Learn how the running expert diagnoses and treats runner’s heel pain.
Let’s face it, as runners one of the easiest places to go for a run is right out the front door and onto the street.
Most runners think that road surfaces are flat. But nothing could be further from the truth.
If you look at the road in cross-section it’s basically a curve with the centerline in the middle of the road being at the highest point on the curve. So the closer you get to the gutter, the steeper the slope.
This of course is by design so when the rain falls it will run off of the road surface so the cars won’t skid in the puddles of water.
The sidewalk also slopes toward the gutter to let the rain water run off of the sidewalk and drain away.
Running on this slope can either increase or decrease the strain on your foot.
Without getting into the confusing biomechanics technical mumbo-jumbo, here’s what you really need to know:
If your right foot is bothering you and you run at the right side of the road with your back to traffic it actually decreases the stress on those structures of the right foot.
But at the same time it increases the stress on the left foot.
So if you have plantar fasciitis on your left foot you should either run on the left side of the road facing traffic, or on the sidewalk on the right side of the road with your back to traffic.
If you have plantar fasciitis on your right foot you should either run on the right side of the road with your back to traffic, or on the sidewalk on the left side of the road facing traffic.
Choosing the correct surface when you run can make a huge difference in terms of the amount of stress on your heel, your arch and your plantar fascia. So now you know how to run on the correct side of the road. So go and enjoy your run!
Runner’s heel pain is often caused by plantar fasciitis. The good news is that plantar fasciitis is easy to treat. But sometimes it doesn’t get better. Here are the most common reasons that runners aren’t getting better when I see them after they have been trying to treat plantar fasciitis on their own.
There is NO single pill that will “cure” your plantar fasciitis. Many people think that since plantar fasciitis starts with inflammation it should be simple enough to cure it with a medication that stops inflammation.
Non-steroidal anti-inflammatory drugs (also called NSAID’s) are the most commonly prescribed drugs for plantar fasciitis. But you must understand…no pill alone will cure your plantar fasciitis. Ibuprofen, naproxen and other NSAIDs may make your heel pain feel better, but they won’t fix it.
While it is possible to keep running and still heal plantar fasciitis, you have to run in a way that reduces the stress on the structures that support the arch…like the plantar fascia. Believe it or not, when you run on the road the slope of the road is always either increasing (or decreasing) the stress on your plantar fascia. It all depends on which foot is bothering you and on which side of the road you run.
I did a quick Google search on “plantar fasciitis stretches” and got 583,000 results. So there is no shortage of stretches out there. Many of the recommended stretches can help. But the overwhelming majority of the time I see patients with plantar fasciitis they are either doing the wrong stretches or they are doing effective stretches incorrectly.
Stretching is the single most effective treatment for plantar fasciitis, but you have to do stretches that will stretch the Achilles tendon and plantar fascia without stressing the plantar fascia. Even subtle mistakes can decrease the effectiveness of your stretching routine. Make sure you are doing them correctly!
You have to understand that the tension in the Achilles tendon is the root cause of plantar fasciitis. Shoes that have a moderate heel of about 2 inches can decrease the stress on the Achilles tendon AND the plantar fascia.
Avoid minimalist running shoes, ballet flats, house shoes, slippers and flip flops while you are recovering from plantar fasciitis. Instead try to wear stable shoes that have a slight heel. A conventional running shoe has a 12mm heel to toe drop.
Don’t wear any running shoes will less than a 12mm drop while you are recovering from plantar fasciitis.
Yesterday a runner called me and said.
“Look I already know that I have plantar fasciitis. I am doing everything that is supposed to help, but I am just not getting better.”
My response was simple:
“If you know what the problem is AND you are doing the things that work, you would be better already.”
If you are trying to treat your plantar fasciitis and you are NOT getting better, there are only two possibilities:
1. You are not doing the correct treatments, or you are doing them incorrectly.
2. You don’t have plantar fasciitis at all…you have another condition that causes runner’s heel pain and has been mistakenly and incorrectly diagnosed as plantar fasciitis.
If you have been trying to treat your heel pain and you aren’t getting better you either need to do some more research or seek a second opinion form a running expert.
