Dr. Segler: Today on the Doc On The Run podcast we’re talking with Darin about plantar fasciitis, being an athlete and what it takes to get back to running, recovery and how to survive a torn plantar fascia.
Darin, thanks for coming on today to talk about your experience and to share what’s happened with you and plantar fascia the last several years. Thanks for coming on the show.
Darin: Thanks Chris! Why don’t I just start with the just a brief history of my experience both with the tear in the plantar fascia and how I go back on track with my athletic endeavors that sounds great.
Dr. Segler: That sounds great!
Darin: So I started running in 1985, really just to lose some weight after my daughter was born. I put on like fifteen pounds with my wife’s pregnancy. I decided that I need to start exercising and just trying to get in to a good shape because she’s going to be around, I need to be around for her. So I did my first 5K in 1985.
I started seeing a podiatrist in 1991 as I started to have heel pain. At that time I had plantar fasciitis. The podiatrist prescribed orthotics. But after I got orthotics, I noticed they were uncomfortable. I tried them for about six months but it didn’t work. The heel pain was all still there. Yet I kept running and just started doing more 10K’s. I started riding my bike a lot more because the heel pain was always notable and running wasn’t as comfortable. I did my first marathon in 2001 and through the training for that I had a little bit if heel pain but not too bad.
I did my first Ironman distance race in 2003. The I started ramping my training up to a really long triathlon. It was an event called Ultraman which is a three-day event. Training for that I started to develop pretty significant heel pain again.
I saw a podiatrist, got more orthotics. They were still uncomfortable, yet I gave them about a six-month effort. The plantar fascia pain never went away, never got better and I had the race coming up so I went ahead and did the race without the orthotics.
I kept doing Ironman races up until 2011 and that’s when I started seeing you Dr. Segler. You worked with me and tried to get me through Ironman Canada that year but unfortunately a long training leading up for that my plantar fascia actually tore partially away from the bone and I literally couldn’t walk.
Dr. Segler: Yes, ruptures of the plantar fascia do happen. This is really an important point because plantar fasciitis is so common it can be disatracting. If you just look online about heel pain, arch pain, running injuries and foot pain, then the majority of the stuff you will find is about plantar fasciitis. I see so many runners who think they have plantar fasciitis when they have what seems based on their story be a partial rupture of the plantar fascia. The story that you described is very clearly indicative of a partial rupture to me as a doctor who sees runners all the time. So why don’t you tell us like what that episode was like when that actually happened.
Darin: Yeah it was, I remember very distinctly because the pain was such that I could no longer ignore the thing, put it that way. I was running on a trail on Montana with a group of runners and a bunch of us were training for Ironman Canada that year. So this was going to be about twenty mile training run on the trails. It was supposed to be the last really hard run before the race and from the moment I started running with the group it felt like someone was pounding a nail in the bottom of my heel. Every single step was painful. There really wasn’t a running step, or way of landing or gait shift that would help the pain go away. The heel pain was constant and it was every single footstep.
I probably made it about thirteen miles into the run and it started to get much worse. So from being just that nail in the heel to a level pain that had me thinking, “I can hardly even stand to put my foot down.” Even just barely touching my toes to the ground was painful. So I found myself alone probably three miles from the car and I had to stop running all together. I was literally kind of hopping on one foot for about three miles to get back to the car and I knew something significant was wrong because I’ve never experienced that type of heel pain before. Then that’s when I got in touch with you and we got an MRI of my heel that confirmed that partial tear in the plantar fascia.
Dr. Segler: Right, so that’s the thing is that with runners and you know triathletes and obviously as someone doing Ultraman and Ironman races and marathons, everybody has aches and pains. Everybody has some minor little injuries. And everybody who’s an endurance athlete has a high-pain threshold.
I actually tore my hamstring during Ironman Tahoe and I still finished the race. I tore it on the bike and still ran the marathon, so I know we asa athletes are used to running through pain. SoI know that I should not run with a torn hamstring but I really wanted to finish. I needed to finish given what I was doing and what I was trying to achieve at that time. So I did exactly what you’re describing in that where you tried all these gait alterations.
I realized when I was on the bike after it tore that if I sat a certain way and paddled a certain way it kind of really didn’t hurt that much and then when I started running I realized if kind of ran with my right, my left foot tilted in toward my right foot. It hurt but it didn’t really hurt that much and I could continue to run.
Everybody does that, everybody when they get injured, whether you’re getting stress fracture or Achilles tendon issue or something else, you kind of try all these different strategies. Most people would say “Well if you get out the car and you start a run on Montana, you’re going to run twenty miles and it feels like someone pounding the nail into your heel with every step, you probably ought to go home and watch TV”.
