Plantar fasciitis – everything you need to know to recover faster

Alongside runner's knee and achilles tendinopathy, Do men and women process pain differently running injuries. Although it's a frustrating and, for some, slow-healing condition, there are several things you can do to fast-track your recovery, from rest to specific exercises, and even ankle supports. Here, sports medicine physician Dr Jordan Metzl and charted physiotherapist Matt Bergin explain everything you need to know.

The plantar refers to the area on the bottom of the foot, and the plantar fascia is the thick band of connective tissue running from your heel bone to the front of your foot. This tissue helps support your foot’s arch and gives it shape, and it aids in stability when your foot strikes the ground and then pushes off.

Historically, plantar fasciitis was thought of as an inflammatory condition. However, more recent studies have suggested that there is often a lack of any true inflammatory signs, and that it is, instead, a degenerative process that brings with it a thickening of the plantar fascia heel attachment. In a similar fashion to that of an achilles tendinitis injury, plantar fasciitis is more commonly known as plantar fasciopathy (like tendinopathy) in the medical world.

An injury to the fascia usually begins where the fascia connects to the bony bump on the bottom of the heel called the calcaneal tuberosity. The inflammation and pain come from excessive tension. The muscles above, and the shape of the foot below, contribute to its development. The calf muscles (specifically, the gastrocnemius and soleus) connect to the heel bone via the achilles tendon. When those muscles are tight, the tendon pulls on the bone from above, stretching the fascia and causing strain. People with high arches are especially prone to plantar fasciitis because the arch itself also contributes tension to the fascia.

A mild case can turn major very quickly if ignored. Tears, although less common, can also occur in the plantar fascia. These are a totally different injury – and an article for another time – but are not to be missed. Tears to the plantar fascia will typically be much more acute and symptoms will be more severe. And there will often be a moment of sudden injury that a runner can quite clearly remember.

To confuse things further, you can also have a chronic, long standing plantar fasciitis ( fasciopathy) alongside an acute plantar fascia tear. If you suspect you are suffering from this, visit a physiotherapist.

The main symptoms are a nasty pain in the bottom of the foot, especially at the inner attachment point into the heel, and usually felt when taking your first steps out of bed in the morning or those first few minutes of a run.

Plantar fasciitis has many causes, so there is no definitive answer to that question, frustratingly. Training errors are often to blame. For example, suddenly ramping up your mileage, or jumping into speedwork or hill intervals.

There are a number of biomechanics that may predispose someone to developing plantar fascia type injuries, and especially around the foot-ankle complex. Stiffness in the ankle and big toe joints have been shown to contribute to stress on the plantar fascia. Both the small intrinsic and larger extrinsic muscles of the foot and ankle have been shown to impact loads placed on the plantar fascia as well – and especially if these muscles are weak. People with high arches often run into issues as well, with the raised arch of the foot stiffening the mid-foot and impacting it's shock-absorbing effect on landing, when running.

Dynamic rest: Take a break from the activity causing the problem. The earlier you address plantar fasciitis, the better. How long you need to rest depends on the severity, but expect at least a couple of weeks. Stick with upper-body activity that doesn’t load your foot. This may be frustrating, but think long term – it’s better than being out of the game for months.

Stretch: Use the stretches described below. Be gentle. Go slow. You’re trying to relieve the tightness in the area, not prepare for a race. As the injury heals, adopt this stretching routine permanently.

This is a good running drill that works on the: An anti-inflammatory such as ibuprofen or aspirin can help reduce pain, if necessary.

Consider splints: Foot splints are available and can help if worn at night. It’s best to have a doctor recommend one, though, as there are several varieties.

Ease yourself back into the game: Don’t restart strenuous lower-body activity until you’re pain-free. You’ll just aggravate the injury and be out even longer.

Extracorporeal shockwave therapy (ECSWT): Another tool that can be useful – especially in the more chronic cases where things have become a little stagnant – is shockwave therapy. This is administered by physiotherapist using a machine that produces shockwaves to initiate a more localised healing response at a cellular level. This is prescribed alongside managing your training load, resolving any underlying biomechanical issues and strengthening the tissues. Not all physiotherapists use, or have access to, these machines so check with them first.