Heel Pain Treatments for Runners
Heel pain is one of the most common conditions affecting Americans. In fact complaints of heel pain account for about 40% of all visits to the podiatrist in the United States. So not surprisingly, heel pain is extremely common in runners as well. As a sports medicine podiatrist and foot surgeon, the most common question I get from runners with heel pain is:
“Do I have to stop running to get my heel pain to heal?” The answer to that question depends on several factors.1. What is causing your heel pain?
1. What is causing your heel pain.
A runner asks me, “is it okay if I continue to run with heel pain?” This seems like a reasonable question. But let’s consider another question as an analogy: “Should I be worried about this headache?”
If your headache happens to be caused by lack of caffeine because you decided to stop drinking so much coffee as a New Year’s resolution, you probably don’t have to be too concerned about the headache. If your headache is caused by a brain tumor, you probably should be worried. If that brain tumor is malignant and could kill you, you should definitely be worried. Aspirin would likely not be the best treatment if your headache is caused by a brain tumor.
If your heel pain happens to be caused by a stress fracture, or crack in the heel bone, you would probably not want to run on it because the heel bone could explode apart and then require surgery. If your heel pain is caused by a partial rupture or tear in the plantar fascia, you might need to stop running to allow it to heal. If your heel pain is caused by a nerve entrapment, it may be possible to run, if you can use some creative strategies to remove the mechanical irritation of the nerve that is causing the pain when you run. If your heel pain is caused by plantar fasciitis, you can likely continue to run, and effectively treat your heel pain with a few simple modifications to your routine.
In the vast majority of cases, heel pain is directly related to your running biomechanics. Over-pronation can put you at risk of plantar fasciitis and partial ruptures of the plantar fascia. Under-pronation can put you at risk of a stress fracture of the heel bone.
Your biomechanics (the way your body moves) are affected by the surfaces upon which you land. So the running surfaces you choose can have an enormous impact on the development and treatment of your heel pain. The types of shoes that you use can also put you at more or less risk for developing heel pain. Your shoes of course relate to your specific running biomechanics and whether you are a fore-foot, mid-foot or rear-foot striker.
I once saw a patient who was running her first and presumably only marathon to prove to herself that she had beaten cancer. She developed a foot injury which normally would preclude her ability to run the marathon. However, she had trained for many months and her family and friends had all purchased airline tickets and hotel rooms to go watch her run the marathon. To her, the risk of running the marathon was well worth the personal importance of the accomplishment, and symbolically putting cancer behind her.
I have also seen patients who have a goal of continuing to run for the rest of their lives. In some cases they can continue to run with an injury without any long-term consequences. In other cases, continuing to run, while attempting to heal, can create a risk of permanent tissue damage that can lead to continual recurring foot problems. Recurring problems could prevent you from happily running for the rest of your life.
Many physicians have standard treatment protocols that they follow in their offices. The goal of standard treatment regimens is designed to increase efficiency within the office, and allow non-physicians to assist the physician and provided patient education and instructions regarding treatment. But sometimes this approach leads to cookie-cutter medicine.
If you see a physician who follows standard treatment protocols, it is entirely possible that the importance of running to you will not be taken into account. If you see a sports medicine physician who specializes in the treatment of runners, it is much more likely that your physician will listen sympathetically to your story, factor in the importance of your running, and evaluate your running biomechanics to determine how you can keep running and still treat your heel pain effectively.
The key here is to understand that runners with heel pain can (and often should) be treated differently than sedentary individuals with heel pain. It is important for you to explain to your doctor that you are a runner. Is important to explain how important running is to you as an individual.
If you feel that your physician is not taking your condition seriously, or is discounting your desire to run, it may be worth seeking out a second opinion from a sports medicine podiatrist who specializes in the treatment of running injuries. If your physician is also a runner himself, then the physician may be more sympathetic to your cause and may work a bit harder to come up with creative solutions to help you maintain your running fitness, or keep you running as you heal.