But as an endurance athlete training up to this very particular race, instead of doing that of course you go “Okay well how can I work around this so I can fit my last workout” and yet it’s really not something you can just ignore. It’s really notable and that’s classic of a partial rupture of a plantar fascia.
People with plantar fasciitis don’t vividly remember the specifics about it. They have these very vague things like “I don’t know maybe it was training for this one race when it started. I don’t know, it just kind of crept up”. But what you described is very very different than a standard case of a plantar fasciitis.
Obviously you realized something was very wrong and you want to figure out what was wrong and so you got an MRI and do you remember what happened on the MRI?
Darin: Yes, I remember you got a call from the radiologist to review the results. The radiologist told you he had never seen two things with a plantar fascia before. He had never seen one that had been so inflamed and enlarged because of long-term abuse basically. Secondly, he had never seen a plantar fascia rupture with such a significant tear. My plantar fascia rupture had grown into epic proportions that way.
Dr. Segler: You never want to be an interesting patient, right? If the radiologist is excited about the appearance of the MRI, that’s generally not a good thing. But it’s good to know the real story and true extent of the injury. Obviously, based on the MRI, we could tell that if you continued to run on the torn plantar fascia it was not going to improve.
To most people, particularly runners, when they hear that they have torn the largest ligament in their foot, they might think that “Well that means I’m done. I’m never going to run again.” That’s just fear and worry.
It’s just not always true. It’s not necessarily true that you will never run again, even if you do tear your plantar fascia. In some ways, a torn plantar fascia is a simple injury to heal.
We can fix a torn plantar fascia. The best treatment for a torn plantar fascia may not be convenient, but it can be fixed. Your body can heal the tear in the plantar fascia.
To heal a torn plantar fascia, you don’t need surgery.
We don’t take you to the operating room and sew the tear in the plantar fascia back together. Plantar fascia ruptures don’t work that way.
So tell us what did once you realized how badly torn your plantar fascia was. What did you have to do? Obviously you were just about to do Ironman Canada. You had just done your last long run. You got this terrible news from the MRI. The radiologist was all excited about it and obviously you have a significant injury on your foot.
How did you shift gears? Mentally that’s not easy because you have been trained for a long time and put in a lot of effort for this event. What did you do?
Darin: Well, part of it was actually working with you. You and I talked about options before the rupture. We discussed all of the different strategies that we could use to help solve my chronic plantar fasciitis problem more permanently. During those initial discussions you gave the me option of the plantar fascia release surgery. You had explained how you could do the surgical procedure that would help solve the problem by releasing all of the chronic tension on the plantar fascia.
Once you looked at the MRI you said, “Well Darin, you basically did the surgery on yourself.”
Dr. Segler: Exactly. There is always a good thing in a bad thing with everything in medicine. For every bad thing, there’s always a good thing. For every benefit, there’s a risk. But “luckily” in some cases, when you tear your plantar fascia you’ve basically done the surgery without an incision.
In your case you ripped the part of the plantar fascia in a way that is similar to the release we would perform in the operating room. Of course, the release is not as elegant and the bill is not as big, but you got the same end result. You released the chronic tension on the plantar fascia.
To be clear though, when people hear a surgeon recommend surgery on the plantar fascia, what they often think is that the surgeon will go in and very cautiously and carefully surgically remove damaged tissue and sew the plantar fascia back together.
There is this misconception that we will somehow repair the torn, damaged plantar fascia, so it will look healthy and new. Kind of like when you wreck your car you take it into the auto body shop. When you get it back it looks like brand-new. Well surgery on a torn plantar fascia doesn’t work that way.
When we do the surgery for chronic plantar fasciitis, the surgery that is most often performed is a plantar fascia release. All that means is that the surgeon will go in and surgically cut through the medial band of the plantar fascia. We slice through the part of the plantar fascia that generally causes the most tension. The goal of the surgery is just to cut the fascia to relieve that tension.
If all goes according to plan you get scar tissue that forms between the gaps or the cut edges of the plantar fascia that we have released. If it heals the way we hope, in essence the plantar fascia is a little bit longer and a has little bit less tension when you stand, walk and run.
In some cases the cut plantar fascia doesn’t heal back together, but because it has been cut, it still relieves all the tension and your heel pain basically goes away. So when a runner like you has a traumatic partial rupture of the plantar fascia, the end result is in many ways exactly the same thing we do in the operating room.
So obviously after we reviewed the MRI of your torn plantar fascia you realized “Okay you have to shift. You’ve got to re-think this whole plan for Ironman Canada.” So what did you do?
