After writing a previous post criticizing some rhetoric and propaganda on plantar fasciitis¹, I got a couple of complaints that I did not say how to treat it! I didn’t as that was not the purpose of the article! Plantar fasciitis is so common, that everyone is an expert in it. Self diagnosis and self treatment is the most common approach; but it still becomes an extraordinary chronic problem with so many suffering from it for years. The internet is a huge source of snake oil, woo and pseudoscience when it comes to plantar fasciitis, so no wonder it does become such a common chronic problem, when there is no reason for it to.
The biggest problem with plantar fasciitis treatment is that its natural history is that it tends to get better on its own (just look at the responses in the placebo groups of clinical trials on it). It may take a while to get better and it may hurt a lot while it does get better, so treatment is still warranted. However, this means that whatever treatment, running shoe change, running technique change, snake oil application, woo, or magical potion, etc that is implemented may or may not be the reason it got better in any one case as the condition may have just been ready to get better on its own at about the same time. See the post I did on Why Ineffective Treatments Sometimes Work. This means that so many who tout snake oil and woo for plantar fasciitis as something that had worked for them, so they do what they can to hawk that treatment as the secret sauce or magical cure that clinicians are hiding from them or don’t know about (often in a $19.95 eBook – certainly cheaper than going to the doctor!). Just look at some of the comments after my previous post. One runner claimed that his maximalist Hoka One One shoes cured his plantar fasciitis; the very next post was from a running saying that the Hoka One One’s caused his plantar fasciitis and based on that he advises everyone to avoid those shoes. Based on those two anecdotes, what should a clinician do? Get all plantar fasciitis cases into Hoka One Ones or get all plantar fasciitis cases out of maximalist running shoes? Can you see the problem?
Because of this dilemma, that is why we need to rely on properly controlled clinical trials to determine if any treatment is more effective than a placebo, so if we use that treatment we know we are going to get an effect.There is some good data on some aspects of plantar fascitiis management to show what is better than a placebo, but this is still lacking on other treatments. None of the snake oil and woo you see touted for it has been subjected to clinical trials, yet somehow they are allowed to ‘sell‘ it and still claim it works, usually based on nothing more than a few anecdotes and the wishful thinking fallacy. Even those treatments that have been subjected to properly controlled clinical trials do not provide all the answers as the actual protocol that was used to apply the treatment may or may not be the same in the way it was used in the clinical trial as the way some use it in clinical practice. Given that, there is still a long way to go in the clinical trials of different approaches to the management of plantar fasciitis. It also means that the snake oil touters and the woo meisters get free rein to suck people in.
Then you have what I call the ‘one hit wonders‘. This is those who use only one tool in their armamentarium and they use that one tool to treat them all; and usually think that everyone else should also use that one tool! Given the natural history of plantar fasciitis, they will probably, anecdotally, get a reasonable success rate in their eyes. This happens as they mostly see what they want to see (see: Why Ineffective Treatments Sometimes Work).
The approach I apply is not only based on the way that I interpret the best available evidence, but as the evidence is lacking in other areas, I apply those three concepts I have mentioned in many posts (eg): biological plausibility, theoretical coherence and consistent with the available evidence. Like any other overuse injury the approach I take to plantar fascitis is no different: reduce the load in the damaged tissues; increase the ability of the tissue to take the load; facilitate the healing of the damaged tissue. This of course, assumes that the diagnosis of plantar fasciitis is actually correct (there are a lot of other things that can cause pain under the heel).
A. Reduce the Load in the Damaged Tissues:
As plantar fasciitis is due to too much cumulative load in the plantar fascia, then it makes intuitive sense to reduce that load at least in the short term to allow the tissues to heal. There are several strategies that can be used for this:
1. Stop running! Or alternatively modify the running activity; do an alternative activity; cut back a bit; have more rest days; above all, use common sense.
2. Low dye strapping. This is a very short term measure and can reduce the load in the plantar fascia immediately. The evidence supports it use. The proviso is that the strapping is actually applied correctly and in a way that does actually reduce the load in the plantar fascia. For this to work in anything other than the very short term, the tape is going to have to be reapplied at least every few days which raises issues of practicalities. For that reason, I tend not to use it. I only tend to use it if the plantar fasciitis is interfering with employment (eg they can’t work as its too painful and they have standing occupation) or its interfering with their training for a race that is coming up (and 1 above is not that practical at this stage).
3. Foot orthotics. All the studies have shown that foot orthotics for plantar fasciitis were better than a placebo, but the effect sizes were small. For a foot orthotic to be effective in plantar fasciitis, it has to reduce the load going through the plantar fascia. Stopping ‘overpronation‘ and ‘supporting the arch‘ is not necessarily going to be enough and if the design parameters are not right (eg arch support in the wrong place),they may actually increase the load in the plantar fascia. “Overpronation’ (whatever that is) has not been shown to be a risk factor for plantar fasciitis, but foot orthotics have been shown to work in numerous studies for plantar fasciitis. We know from the work of Geza Kogler that lateral wedging under the forefoot was most effective at reducing strain in the plantar fascia. We know from our own unpublished experiments that inverting the rearfoot and everting the forefoot lowers the force to get the windlass mechanism established, which would lower the forces going through the plantar fascia. From this it appears as though the design features needed to reduce the loads in the plantar fascia would be medial heel wedging and lateral forefoot wedging. Given that the RCT’s that show foot orthotics work did not specifically use these design features, we can only speculate what the effect sizes may have been if they had. In my own anecdotal experience, every time I have seen a foot orthotic that is not working in a case of plantar fasciitis, when I do Jacks test on and off the foot orthotic, there is no difference. This suggests that the foot orthotic did not have the right design features to reduce the load in the plantar fascia.