If you are a runner and your doctor tells you to stop running, you should never take that as the final answer. Always seek a second opinion from an expert physician to see if there’s another option. Heel pain treatments are not “one-size-fits-all.” The treatment has to be tailored not only to the condition, but to the patient, and the patient’s active lifestyle as well.
If you understand your running biomechanics, you can evaluate your own running form, and if you understand the causes and treatment of your heel pain, you can then decide whether not running should be a part of your recovery routine. When in doubt, always seek more information to fill in the gaps. Whenever you can’t get an answer that makes sense to you, seek the help of a physician who specializes in the treatment of running injuries.
In many cases of plantar fasciitis it is possible to run and still heal. The plantar fascia ligament is irritated, inflamed and perhaps even has some micro-tears in it, but it can still heal if you take some simple actions and precautions.
We know the average person (non-runner) with plantar fasciitis should get better with the proper treatment. Part of the treatment focuses on decreasing stress and strain to the plantar fascia. But we don’t expect the person to stop walking. Running certainly causes more stress than walking, but there is a range of force. Just like running is more straining than walking. Running hills is more stressful than running on flat ground. Running fast and landing as a heel striker is more stressful to the plantar fascia than running at a moderate pace and landing as a mid-foot striker.
The first step in figuring out how to run with plantar fasciitis is realizing that you have several variables that can either increase or decrease the amount of stress and strain on the plantar fascia. Once you have identified the variables that stress the plantar fascia, you can manage the forces applied to the plantar fascia. If you decrease the strain below the threshold at which healing can still take place, then you should be able to run even while you are treating plantar fasciitis.
Pronation is the motion that irritates the injured plantar fascia. Pronation is your body’s way of adapting to uneven surfaces and absorbing the jarring force of gravity when you walk and run. As you pronate, the foot moves in three directions: dorsiflexion, eversion and abduction. Every one of these three directions of movement stretches the plantar fascia. It may help to understand each one individually.
Dorsiflexion is the motion of the foot moving up away from the ground and toward the front of the shin. Dorsiflexion happens when you sit in a chair, keep your heel on the ground and pull your foot and toes up off the ground. Dorsiflexion also happens when your pull your toes and foot upward to avoid tripping over your toes as your unweighted leg swings forward over the ground at mid stride. Technically, dorsiflexion also happens when you stand with your foot flat on the ground and move your knee forward; your foot is moving closer to the front of the leg. The steeper the slope, the more you must dorsiflex your foot.
The most stress on the plantar fascia happens at the moment when you are running up a steep hill, your knee moves forward over your foot, your heel comes up off the ground and the big toe is forcibly flexed. This motion tightens the fascia to its maximum tension. When this extraordinary tension on the plantar fascia is coupled with the force of propelling your entire body weight up the slope, the strain can stretch the plantar fascia to the point of tearing. Running on hills is the first thing you should eliminate when trying to run with plantar fasciitis. Stick with flat ground if you want to mitigate the dorsiflexion component of pronation.
The next motion to consider is the sideways titling of the foot adapting to sloping ground. If you stand on the side of a hill and face across the slope (not facing uphill or downhill), your uphill foot will pronate and your downhill foot will supinate. The difference is the direction of tilt of the heel bones. The medical or biomechanical terms for the inward and outward tilting of the heel bones are “calcaneal inversion” and “calcaneal eversion.”
Calcaneal: adjective; pertaining to the heel bone.
Inversion: verb; titling with the base of the heel toward the midline of the body.
Eversion: verb; tilting with the base of the bone away from the midline of the body.
Standing facing across the slope, the downhill foot is inverted. The ankle is rolling outward, heel bone is titling inward with the base of the heel bone toward the midline. The foot is supinated which is decreasing the tension on the plantar fascia. The uphill foot is everted. The ankle is tilting inward, the heel bone is titling outward with the base of the heel bone away from the midline. The downhill foot is pronated which is increasing the tension on the plantar fascia. The point of all of this is not to bore you with jargon. The point is to make it clear that one slope makes plantar fasciitis worse, but one slope can actually put the foot in a position that decreases stress on the plantar fascia and can help it heal.