Darin: You and I talked about the race and you said “Well you can still do Ironman Canada but you’re going to be in a lot of pain and you’ll continue to do damage with every step of that marathon.” So I decided it was not worth the risk of causing more damage. I bowed out of the race. I decide I was not going to do the race.
After I decided tok skip Ironman Canada, I realized I also had bunions on both feet. We talked about how bunions can contribute to plantar fasciitis in runners. You and I talked about what would be the best a kind of sequence of events to get my feet back to optimal health for a return to running.
You and I then discussed strategies and we planned to have me go through bunion surgery on each foot but separately one after another so that I wasn’t completely disabled while healing from the bunion surgery.
I went through that process and each bunion surgery recovery took about six weeks. You advised that at the end of the roughly twelve weeks, my plantar fascia would have had the chance to start to re-attach as it should naturally and we’ll see where my pain level was at the end of all that recovery period and go from there.
At that stage I had no idea, I had no expectations of when I would be able to run again. I knew I’d be able to walk. But I didn’t know what the end result of the surgeries and recoveries would end up being. So mentally I just decided it will take up whatever time is necessary.
I did not even plan for a time on when I was going start running again. IO just focused on getting through the surgery recovery. Because I have two dogs I was anxious to get back to just walking with the dogs. But mainly I decided I was going to take it super easy through that roughly twelve-week period of recovery after surgery.
Dr. Segler: There is no question that recovery after surgery is tough and I will say for any athlete, it’s especially difficult.
About I a year-and-a-half ago or so I had to have surgery. It was not related to my feet, so I of course thought, “why not exercise.”
But my surgeon said “I want you to promise me that you will not exercise for three weeks.”
I said “Okay but I can go for an easy run right? You know just few miles, easy pace?”
My surgeon said, “No Chris. No, no, no, no, no.”
I asked, “So I can go for bike ride, because I mean a bike ride isn’t really that stressful. Right? I can go for bike rides?”
My surgeon said, “No. No exercise at all.”
In desperation I asked, “So I can go for a hike right?”
My surgeon sighed and said, “Chris, let me explain this to you. If an elderly obese person would consider it to be exercise, you’re not allowed to do it for three weeks.”
I really thought about. When was last time I didn’t exercise at all for three weeks? Maybe in high school. So when an athlete thinks about taking six weeks (a month-and-a-half) of no exercise, not even walking your dog, it can be difficult.
For somebody who’s an athlete who is so used to doing workouts that they will make sure they go for the final twenty mile run when it feels like somebody’s driving the knife in your heel, it must be hard to think about giving up exercise ton recover. That kind of shift can be really tough. Mentally it’s very difficult.
For athletes, for like for us, our stress hormones go way up. My personal belief is that recovering athlete’s are way more prone to depression and anxiety that seem to be alleviated by our exercise.
Once you start to recover and get back to doing something that’s little more normal, like walking your dog or riding your bike that anxiety and mental fog suddenly starts improve. With your return to exercise you accelerate out of there and you start to heal and recover pretty quickly.
So when you got to that place where you could resume exercise, what happened? How did you get back into “real” exercise? How long did you spend just with really moderate things like walking your dog before you really got back into what you think of as rigorous exercise?
Darin: I think probably I spent at least two months after the twelve week recovery period. So each bunion surgery and recovery was six weeks. A total of twelve weeks just to get through the bunion surgery and recovery. After that, I was walking my dogs in the neighborhood for about two months and I felt really good. I started to do upper body strength conditioning, a little bit of lifting weights at home and it all felt very good.
But I knew that if I was going to try and get back to running at the marathon distance again I was going to have to take it really slow and basically learn how to run again.
Dr. Segler: Well your foot was different. Realistically after you have a bunion surgery your foot is very different. The shape of the foot is different. The pressure distribution through the foot is different. Many people think of bunion surgery as just removing a bump or straightening the toe. But the fact is, bunion surgery is a reconstructive procedure where we change the position of the bone. We change the structure of your foot and functionally bunion surgery changes the way that your works when you run. So you do have to learn how to run again.
Darin: Yup! At the end of the five month surgery recovery period I started a short bike rides, but I decided I wasn’t going to attempt to run for quite some time. But I felt like it was safe to start biking again because I felt no pain in my feet when biking. I needed to get the cardiovascular effects of aerobic exercise again. So I started doing cycling, which felt really good.
I made it through the rest of that year, which was 2012. Since I felt really good with the recovery I decided to sign up for another Ironman race. I was aware of the possibility that I might have to just walk the entire marathon of the Ironman race, but I was fine with that.
After all I had been through, I was just happy to be able to get back out and exercise.
