PLANTAR FASCIITIS: HEEL PAIN IN RUNNERS
If you’ve ever woken up in the morning, taken your first steps, and felt a sharp pain in the inside of the heel it is likely you have experienced plantar fasciitis or plantar fascia pain syndrome. The pain typically presents after prolonged sitting or laying down when beginning to stand and walk again. It gets better after the first few minutes of standing and walking in the morning, with a reduction in pain as activity increases up to a point – the pain can worsen again with long bouts of activity or running. Plantar fasciitis can be frustrating at best and debilitating at worst, sidelining runners for weeks or even months if it persists.
The plantar fascia is a thick band of connective tissue that spans the bottom “plantar” surface of the foot to support the arch of the foot while protecting the soft tissues from the ground. Anatomically it connects the heel bone “calcaneus” to the toes. With repetitive stress and loading, the plantar fascia is susceptible to inflammation which can precede tissue thickening and degeneration. In this post, we'll explore the causes of plantar fasciitis, the latest research on the condition, and the best interventions for treatment and prevention.
Who Gets Plantar Fasciitis?
The onset of plantar fascia pain is multifactorial, but there appears to be a correlation between mechanical load and the onset of symptoms. This is commonly an overuse injury. Repetitive stress and strain on the plantar fascia are common in runners who increase mileage or intensity too quickly without allowing sufficient recovery time. Think of going from couch to 5k, or preparing for your first marathon and ramping up your running volume significantly over a short period of time.
Biomechanical factors may play a role in the onset of plantar fasciitis. Excessive pronation (flat feet), allowing the arch to collapse excessively during the mid-stance phase of the running gait cycle can apply strain on the plantar fascia. Up the chain, we have to consider the role of the ankle and posterior leg. Limited ankle dorsiflexion (allowing knee over toes) mobility or decreased flexibility in the calf muscles and Achilles tendon will influence a collapsed arch during the gait cycle. Additionally, strength deficits in the gastrocnemius and soleus muscles will increase the load on the inert, non-contractile connective tissues such as the Achilles tendon and plantar fascia.
Footwear may play a role as well and is worth taking into consideration. Running high volumes in shoes that lack the proper arch support may accentuate any issues with overpronation. Adequate cushioning is also important in running footwear, especially when running high mileage volumes on hard man-made surfaces.
However plantar fasciitis is not a condition reserved for runners. This type of heel pain can occur across the spectrum, in sedentary individuals as well as highly active ones. The greatest known risk factors for plantar fasciitis are elevated body mass index (BMI) and a sedentary lifestyle. So more often than not, the answer to plantar heel pain is NOT complete rest. Rather, this condition requires an active approach to decrease pain and return to running pain-free.
Managing Plantar Fasciitis
The first line of defense in both preventing and managing plantar heel pain is load management. This means taking some time to reflect on your past training and activity levels – look at your training volume and training intensity for the 4 weeks prior to onset of symptoms. It is recommended to decrease training volume by 50% in the short term to allow symptoms to reduce. If you have been running 4-6 miles for your daily runs, decrease this to 2-3 miles for one week and monitor your symptoms both during and after the run. To maintain fitness during this period, consider supplementing with low-impact cross-training like aqua running, cycling, or swimming. Monitoring pain will be important during this period, as this will determine progression. If symptoms decrease throughout the week and are no greater than a 2 to 3/10 intensity, you may add volume gradually before returning to speed workouts. If the pain during activity is tolerable and is not increasing later on in the day or the next morning, you are likely moving in the right direction.
During the recovery phase, systematic reviews have shown that both stretching and strengthening exercises can help reduce symptoms and facilitate healing. The plantar fascia can be stretched in an unloaded position by sitting, pulling the toes upward toward the shin, and holding this position. You can add body weight for loading the plantar fascia by standing barefoot, doing a calf raise, and holding this position for 10 seconds for 10 repetitions. Start with performing this stretch on two feet, then progress with performing on one foot.
Progress the loading of the plantar fascia and surrounding tissues by performing standing heel raises with a towel or wedge under the toes, placing the toes on a rolled-up towel, and performing a heel raise. Increase the difficulty and intensity by performing this from a deficit, off the edge of a step to strengthen the calves through a full range of motion, and load the plantar fascia in a stretched position. Be mindful of the tempo when doing this heel raise variation - rise up for 3 seconds, hold for 2 seconds, and lower for 3 seconds through a full range of motion.
Another piece of the puzzle includes footwear and orthotics. There is a deep rabbit hole here to be explored in another article. Finding the right footwear is highly specific and depends on the individual. Some swear by a minimalist, zero-drop shoe to allow for natural foot mechanics while others a rigid and supportive shoe. Research by Nigg and others has suggested the most important factor in selecting a shoe is comfort, and therefore my recommendation is often to run in the most comfortable shoe you can find.
However, if you are a runner with excessive pronation, and flattened feet with a collapsed arch, you might consider wearing shoes with proper arch support and cushioning. Custom orthotics or over-the-counter insoles can provide additional support and distribute pressure more evenly across the foot as well to offload the plantar fascia. A 2019 clinical trial by Whitakker and colleagues assessed interventions with individuals with plantar fasciitis and found that foot orthoses were more effective long term compared to corticosteroid injections although injections provided more rapid short-term relief. Other options for short-term pain relief include ice, or using a frozen water bottle to roll on the bottom of the foot. This can help with short-term pain relief and address any inflammatory factors, however it should not be a stand-alone intervention.
What to do if pain persists
If pain persists for several weeks despite conservative efforts of managing training load and utilizing the strategies above, consider seeking care from a local health care provider or physical therapist. Techniques like soft tissue massage, myofascial release, and physical therapy modalities such as dry needling and shockwave therapy have been shown to reduce pain and promote healing. Night splints can help keep the foot in a dorsiflexed position overnight, preventing the plantar fascia from contracting and becoming painful in the morning.
Plantar fasciitis is, for the most part, a self-limiting and pain-limiting condition. It is a common and often challenging condition for runners. Understanding its causes and implementing evidence-based interventions can help alleviate symptoms and prevent recurrence. As always, listening to your body, maintaining a gradual and balanced training regimen, and seeking professional advice when needed are key to staying healthy and enjoying your running journey.
Van Leeuwen KDB, Rogers J, Winzenberg T, Van Middelkoop M. Higher body mass index is associated with plantar fasciopathy/’plantar fasciitis’: Systematic review and meta-analysis of various clinical and imaging risk factors. Br J Sports Med. 2015;50(16):972-981.
Nigg B, Baltich J, Hoerzer S, et al. Running shoes and running injuries: mythbusting and a proposal for two new paradigms: preferred movement path and comfort filter British Journal of Sports Medicine 2015;49:1290-1294.
Whittaker GA, Munteanu SE, Menz HB, Gerrard JM, Elzarka A, Landorf KB. Effectiveness of Foot Orthoses Versus Corticosteroid Injection for Plantar Heel Pain: The SOOTHE Randomized Clinical Trial. Journal of Orthopaedic & Sports Physical Therapy 2019 49:7, 491-500.
Morrissey D, Cotchett M, Said J'Bari A, et al. Management of plantar heel pain: a best practice guide informed by a systematic review, expert clinical reasoning and patient valuesBritish Journal of Sports Medicine 2021;55:1106-1118.
Koc TA, Bise CG, Neville C, Carreira D, Martin RL, McDonough CM. Heel Pain – Plantar Fasciitis: Revision 2023. Orthop Sports Phys Ther 2023;53(12):CPG1–CPG39. doi:10.2519/jospt.2023.0303