Stretch it...

Put your toes and the ball of your foot against the top of the vertical edge of a step with your heel on the floor and slowly lean forwards, keeping your leg straight, until you feel the stretch at the top of your calf. Repeat with your knee bent, feeling the stretch further down the leg. Hold each stretch for 15 to 20 seconds and repeat several times in each position. Do this daily, before and after exercise.

Roll it...

A simple preventative measure you can do anywhere, even sitting at your desk. Roll a tennis ball back and forth under each foot for five minutes a day. The ball massages and loosens the fascia. Also, working into your lower calf and especially the musculotendinous junction – the bit between the bulk of your calf muscle and the achilles tendon – can help to take some tension off the plantar. Some research has shown a continuous connection between the plantar fascia and the achilles through the achilles-calf complex can contribute to an increase in plantar fascia loads.

Load it…

Tip-toe knee bends achilles tendinopathy, to expect a successful return to running you must ensure the tissues can tolerate the loads you are placing upon them. Try the following strength and movement control exercises.

Strength exercises

Isometric heel hold (perform with knee bent and with knee straight)

1. Stood on the floor or off over the edge of a step (harder), place a towel under toes.
2. Raise up onto tip toes so that you are roughly 50% of the way up.
3. Transfer your weight onto the affected leg and hold this position.
4. Runners World, Part of the Hearst UK Wellbeing Network.
5. Eccentric heel drop.
6. Back pain from running? This could be why.
7. As symptoms settle, work towards holding for 30-45 seconds and repeat this 3-4 times.
8. Then, progress from bodyweight to adding in some external weight. Start with 5kg and increase weight from there – 15-20kg is a good aim.

Eccentric heel drop (What are the symptoms of plantar fasciitis)

Double leg raise to single leg lower

1. Stood on the floor or off the edge of a step (harder), place a towel under your toes.
2. Transfer all your weight onto the affected leg and then slowly (3-5 seconds) lower your heel towards the ground.
3. Perform 3 x 12-15 repetitions with just bodyweight – and repeat once a day.
4. As symptoms settle, increase the amount of resistance while reducing the number of repetitions, for example: 3 x 10 repetitions with 10kg.

Ankle inversion with resistance band

1. Sit on the floor with your legs straight out in front of you. Bend one leg and, with the other, place a band – securely tied to a stable piece of equipment out to your side – around the inside of your foot.
2. What causes plantar fasciitis.
3. Slowly release and return to the starting position.
   
4. Repeat on both legs for 3 x 12-15 repetitions.
5. Do this exercise 2-3 times weekly.

Reverse lunge

1. Knee pain after running: How to spot and fix it.
2. Step back with your right foot and lower into a lunge – your right knee should almost touch the ground and your left thigh should be parallel to the ground.
3. Injured? Read our complete guide to cross training.
4. Return to start position.
5. Repeat on both legs for 3 x 12-15 repetitions.
6. Do this exercise 2-3 times weekly.

Movement control

Movement control exercises do not involve big heavy weights like in a deadlift or squat, but rather they stress the neuromuscular system, where your brain really has to work to think about the position, control and quality of the movement.

Tip-toe knee bends

Perform as a walk initially, keeping your chest high throughout.

1. Stand balancing on one leg.
2. Keeping all the toes in contact with the ground, raise the inner border of the arch of your foot slightly, and then slightly raise up onto tip toes so that you are in a mid-heel raise position. Maintain this position throughout.
3. From here perform small knee bends on the same leg, ensuring the knee remains over the middle of the foot and the arch of the foot remains high.
4. Perform 3x 15 repetitions.
5. Do this 2-3 times weekly.
6. To make things harder, place a resistance band around the knees and pull the opposite leg out to the side – this will provide added resistance for the standing leg and force you to work harder through the stabilising gluteal, foot and ankle muscles.

