Thursday, July 23, 2009

The Plantar Fascia: That Fickle Bitch

One of the most common injuries experienced by runners is plantar fasciitis (often incorrectly referred to as a heel spur, which is technically a different, but often related, injury). And like the hundreds and thousands of runners before me who have experienced the pain of PF, I too am afflicted with this condition. In fact, I had a mild case of PF for over a year (even when I wasn't running) and didn't really know what it was.

What is Plantar Fasciitis?
According to one of the best websites on the subject,, "plantar fasciitis (pronounced PLAN-ter fa-shee-EYE-tiss) is an inflamation of the plantar fascia in your foot. The plantar fascia is a large band of connective tissue between your heel and the ball of your foot, and it acts to support your arch when you walk. The plantar fascia experiences tension as you lift your back heel off the ground when you walk or run. The tension is greatly increased (leading to PF) when the calf muscle is tight and inflexible. The following two pictures (again, from the wonderful site show the plantar fascia and the most common point of pain for PF.

The "Pain Often here" spot on the second picture is exactly where I felt a sharp stabbing pain when I walked, particularly after I started ramping up my running to about 15 miles per week back in April. The weird thing about PF is it hurts the worst right when you get up in the morning, and it gets progessively less painful throughout the day. For me, the pain usually went away completely when I ran, so I never equated it with running until I looked into it more. The reason PF hurts the worst in the morning is when you sleep, your feet generally flatten out, releasing the tension in your calves and causing them to tighten so that when you get up and start to walk, your plantar fascia starts screaming because the tension on the plantar fascia increases as the calf gets tighter and more inflexible. Similarly, PF pain tends to go away as you walk or run around because your calves warm up and become less tight, relieve the tension on your plantar fascia.

Unfortunately, there is no quick treatment for PF. Also, while resting (i.e. laying of on exercise) helps, it often isn't enough to cure PF (unless you are able to remain in bed 24/7 for an extended period of time). You pretty much have to stick with some common sense remedies for a long period of time to reduce or eliminate the extra stress on your plantar fascia while the inflammation heals. Here are the treatments I have used that have helped reduce, and on some days eliminate, my PF pain.
1. Stretching - Regular calf stretches help a lot. I do a couple pushing up against a wall (the "Gastroc" and "Soleus" stretches demonstrated here). Another that helps me a lot (although you have to be careful not to overstretch) is to stand on the edge of a stair step on the balls or toes of my feet (either both feet, or you can isolate your left or right calves) while slowly lowering my heels below the level of the step. You have to be careful with this method, because it can lead to injury to the plantar fascia or the achilles tendon, but if done slowly and carefully, it has worked wonders for me.
2. Strassburg Sock/Night Splint - Technically, this is really another form of stretching, but it was quite new and different for me, and I suspect for many others too. You wear one of these at night to keep your foot flexed instead of laying flat. This keeps your calf stretched throughout the night to prevent the tightening described above. I have used the Strassburg most nights for a few weeks, and the difference was remarkable. I noticed a big difference the very first night I wore it. In fact, when I was forced to stop wearing the Strassburg for a week and a half to avoid aggravating my toe injury (which was on the same foot as my PF), I noticed an almost immediate worsening of symptoms, particularly in the mornings. The Strassburg Sock takes some time to get used to, so you may have one or two nights of less than ideal sleep, but I don't notice it much anymore. I have heard the same about night splints. Of all the treatments so far, I think the Strassburg, and possibly insoles (discussed next), have made the most difference.
3. Insoles/Orthotics - arch support is very important to avoid and treat PF. I credit wearing insoles with great arch support for really helping me to keep the PF pain at bay and to help me get better while I'm doing all the other treatments. At the recommendation of, I got Powersteps (the original Powersteps for my day to day shoes, and Pinnacles for my running shows), which have been a godsend. Once I got used to wearing insoles with such aggressive arch support (which took a couple days), I noticed a big reduction in PF pain, even on days when I hadn't worn my Strassburg, stretched much, or iced my arch (discussed below). There are other good over-the-counter insoles out there (I have also used Superfeet, which are OK, and Sole, which could be great but the arch support hit my foot at the wrong spot and caused a huge blister... and Spenco seems to have been the industry "standard" for awhile), but the Powersteps seem to come the most highly recommended by podiatrists. Powersteps were a little harder to find (I had to trek out to a specialty running shop in St. Paul, which is way out of my way) but they are worth it for reduced foot pain.
4. Ice - ice is also great because it helps control plantar fascia inflammation. I purchased a couple of great general purpose, reusable ice packs from Target (there are also specialty ice packs designed specifically for ankle and foot injuries, like the ActiveWrap, but these seemed overly expensive and even harder to find than the Powersteps insoles). (By the way, the ice packs I did get, the ThermiPaq, is by far the best ice pack I've every used. It uses a ceramic clay material that gets cold fast in the freezer, but holds its cold for longer than traditional gel packs... they also come with a great washable cloth cover with a velcro strap for securing it to wherever you need icing). When my PF was at its worst, I would ice my arch immediately after I got up in the morning while I ate breakfast minutes, 3-4 times a day while at work, and 1 or 2 more times at night (with at least 1 immediate before bed), which each icing being for at least 10-15 minutes, and preferably 20-30. I also did my best to ice it immediately after a run. Icing helps a lot because not only does it reduce inflammation (which causes pain), but it also causes the blood vessels to contract and essentially massage the "junk" (for lack of a good technical term) out of your tissue.
5. Ibuprofen - like icing, ibuprofen is also good to help reduce inflammation, and if you are really hurting to help reduce pain (although you should be taking it for the inflammation... if the pain is so great that you can't tolerate it without ibuprofen or some other pain killer, you might want to see a podiatrist because your PF is much more advanced than mine). I didn't use ibuprofen as much as the other treatments because I like to avoid taking drugs if I don't have to, but if I'm having a bad day and my arch feels particularly sore, I do take some to help.

So that's it for my treatments. I am not all the way to being pain free (as a couple of my recent workouts show), but when I am aggressive with these treatments, the pain usually stays at bay and I am able to keep running while still healing, which is what is really important when training for long races.

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