You probably already know that most road surfaces slope. The slope of the road is designed to allow rain water to run off the driving surface and drain through the gutter. The center line is painted at the peak or “crown” of the road. In the very middle of the road, the surface is flat. This is why many marathon training manuals recommend running in the middle of the road during a marathon. Running on one side or the other of the road puts an extra strain on the structures of the foot and ankle. Running at the far right of the road (with your back to traffic) has you running along a slight slope. The right foot is supinated, the heel bone is inverted and the stress on the right plantar fascia is decreased. The left foot is pronated, the heel bone is everted and the stress on the left plantar fascia is increased. You probably also have realized that sidewalks are also titled toward the road to allow rain water to run off to the gutter.
If instead of running on the road you run on a sidewalk at the right side of the road (with your back to traffic) you are running along a slight slope. The slope on the sidewalk is the opposite of that on the street. The left foot is supinated, the heel bone is inverted and the stress on the left plantar fascia is decreased. The right foot is pronated, the heel bone is everted and the stress on the right plantar fascia is increased.
Most runners are creatures of habit. We run the same routes, on the same sides of the road, in the same direction day after day, for whichever distance fits our training schedule. Knowing what helps or hurts the plantar fascia in your routine can be the difference between running and limping.
Many runners have a rule of “always facing traffic” when they run in the road. The main reason for this is to avoid getting hit by a car. Running at the edge of the roadway facing traffic can place an excess strain on the right plantar fascia. But at the same time it decreases stress on the left plantar fascia. So if your left plantar fascia happens to be the one that is aching, you should run at the edge of the road, facing traffic. If you instead have plantar fasciitis on the right, you should not run in the road facing traffic. But you could keep facing traffic, simply hop on the sidewalk, reverse the slope, invert the right the right heel, supinate the right foot and help the plantar fascia to heal.
To decrease stress on the right plantar fascia, run on the right side of the road with your back to traffic or on the left sidewalk facing traffic. In cases of plantar fasciitis on the left foot, run on the left side of the road facing traffic or on the right sidewalk with your back to traffic. One special hazard to keep in mind when running on the sidewalk are the driveway cut outs. The sharp slope as a driveway is cut through the sidewalk can be as much as 30 degrees. Make sure you avoid the abrupt drop-off and jarring pronation of landing on the driveway cutouts.
The last of the three forces related to pronation is abduction. Abduction is an outward rotation of the foot relative to the leg. A duck abducts its feet when it waddles along. Most humans abduct only as they pronate. The abduction is also more pronounced when a rotational force is applied. The most common way this happens is when changing direction and pushing off.
Think about running around a left hand turn, such as the curve on a running track. As you round the curve, you are leaning slightly to the inside of the curve (to the left). Your left foot is internally rotating underneath you as you overtake the leg and push off toward the right. The right leg externally rotates, but also pushes off toward the right, or outside of the curve. As you round the curve, the external rotation of the right leg beneath you causes the right foot to pronate. As the foot pronates, the right arch lowers, lengthening the distance between the heel bone and the base of the big toe. As the foot elongates, the plantar fascia becomes taut, stretching out to resist the load as the foot rolls inward under the force of pronation.
In contrast, the internal rotation of the left causes the left foot to supinate. The left arch heightens, shortening the distance between the heel bone and the base of the big toe. Because the plantar fascia spans these structures, acting like a bowstring, the supination lets the left plantar fascia relax.
One direction around a curve increases the stress on one plantar fascia, while one direction decreases the strain on the other plantar fascia. You can use this knowledge to run with a minimal amount of force on the injured plantar fascia. If your left foot is the one suffering from plantar fasciitis, you are in luck! All you have to do is run the conventional counter-clockwise pattern around your local jogging track. If you run in one of the outside lanes, you will spend a larger percentage of the distance on the curve, hence capitalizing on the rotational forces that can give your plantar fasciitis a break.
If you are a math fan, you can calculate the distance of curved running in each lane. Use the formula, L = 2S + 2pi(R + (n-1)w) to calculate the distances around the track for the various lanes. If you are not a fan of math equations, all you need to know is that lane 1 (the inside lane) is typically 400 meters. The straightaway is also 400 meters. Lane 8 (the outside lane) is about 450 meters.