As with the running you must monitor your symptoms once you initiate these exercises. You want there to be no increase in symptoms immediately after or within the 24 hours following. Worsening of that morning stiffness is a sign you are pushing things too much, so adjust things as required.

The prescription for repetitions, sets, weight and frequency would be based on the individual, depending on current volume of running and the extent of the plantar fasciitis, but you can use those prescribed above as a rough guide.

Once you're confident in your ability performing these exercises, and are not experiencing symptoms afterwards, you can progress to As symptoms settle, work towards holding for 30-45 seconds and repeat this 3-4 times, like double-leg pogo hops and single-leg pogo hops.

Running drills utilise the strength you have developed in the specific groups of muscles and transfer this into more dynamic movements, that mimic parts of the running cycle.

By initially performing these movements walking, before progressing into more dynamic skipping movements, you can train what we call the neuromuscular system – the connection between brain and muscle. By recruiting the correct muscles at the correct time during certain movements, you can train your body to become more efficient while running.

Shin splints how to treat and prevent them.

Active plant walk

This is a good running drill that works on the strength of the calf muscles, as well as the smaller stabilising muscles of the foot and ankle. It’s also a nice introduction to some low-level plyometrics that will load the plantar fascia, as well as the achilles tendon.

1. Begin by raising up onto the balls of both feet. Pull the toes of one foot off the floor and up towards your shin, as the opposite foot stays planted into the ground on tip toes.
2. Then switch – actively planting your foot (remaining on tip toes) into the ground as you then pull the toes of the other foot up towards your shin. Repeat this for 2-3 x 15 reps.
3. Perform on the spot initially and progress to performing the movement as you walk forwards. As you gain confidence, try to increase the speed of the movement.

A-walk

A group of drills known as 'A' drills focus on getting into a good high-knee position at the point of push off when running.

1. Begin by driving the right leg through into a high-knee position, where the thigh is parallel to the ground, the knee is bent to 90 degrees and the foot is pulled tight to the shin.
2. On the standing left leg we want to get into a position of triple extension, where you role from your heel through the foot up onto your tip toes, straightening through the knee and locking out through the left hip – as if you’re driving yourself forwards.
3. From here step onto the right foot, landing on the heel and rolling through the foot, before raising up onto tip toes, while driving the left leg up into the high-knee position.
4. causes of hip pain and how to fix the problem.
5. Best wireless headphones.

Over-the-counter insoles can be helpful, especially for high-arched runners. Prescription orthotics are another option – they are custom-made for your foot – but try the (much cheaper) over-the-counter orthotics first, and if they don’t work, see a podiatrist.

Running shoes with a higher heel-toe drop may help in the short-term, especially if you’re currently running in a shoe with a low drop (0-5mm) or have recently transitioned.

Do I need a cortisone shot or PRP (platelet rich plasma)?

If first treatments don’t go according to plan, it might be worth speaking to your doctor or physiotherapist about getting an injection, to get the foot into a less inflammatory state.

Your doctor might add a bit of numbing medicine mixed with cortisone to the foot. This is a high dose anti-inflammatory that’s usually targeted right at the plantar fasicia origin as it comes off the calcaneus (heel bone). After the injection, it’s important to take a few days off of running to give the medication time to work.

In today’s medicine, when cortisone doesn’t help, we’re getting some traction from platelet rich plasma (PRP). This is harvested by taking blood from the arm, spinning it in a centrifuge, isolating the platelets and their associated platelet derived growth factors (PDGF), and then injecting them into the area of the chronic pain. This treatment can be quite helpful, especially if the cortisone doesn’t work, but it takes weeks rather than days to kick in and it’s quite a bit more painful.

Raise up onto tip toes so that you are roughly 50% of the way up The Athlete’s Book of Home Remedies by Dr Jordan Metzl.

Expert consulted:Matt Bergin BSc (Hons) MSc

Chartered Physiotherapist

Matt is an international middle-distance runner with a keen interest in running-related injuries, rehabilitation and prehabilitation.