I signed up for 2013 Ironman race. Probably early in 2013 I started doing really short runs. Three miles, gradually worked up to about six miles. Because I wanted to be cautious, I think I never did a long run more than about six or eight miles when preparing for that Ironman race. I wasn’t having any heel pain at all. So again, I wanted to take it nice and easy, didn’t want to push it and I felt good.
Let me back up just one second, I would like to explain one of the things that I did before I even put on running shoes again.
I was reading a lot about people with flat feet. I learned about the problems people with flat feet can get with plantar fascia. I learned that plantar fasciitis is very typical in people with lat feet, and how in fact, that’s one of the reasons that the military used to exclude people with flat feet from military service. It was all because the problems with plantar fasciitis.
I looked on the Newton running shoes website and I started to get the idea of “Well I do know that I’m a heel striker and being flat-footed heel striker is almost guaranteed you’re going to have plantar fasciitis.”
So I got a pair of Newton running shoes. They were very uncomfortable at first, but I was convinced they could help me change my running form. The activator pads on the Newton running shoes really helped me understand where my foot was landing.
In those first one mile, two-mile and three-mile running efforts I could sense when I needed to adjust my foot strike. Gaining that sense of where my foot was landing made all the difference in the world.
Fast forward now and it’s been five years since I started running again.
It has been almost six years since I tore my plantar fascia and I had no heel pain at all, NONE!
After I tore the plantar fascia and recovered, two years ago in fact, I had a personal best in the marathon distance, just the marathon alone. I had a personal best at 53 years old!
Dr. Segler: Wow! That is incredible! But we have t9o realize that you had all these different factors in play. Obviously you had a significant injury. But you took steps to recover appropriately. You had surgery to correct what is basically an imbalance in your foot from the bunions. You were thoughtful and cautious about how you re-trained yourself to make sure that you didn’t get injured. In addition to that, you got some Newton running shoes and started functionally changing your running form so that you became less of a heel striker and more of a mid-foot striker. There is evidence that forefoot and midfoot striking is more efficient than running as a heel striker. There’s lots of research that says running with forefoot and midfoot striking may be more efficient. In theory, you should be faster or more efficiency in the marathon distance.
For me personally, I was asked many years ago to write a review for Newton running shoes when they were relatively new. I figured if I was going to write a review I should do it the way that the instruction card said and so I followed their instructions on learning how to use Newton running shoes most effectively.
Initially I just used once a week when I would do mile repeats on the track. I didn’t run in my Newton’s at other times in training.
The next marathon I did was 20 minutes faster than my previous best!
Obviously being older you might not expect to get faster in marathons.
But you can get faster, particularly if you’re more efficient in the way that you run.
So you have lots of factors that could have contributed to that increase in speed.
No matter how you look at it, it’s impressive when somebody in their fifties has a PR.
Obviously you survived the injury to your plantar fascia in a way that a lot of runners don’t think they can. Many doctors will tell runners when they’ve had a partial rupture of the plantar fascia (or even chronic plantar fasciitis) they just have to stop running. Clearly that’s not true in your case.
In defense of doctors everywhere I will say they’re trying to get you to stop running because they believe running is high force. It’s high impact. The doctors may believe it’s high stress to run and they want you to get better.
This mentality isn’t just applied to foot injuries.
Over 25 years ago I had to have a reconstructed knee surgery. At that time my orthopedic surgeon told me that I should never run because if I did, within 10 years he though I would wear out my knee. He said if I ran, within 10 years, and I would have to have a total knee replacement. He explained that I was way too young for that procedure because the implant wouldn’t last long enough.
Well now it’s been over 25 years since he told me I would wear out my knee. I’ve done lots of marathon, I’ve done 15 Ironmans. I run a lot still and I don’t have any knee problems. So in retrospect clearly the advice he gave me was wrong.
That doesn’t mean that he wasn’t giving me the best advice he could, given what he knew about my condition. But to stop running is an easy way for doctors to try to reduce stress and risk for you. But obviously, someone like you who is an active athlete and who has been an endurance athlete for many years, that’s just not really reasonable. It’s not a reasonable request of a runner.
If you’re thoughtful about your running and you do things deliberately as you have, there’s almost always a way to figure out how to keep running. In most cases you can continue to run, regardless of the type of injury that you’ve had even if it’s a partial rupture of the plantar fascia. Clearly that’s worked for you.
So what’s your activity like now? What are you doing now?
Darin: Today I am still doing Ironman races. I have another Ironman coming up in May of this year. I am also doing marathons. Typically when I’m training in the off-season I run about thirty miles a week. When I’m training specifically for a marathon, I ramp up to running about 55 to 60 miles a week.