If you run in Lane 1, you spend 50% of your time on the curves and 50% on the straights. If you run in Lane 8, you will spend an extra 100 meters on the curves for each lap around the track. If you want to increase your running distance while simultaneously decreasing the stress on the plantar fascia, stay wide and run in lane 8. If your right foot is the one with plantar fasciitis, you have to run the track in reverse. Unless you are there alone, it is better to stay in one of the outside lanes. It is just plain rude to run the wrong direction in lane 1. But nobody will care if you are running clockwise on the outside lanes 7 or 8.
Keep in mind that running on a track to decrease the stress on the plantar fascia is only helpful if you have plantar fasciitis on only one foot. If you are suffering from plantar fasciitis on both feet it is simply not helpful to run the curves. The key to running with plantar fasciitis is to maximize every opportunity to lessen the stress and strain on your injured but healing plantar fascia. Stay on flat ground and avoid hills. Look for a track and run in the direction that will supinate your injured foot to lessen the irritation.
The simplest way to assess whether or not your strategy is working is to assess your pain level and the frequency of painful episodes. The most accurate way to track your pain and correlate it road surface conditions is keep a pain journal.
Let’s say that right now you run on a flat jogging path and sense a small but notable amount of pain in the left heel and arch with every single foot strike. If you then alter your route and run on the street at the edge of the road, facing traffic, you might only feel the heel pain occasionally. If you are really fortunate, you may notice that your heel and arch pain instantly vanishes. In either case, it is likely that you have found a routine that will supinate the left foot enough to relax the plantar fascia and permit you to run without further damage to the plantar fascia.
If you don’t get immediate feedback, don’t give up. You can still make a judgment call by keeping a pain journal. One simple way for runners to do this is by adding a column to their training log. Rate your pain on a scale of 1 to 10. Note how many times you felt the heel pain during the run. If you only noticed the pain a few times, note how many miles it took before you noticed it. If the number of painful moments decreases, you are on the right track. If you supinate your foot by running on a supinating surface, and it takes more miles before you start noticing pain, this is another indication that you are on the right track. In addition to the immediate feedback of determining who much heel pain you have when you run, you should also assess how you feel after you run.
If you are running and placing too much stress on the plantar fascia, you may not have pain during the run, but might have pain later on. Delayed onset pain in the heel and arch results from the accumulation of inflammation within the tissue. This process begins during the run and continues for hours. If the inflammation is significant enough, you may notice throbbing in the heel and arch in the evening while you are relaxing. Some runners will report no pain during the run, or later that day, but will note a substantial increase in the morning pain level.
If you currently have pain that you would rate as a 5 out of 10 when you step out of bed, and then you run on a supinating surface, your first step out of bed may drop to a 2 or 3 out of 10. Monitoring your morning pain level is an important indicator of whether or not you are doing enough to decrease stress on the plantar fascia while running. If you run on a supinating surface and feel certain that your heel pain is getting worse, you might want to experiment and run in the opposite direction. It may simply be that you are actually pronating the wrong foot. If this happens, don’t feel bad. I have tutored some brilliant medical minds on running biomechanics, and I have seen some very smart people get them backwards.
If you are confident in your assessment, keep running while you treat your plantar fasciitis. Continue to monitor your pain level, making note of how far you run on a given surface. Once you are fully healed you can likely go back to your old routine and favorite running routes.
My bursa issue under my right heel is now completely healed. I just finished an 8 mile run and absolutely no pain. Thank you so very much for the spot on diagnosis where so many had gone wrong.
Dr. Christopher Segler is a San Francisco-based sports medicine podiatrist and foot surgeon who specializes in treatment of running injuries. He is also a runner himself, 14-time Ironman triathlon finisher and marathon runner. He is often invited as a guest lecturer a prestigious medical conferences to help teach other physicians about running biomechanics and the treatment of complicated running injuries. If you have a running injury, you can reach him directly at 415-308-0833. You can learn more about heel pain at AnkleCenter.com