Today on the Doc On The Run podcast, we’re talking about the top 10 myths about plantar fasciitis in runners.
Now look, there are a lot of myths surrounding plantar fasciitis, and plantar fasciitis is common, but you have to understand when you’re a runner that not all the stuff you read is true.
The first myth we’re going to talk about is that plantar fasciitis is caused by running too much. I mean, think about it. Does this really make sense to you as a runner? I mean, have you had periods in your life where you were running more and didn’t get plantar fasciitis? I certainly have.
So, I’ve gotten plantar fasciitis myself. I’ve gotten it from stepping on one of kids’ Legos, I’ve gotten it from running on the wrong surfaces in the wrong shoes, I’ve gotten it for lots of different reasons. A number of times I’ve had plantar fasciitis three times. I’ve always been able to fix it very quickly and very simply with figuring out what caused it and then not doing that thing again, and then doing the right stuff to calm down the inflammation and take the stress off the fascia. That’s the main point.
Plantar fasciitis is inflammation of the plantar fascia caused by stress applied to the plantar fascia in excess of what it can handle before you do your next workout. It’s not running too much.
Now, I lecture at medical conferences all over the world about runner’s heel pain. I wrote a book on runner’s heel pain, and I teach doctors about runner’s heel pain. And when I go to those conferences, doctors always tell me plantar fasciitis isn’t getting better because runners run too much. They try to imply, or outright say, that you are not getting better just because you won’t stop running, but that’s absurd.
Plantar fasciitis stays irritated because you’re walking on it, you’re stepping on it, you’re driving, you’re standing on it. It’s not just running. You just have to stop the stress applied to the plantar fascia if you want it to heal. It’s not that you’re running too much, that’s not what causes it. It’s running on the wrong surfaces in a way that puts too much stress on the plantar fascia. It’s doing too much stuff before it fully recovers.
That’s all. It’s not running too much, so don’t let people fool you into thinking that it’s really just running, and if you stop running, your plantar fascia is going to miraculously heal and you’ll be fine and can resume running. It’s not true.
The only thing that’s a hundred percent for sure is that if you stop running, you’re going to lose your running fitness. That’s all. It doesn’t mean you’re going to cure your plantar fasciitis just because you stopped running.
Now, the second myth we’re going to talk about is that plantar fasciitis is is caused by pronation. Well, pronation is sort of a dirty word among runners now, and you can buy pronation control shoes, which imply of course, that everybody should control the pronation in your foot, but pronation is a natural movement. You have pronation, which is a movement that allows your foot to become more flexible, to absorb force when you land when you’re running, to adapt to uneven surfaces. And then you have supination, which is the opposite of pronation, which converts your foot from a flexible, mobile adapter, to a more rigid lever that allows you to actually fire all the muscles in your leg and use your foot like a lever to push off and spring forward and propel yourself when you run.
They’re both normal. One of them leads to some problems, and the other one leads to other problems, if they’re excessive, but they’re not excessive in most people. So, if you’ve been running for 20 years, and you got plantar fasciitis, and you’ve never had plantar fasciitis before, why would you think that pronation is your problem? I mean, unless you changed your running form or you changed something significant in the way that you’re running, it’s unlikely that pronation is really the root cause of your plantar fasciitis. Certainly it can contribute, but the problem is when you go to the doctor and they tell you have pronation and they say you have to have motion control shoes or custom orthotics to control all the pronation in your foot, you wind up with a different set of problems.
So, it’s not always necessary, that’s the main thing. There are lots of things you can do to adjust the amount of pronation when you run. If you’re running in really flexible shoes and you’re landing as a heel striker, you’re going to wind up pronating more than if you protect yourself with more normal running shoes, for example.
But it doesn’t mean you have to do that. It doesn’t mean you need inserts in your shoes, it doesn’t mean you need custom orthotics. There are many things that you can do to adjust the amount of pronation when you run.
Even if you run on the street, where you run actually matters. If you’re running on the side of the street where the road slopes, one foot’s pronating, and the other foot is supinating, and that difference between the pronation and the supination can be a huge difference on the amount of stress and strain on your plantar fascia.
It’s also true when you’re running on the track. When you run in one direction, let’s face it, a large section of it you’re running around the curves. Well, on the curves, you’re basically changing direction, and as you change direction, one foot is pronating, the other foot is supinating.