I ride about 1,400, to 1,500 hundred miles per year and on the bike. I bike year round since it’s so beautiful here in the Bay Area. So it’s easy. Typically biking, training for an Ironman I ride is about 3,500 miles. I start to get through the swim as necessary. But all of that has literally been pain-free since my self-induced plantar fascia surgery.
Dr. Segler: Well that is good news! It sounds like you’re still on track. Are you excited about your race in May at this point?
Darin: Yeah, it is really two things, as you have experienced doing fifteen Ironman races. It’s a feeling like you just can’t get anywhere else. It’s that high that you get during the actual race. It’s the training leading up to it. It’s being able spend long bike rides with friends. And it’s honestly the other thing that has been really rewarding is just being able to go on runs with my dogs.
My dogs were there after my surgery when all we could do was to get a three mile walk around the neighborhood. Now I’m able to do three to six mile runs with them several times a week and they’re much happier. I enjoy running with them, so I couldn’t be happier.
Dr. Segler: That’s great and I’m glad you’re still running and racing.
To me it’s a shame when I hear runners who have given up running because they’ve been told by some doctor they have to stop running. I just don’t believe that it’s always the case.
My primary advice to a runner with a partial rupture of the plantar fascia, who sees a doctor who tells you to stop running, the first thing is you just get a second opinion from somebody else in your area who sees runners. Don’t take “no running” as an answer. That’s the bottom line.
Darin: There is one other thing I’d like to add for people reading this who are working on recovery and getting back into running. The technology that’s available now can actually really help people change their running styles. The Newton shoes have helped me. They don’t help everybody, but Newtons have helped me. Mainly just because Newtons kind of forces the change in strike. Less heel striking, more midfoot to forefoot landing and also increasing the cadence. If you increase the cadence, it’s a much easier stride landing on your midfoot.
Another tool that really helped me get there is the Garmin. I got a new Garmin watch that actually tracks your cadence for you. I can do a six-mile training run, come home and look and see exactly what my cadence has been through the whole run. I now know that if my gait stays at a cadence of about 180, I don’t feel any discomfort. My feet are just perfect. But if I start to lengthen my stride at all, I can begin to feel things are not going to end well.
Dr. Segler: Right, it’s true. It can be very tedious counting foot strikes and a tool like a Garmin that can track your cadence can help.
When I first started focusing on cadence during my runs I noticed how much more efficient it can be. I remember at Ironman Texas one year, I was not having the best race so I just decided to see what would happen if I experimented by increasing my stride. It was during the race and it was at least halfway through the marathon portion. I was tired and my running form was already falling apart.
So basically what it did was I measured my stride by just by counting to figure out what cadence was. Watching my watch, I ran at same pace for two miles and then the next two miles I increased cadence by 10%. After I increased my cadence, my heart rate dropped about 20 beats per minute. It was interesting, but it was extremely tedious watching my watch while running and counting steps for a minute to figure out my cadence.
But obviously these new tools, like you said, the new Garmin is pretty amazing. You can get heart rate read from your wrist. You can get cadence measured for you. They can be very very helpful tools.
Newtons are also helpful tools. You can look at the forefoot lugs and so clearly identify your wear pattern. Then you can make adjustments to your running form and evaluate how the wear pattern changes. The forefoot wear pattern can help you determine how you’re really landing. You can see whether you’re really truly forefoot or midfoot or if you are heel striking.
All of these tools really do help runners analyze their running form and change their gait. So if you are interest in modifying your running form they can be beneficial. Thanks for sharing that.
Darin: Thanks for giving me the opportunity share my story, Dr. Segler. And Thanks for working with me to give me the tools and knowledge I needed to heal. It’s returned me to being a happy athlete again!
Dr. Segler: That’s great Darin, thanks again! I appreciate you coming on the show. Best of luck in your next race. I hope you’ll have many more marathons and Ironman races to come in the years ahead.
Darin: Thanks a lot Dr. Segler!
If you have a question that you would like answered as a future addition of the Doc On The Run Podcast, send it to me PodcastQuestion@docontherun.com. And then make sure you join me for the next edition of the Doc On The Run Podcast!
Dr. Christopher Segler is a podiatrist and ankle surgeon who has won an award for his research on diagnosing subtle fractures involving the ankle that are often initially thought to be only ankle sprains. He believes that it is important to see the very best ankle sprain doctor in San Francisco that you can find. Fortunately, San Francisco has many of the best ankle sprain specialists in the United States practicing right here in the Bay Area. He offers house calls for those with ankle injuries who have a tough time getting to a podiatry office. You can reach him directly at (415) 308-0833.
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