There is no doubt that foot orthotics are a very effective short to medium term strategy to reduce the load in the plantar fascia. They do not weaken the muscles (the evidence on that is clear; and neither do running shoes, while we on this topic!). As to if they are needed in the medium to longer term will depend on a number of factors (see this discussion on short or long term use). They may or may not be needed in the long term.
4. Calf muscle and plantar fascia stretching. The evidence on this is really clear with a number of studies showing both are effective. The fibers from the Achilles tendon are continuous to the plantar fascia. The stretching of the calf muscles is going to help lower the load in the plantar fascia. I generally get people to do this at least 2-4 times a days. The stretching also probably plays a role in allowing the tissues to adapt to increasing loads (see below). This may also progress to the use of night splints which has some good evidence to support it, despite the practicalities of wearing a splint in bed at night!
5. Running form changes. There is NO evidence for this and I do not believe that foot strike pattern or running technique has anything to do with plantar fasciitis (both forefoot and heel strikers get plantar fasciitis; and so do minimalist and traditionally shod runners). It does matter for other conditions, but not this one. See this discussion.
6. You often see muscle strengthening mentioned, especially of the small intrinsic muscle of the foot to take the load off the plantar fascia. There is no evidence that this helps and no evidence of any muscle strength deficits in plantar fasciitis (see some of the points I raised here). These muscles do not even fire until later in the stance phase so are not even capable of supporting the plantar fascia, even if they could! This does not mean that strengthening these muscles is not useful for other reasons; I just can not see how it helps plantar fasciitis.
B. Increase the Ability of the Tissues to Take the Load:
This is probably where the understanding and thought processes have changed the most in recent years. The concept is based on progressively and slowly increasing the load on the plantar fascia so that it can adapt to increasing loads and better tolerate the loads that are placed on it. This is a medium to long term measure and probably has to be done in the context of the principles above of decreasing the load to let the damaged tissues heal, and then going through the longer term process to load the plantar fascia and then let it adapt. It also relies on a certain amount of compliance from the runner and a long term commitment.
There is NO evidence to support this, but it does meet the criteria of biological plausibility, theoretical coherence and consistent with the available evidence; ie its makes intuitive sense to do this. The evidence that it is consistent with is the research that has been done on tendinopathy and the progressive resistance and overload to adapt tendons to load as part of the rehabilitation. Tom Goom did a good summary of the staging of tendinopathy and applying it to plantar fasciitis over at Kinetic Revolution. However, I do have a concern that the plantar fascia is NOT a tendon, so the research and principles developed in the context of tendinopathy may not necessarily be applicable to the plantar fascia. That does not mean its not; it means we got a way to go to get more information, data and understanding on this.
Also of relevance here is the genetic issues. A lot of work has been done on genetic risk factors for achilles tendinitis, which I presume affects the ability of the tendon to take loads. Nothing is really known about the genetic risk factors for plantar fasciitis, but they must exist and must affect the ability of the plantar fascia to take load. There is a high probability that these can not be adapted to load as well, so reliance is going to need to be placed on the strategies above to reduce load to below what the tissues can tolerate.
Nutrition also need to be considered so that tissue health is at an optimum so it can be adapted to loads.
C. Facilitate the Healing of the Tissues:
In my opinion, the above two of reducing the load in the damaged tissues and increasing the ability of the tissue to take the load are the most important and crucial parts of the management. If they are not done then the problem is more likely to be a long term chronic problem and more likely to happen again. However, sometimes the above two are not enough and direct work on the damaged tissues is needed to facilitate the actual healing of the damaged tissues, so that the load reduction can work and the tissues can be adapted to the load. I often see a lot of the treatments in this category as giving the ‘window of opportunity‘ that is needed for the load reduction and tissue adaptation to take place. The obvious example here is ICE in the early stages. A number of other treatments such as manual therapy, cortisone injections and NSAID’s came into this category. The strength of evidence for one versus the other is mixed or non-existent. For example, Andrew McMillian showed the effectiveness of the cortisone; meta-analyses are showing shockwave is effective at the appropriate doses; the data on platelet rich plasma is mixed and not clear. I tend to use treatments in this category once the load reduction is in place and there is not a short term clinical response to that.
Hopefully all this makes sense. There is so much rhetoric and propaganda when it comes to plantar fasciitis; so much snake oil touted by woo meisters. We need to rely on the evidence, the biological plausibility and the theoretical coherence.
Start by reducing the load on the damaged tissues; then do things to facilitate the healing if there is not an immediate response; and then progress to the progressive adaption to increasing loads. It is not complicated. There is no need for plantar fasciitis to become a chronic problem.
As always: I go where the evidence takes me until convinced otherwise, and this is where the evidence has taken me.
1. I not going to get into the discussion here if its plantar fasciitis (an inflammation) or plantar fasciosis (a degeneration) or if it should be called plantar heel pain or whatever. That can wait for another time and place. Plantar fasciitis is the most commonly used term for this, so I going to use it.