Despite its complex name, many runners can pronounce plantar fasciitis because they’ve had the misfortune of personal experience. I’ve heard it called the ME of sports injuries because it’s so hard to pin down what triggers it and equally hard to find a way to get rid of it. It’s not uncommon for the condition to last six months or more. Part of the problem with defining the cause and solution is the fact that there’s little agreement on what PF actually is. The ‘itis’ in the name suggests it is a condition that involves inflammation but this has been challenged in recent years and some podiatrists and sports medicine experts have called for it to be known as plantar fasciosis instead. An ‘osis’ is degeneration of tissue, rather than inflammation – and as such, requires a different approach when it comes to treatment. (That might explain why the ‘usual suspect’ remedies, such as rest, ice and anti-inflammatories – or even corticosteroid injections provide little more than passing relief.)
In one study, tissue biopsies were taken from people suffering from severe PF and then assessed. There was no evidence of inflammation in the plantar fascia, but there were numerous microscopic tears and signs of degeneration (necrosis) both in the plantar fascia itself and within the intrinsic flexor muscles of the foot.
Caused by what? Well, you may not need to look further than your own footwear. A lot of running shoes (in fact, a lot of shoes in general) don’t have enough space – or the correct shape – in the toe box, causing the big toe to be drawn towards the other toes (adducted). Then there’s the common shoe feature called ‘toe spring,’ which pulls your toes into extension because the front end of the sole curves upwards (shown below). Add this to the fact that in most shoes your heel is raised higher than your toes, and you end up with the toes – most notably the big toe – being forced into both extension and adduction. As a result, blood flow (via the posterior tibial artery) to the PF and surrounding structures is compromised, allowing degeneration to take place.
To get a sense of the position in which the foot is held in most footwear, push your toes together, raise your heel off the floor and pull your toes into extension. If you now press your fingers along the medial side of the heel, you may well find you can recreate your pain symptoms. This position will greatly increase tension in the flexor muscles on the bottom of the foot as well as the PF – an effect magnified by the forces of running.
So please, if you have PF, DON’T STRETCH YOUR PLANTAR FASCIA EVEN FURTHER! Besides this exacerbating the problem, you are also stretching what is an essential part of your elastic energy return system, which helps to propel you through your running stride without using up precious energy.
So what’s to be done? First, you need to allow the toes to sit properly. That means a shoe with enough space in the toe box but more specifically, space for the big toe to sit straight, not curving in towards the other toes. I highly recommend Altra, Vivobarefoot and some Inov-8 models (those described as standard fit, not precision fit). You can check out my shoe reviews to see which brands and models fit the bill.
I also recommend Correct Toes toe spacers, which are designed to be worn inside footwear (or barefoot, of course) to help realign your toes back to their correct anatomical position. They were created by a running podiatrist in the United States, and I found them invaluable in getting over my long-standing PF (and that’s why, unashamedly, I’m now involved in selling them in the UK online).
The other important shoe-related thing to avoid if you’re suffering PF is excessive toe spring (ie. when the shoe curves upwards at the toes, court jester style) or an overly stiff midsole. Check whether your running shoe allows the foot to bend where it’s designed to bend – across the ball of the foot.
PF sufferers also need to get those feet supple and mobile again. Stretching the tight toe extensors is the best starting point.
This position stretches the toes at the metatarsophalangeal (MTP) joint – the ‘knuckle’ of the foot. You can do this sitting or standing (sitting is easier to get to grips with). Extend one leg a little way back behind the body and place the upper surface of the toes on the floor. Exert a little pressure. This should bend the toes at the MTP joint.
You’ll feel the stretch across the top of the foot and perhaps across the front of the ankle. As the muscles become more flexible, bring the foot further forward, relative to the body, to increase the stretch.
Deep tissue massage is also helpful in mobilising the feet and improving blood flow when rehabbing from PF. A golf ball underneath the ball of the foot can help get that MTP joint moving, as shown below.
I also regularly use a pedi roller to stretch and ‘iron’ out the connective tissue on the soles of my feet, and get my fingers in between the big toe and second toe to massage between them, both from above and below.
There will undoubtedly be physios, podiatrists and the like who will dismiss outright the notion that modern footwear and its effect on foot structure/alignment causes plantar pain. Indeed, people suffering from PF are often given MORE cushioning and MORE support in their shoes when they actually need less. But the huge number of runners with ongoing, stubborn plantar pain that doesn’t respond to the usual bag of tricks might be more open to suggestion. That’s how I felt after I’d had a corticosteroid injection, two different pairs of orthotics, done copious stretching, icing and resting and was still on the bench nigh on a year later. Why not free your feet and see what happens? And please report back!