So, believe it or not, even the direction you run on the track can influence the amount of pronation in your foot and consequently the amount of stress on the plantar fascia. But pronation in itself is not always a bad thing, so don’t think that if you just fix the pronation, control the pronation, or do something to reduce the pronation, that’s the only thing you have to do to get rid of your plantar fasciitis and make sure that it doesn’t come back. It’s just not true.
Now look, if you get plantar fasciitis over and over and over, and you’re running in unstable shoes, and you know that you pronate a lot, then maybe that’s a contributor, but it’s not the case for most people.
Now the next myth is that plantar fasciitis is caused by flat feet, and that actually is related to the precious one, because we know that people that have flat foot are essentially pronated, because pronation is where the arch collapses down toward the ground. So when you have flat feet, you’re basically pronating.
So, that’s the thing, is that when people have flat feet, they think it’s going to be a problem. I mean, many, many years ago, of course, there was this idea that if you had flat feet, you didn’t have to go into the army when there was a draft, because you’d be more prone to getting injured.
Well, we know that that’s not true for recruits in the military, and we know that it’s not true for runners either. There are lots of successful runners, lots of professional runner, who have flat feet. Having flat feet does not doom you to plantar fasciitis. So, you have to be aware of your foot type, and if you have flat feet and you know that you’re putting a lot of strain on the plantar fascia and you’re getting plantar fasciitis over and over, then maybe you need arch supports, maybe you need some more stability in your running shoes, but you don’t necessarily need motion control shoes or custom orthotics for that matter. It just depends on your foot type and the pattern of injury that you’ve had and how it started. So, it’s not that you’re going to get plantar fasciitis just because you have flat feet. It’s just not true.
Now the next myth is that minimalist running shoes actually cause plantar fasciitis. I hear this from doctors when I lecture at medical conferences on injuries associated with minimalist vs. maximalist running shoes. There’s a specific talk I give at conferences that I’ve given a number of times related to this topic to help educate doctors on the differences between patterns of injury that happen in runners who are running in minimalist shoes vs. maximalist running shoes.
And a lot of doctors seem to think that because minimalist shoes inherently have less stability, less material, and less support for your foot, that you’re going to get plantar fasciitis if you run in minimalist shoes, but that’s not true. Again, this comes back to that same idea of plantar fasciitis being related to too much stress and strain placed on the plantar fascia. It’s not because you’re running too much, it’s not because of the type of shoes you’re running in necessarily.
So, it can be related to lots of different things. It can be because the side of the road that you’re running on puts too much stress on it, that the shoes you’re running on are inappropriate for your particular type of running form. If you’re a heel striker and you’re running in unstable shoes and you’re pronating and putting a lot of your force on the plantar fascia, well that may do it, but it’s not just the shoes.
So, it really depends more on your type of running shoe. I run in four different kinds of shoes for different types of workouts. I even race in minimalist shoes. I do my long runs in other shoes that are going to protect me and provide a little bit more cushioning stability just so that I make sure that I’m protected a little bit more for those long runs.
Don’t just blame the shoes, and don’t just think that if you switch shoes from a minimalist shoe to a different shoe your plantar fasciitis is going to miraculously go away, because it won’t.
Now, the next myth is a really important one, and this is that heel pain is almost always plantar fasciitis in runners, and that’ sort of true. Plantar fasciitis is by far the most common cause of runner’s heel pain, but it is not the only cause. Now, what’s interesting to me is that when I go to conferences and I lecture on runner’s heel pain, one of the first things I’ll do is I’ll say, you know, “Okay,” there’s usually hundreds of doctors there and I’ll say, “Okay, who in the room here saw plantar fasciitis this week?” All the hands go up. Every doctor in the audience will raise their hand, because everybody’s seeing plantar fasciitis every day.
And I’ll say, “Okay, who in the room saw a case of infracalcaneal bursitis this week?” And I’ll usually raise my hand, because I usually saw one that week. And then I’ll say, “Okay, who in this room saw a case of medial calcaneal neuritis this week? Who saw a nerve issue that they thought was plantar fasciitis?” Maybe there’ll be one or two people mentioning neuritis or bursitis as a cause of runner’s heel pain, but usually only one or two.
Now the thing is, I usually stop and say, “Okay, this is important to understand. So, I see a small fraction of the number of patients you guys see, and I know, because I used to have a standard practice. Well now, I do all remote consultation, Skype visits, online visits, and I do house calls. So I typically see fewer patients during a week in person than I used to see before lunch on Monday. And that’s true for most other doctors, I say, “Look, I know you guys are busy, so tell me how it is, why is it possible that I saw a tenth of the patients of any of you, yet I saw a case of each of these, and most of you didn’t see any. Is that possible? Or is it possible you’re just missing it?”
