions of my feet. Repair occurred, and the pain went away.

The above story sounds good, but it’s just my speculation about what worked. One of my goals in the future is really to dig into the literature on specific running injuries and summarize what we do and don’t know (I hope it doesn’t lead to another book…).

If I had to give advice to anyone dealing with chronic plantar fasciitis it would be to not focus solely on the feet. Consider your calves, as well as regions higher up in the leg. The pain in your foot may simply be a reaction to a problem somewhere else (e.g., incredibly tight calves from going minimalist without any attempt to maintain tissue quality in transition – I’m a disciple of Jay Dicharry in this line of thinking, read his book!).

If you have tight calves, get a foam roller – I really have become a believer in what they can do with regular use. I’ve come to believe that a foam roller should be mandatory equipment for anyone planning to go minimalist, particularly if your goal is to go zero drop. You need to take care of those legs in transition! Do as I say, not as I did – I hope people can learn from my mistake :)

I also think that being in zero drop shoes almost full time prevented progression of my pain into something more severe. Pain occurred for me immediately after any time I relaxed my calves for an extended period of time – at night while sleeping, in the evening on the couch, etc. Wearing flat shoes all day helped to keep my calves fully lengthened while standing and walking, whereas a heel lift would have shortened their working range during the day.

And don’t think that treating pain always requires rest – my pain went away in concert with the biggest ramp-up of mileage in my life! Rest can definitely be helpful in overcoming acute pain, but it doesn’t necessarily resolve the underlying cause – you need to get at the root of the problem if you want long term resolution of the issue. Again, for more on this read Jay Dicharry’s book.

Most importantly, don’t despair – my heel pain, though never acute, lasted for upwards of 16 months. But it’s now gone, and I just ran a half-marathon PR last weekend. There is a light at the end of the sometimes very dark plantar fasciitis tunnel!