And this is true for a lot of runners that do self-diagnosis. They think they have plantar fasciitis, they could have a stress fracture in the heel bone, they could have bursitis under the heel, they could have a nerve injury that’s masquerading as plantar fasciitis, and you could even have a tear or a partial rupture in the plantar fascia, and those things will not get better if you treat them like plantar fasciitis. There are different treatments.
So that’s the thing, is you have to understand that all runner’s heel pain is not plantar fasciitis, and if you think it’s plantar fasciitis and you treat it like plantar fasciitis, and you’re not getting better, then it’s probably something else.
Now the next thing is myth number six is that you need to have X-rays or an MRI to diagnose plantar fasciitis. That is just not true. Plantar fasciitis fits a very particular pattern, and the story that we hear from you, the story of how it started, what it feels like, when it hurts, how it hurts, how it responds to certain treatments, that’s really all that’s needed to diagnose plantar fasciitis.
Most of the time, however, when you have plantar fasciitis and you go in to see a podiatrist, they will do X-rays of your feet to rule out some other problem, and they’ll say, “Well, maybe you have a bone spur, maybe you have a stress fracture.” First of all, stress fractures don’t show up on X-rays in the overwhelming majority of cases when you go in and you’ve just had plantar fasciitis or runner’s heel pain. Maybe you think it’s plantar fasciitis, but you’ve had heel pain for some short period of time, you’re almost never going to see it on the X-ray.
You do not need an MRI. If you think you really have a stress fracture in the heel bone, or you think that you just ruptured the plantar fascia, well, I don’t actually think you need an MRI for those most cases either, because you can do some things to diagnose them yourself, just looking at the foot, pushing on the right places, squeezing the right things, and you can tell whether or not you have those things without those fancy tests.
So doctors will often do it, of course they’re billing your insurance for the X-rays, and they have to see you back again when you get an MRI, and they get to see you again and charge you again, but it’s not always necessary. So that is completely a myth that is just not reality.
The next thing that’s also super important, I’ve heard this over and over and over from runners, that plantar fasciitis is self-limiting. They say, “Okay, well I read this, I got this plantar fasciitis thing, and I understand it’s self-limiting, that if I just take it easy, if I ice it, it’ll just, eventually it’ll just go away.” That is not true.
If you did something to injure the plantar fascia, this is not complicated, if you injured it, and you keep doing the same thing that did injure it, it’s not going to go away. I’m not trying to suggest here that you should stop running, I’m just saying that it’s not going to just magically disappear. Why would it? If you think about it, you’re stepping on the plantar fascia every time you walk. Every time you move around, every time you wake up and step out of bed and you have this sharp pain in the bottom of the heel, well, you’re stretching the plantar fascia, and you’re squishing all that inflamed tissue, and it causes more pain, that stimulates more inflammation.
And so you very quickly get locked into this cycle of inflammation and irritation of the plantar fascia, and why would it go away unless you do something? So, you have to do something to treat plantar fasciitis. Those things are not complicated at all, and I believe that the overwhelming majority of patients who have plantar fasciitis can figure out how to do this at home, do the right treatments, and as long as you know the right treatments and you know what to do, you can get it to improve. But if you do nothing, there’s no reason to believe it’s just going to magically go away. It just doesn’t work that way.
Myth number eight is that you have to sleep in a night splint to cure plantar fasciitis. So, night splints are a very popular treatment, and I think part of the reason they appeal to people so much is that there’s this idea that you can literally make it heal while you’re sleeping. So you put on a sock or a brace that holds your foot in this position where it pulls your foot upward, and the theory is that it keeps the tension on the plantar fascia so it doesn’t become inflamed when you get out of bed in the morning.
The problem with that is that the main contributor to plantar fasciitis is actually not a tight plantar fascia ligament on the bottom of your foot. The main contributor to plantar fasciitis is actually a tight Achilles tendon, and virtually every runner I have seen, other than three, truthfully, I’ve seen three in the last 15 years that did not have a tight Achilles tendon.
So almost all runner have what we think of as a tight Achilles tendon, and when you stretch the Achilles tendon, there are two components. There’s the Soleus part of the Achilles tendon, and the Gastroc part, and the details of that really are not specific that you know that right now, but all you have to understand is that when you bend your knee, you do not stretch the Gastroc portion, and that’s the part that is almost always contributing to the tight Achilles tendon that leads to plantar fasciitis.
So when you put on a night splint, you hold your foot in what we call a corrected position and go to sleep, you will not sleep with your knee bent. So, I actually created this concoction of sort of combination of devices where I had a night splint and a straight leg immobilizer that would lock my knee and hold it straight while I was sleeping with the night splint.
That actually worked. Of course it was terribly uncomfortable, completely cumbersome, and it was kind of a ridiculous thing, but it worked. And there’s actually a new device called the Equinus Brace that’s been developed by a podiatrist who specializes in Equinus deformity, and it actually will hold you straight, but you don’t have to sleep in it, you only have to do it an hour a day, so it’s way better than a night splint.
So, night splints are not going to cure your plantar fasciitis. If you want to use a brace, there is a much better one called the Equinus Brace, and we’ll put a link in the show notes if you want to check that out.
Now the next myth is that a cortisone shot will cure plantar fasciitis in a runner. Now this is a dangerous one, and you have to understand this. So, one of the things that we know is that corticosteroids, like a cortisone injection, they are one of the most powerful things on the planet to stop inflammation. Cortisone injections are also one of the most powerful things on the planet to stop the formation of collagen bonds and weaken collagen.
So if you have scar tissue, one of the treatments, scar tissue is just a bunch of indiscriminate little strands of collagen that kind of run in every direction through the tissue. If you have scar tissue that is restricting motion or causing a lump, if we inject it with corticosteroids, it will actually weaken the collagen bonds, break them up, and dissolve them.
Now, your plantar fascia is a huge sheet of collagen. So when you inject the plantar fascia ligament itself with cortisone, you can weaken the collagen. That can lead to a rupture or a tear in the plantar fascia, and that is a way worse problem.
The problem is that first of all, when you get a cortisone injection, you will have a dramatic improvement right away, but when you look at studies that compare a short term improvement vs. a long term improvement with cortisone injection, there’s no difference at 12 weeks. So, if we inject you with cortisone, you’ll have an improvement right away, but because it doesn’t hurt, you’re then less likely to do the other things that will actually really cure your plantar fasciitis, and because you’ve been worrying about your heel pain and probably running less, you will often ramp up your training and ramp up your mileage significantly that puts your plantar fascia under more strain while it’s been weakened by the cortisone, and that can lead to a partial rupture in the planter fascia.
I do see lots of runners who are not getting better. They call me, they ask me all this advice, they want to know specifically what to do, because their plantar fascia is not getting better, and then we figure out that they have a partial rupture. Many times this has, I think, contributed to the fact that they had a cortisone injection before, and that is a serious problem that you can avoid, so don’t get a cortisone injection when you go to the doctor. That’s not the best way to treat this.
Myth number 10 may be the most important to you. That is that you have to stop running to heal plantar fasciitis. Now this myth is absurd. Again, if you stop running, the only thing that’s going to happen is you’re going to lose all your running fitness. Does that appeal to you? I bet it doesn’t. I mean, if you lose all your running fitness, how long is it going to take you to get it back? And how long do you think you’re going to have to stop running to get it to go away, to get your plantar fasciitis to heal?
And again, you’re stepping on your plantar fascia all the time. You’re putting stress on it when you drive your car, you’re putting stress on it when you step out of your car. You can’t even get out of bed and walk to the bathroom without putting stress and strain on it, and you feel it first thing in the morning. You know that it hurts, so you know you’re aggravating it.
You’re not going to stop doing that. And yes, I understand why doctors will say, “If you run less, it puts less stress and strain on the plantar fascia,” but that’s not the only thing you have to think about. The most important thing that you should think about from this episode is that somewhere between zero activity, like bed rest, and running an ultramarathon every day, somewhere in between that continuum of zero activity and way too much activity is what we can think of as your threshold for healing.
All you have to do is get your activity and stress, not your activity, but your stress to the plantar fascia, below that threshold for healing. If you get below that threshold for healing, you’re going to get better. It’s as simple as that.
So there’s ways to do this. You can, sure, you could run less, that wouldn’t be my first choice, but you can run one direction on the track and it will decrease the stress on your plantar fascia. If you run the other direction on the track, it will increase the stress on your plantar fascia. If you run with the slope of the road underneath you, supinating one foot, it decreases the stress on the plantar fascia. If you run on a sidewalk in a way that actually slopes you and pronates you, that increases the stress on the plantar fascia.
And yes, inserts, there’s all kinds of things you can do that will decrease the stress and strain on the plantar fascia, but you have to figure out what you can live with. You have to figure out how to decrease the stress and strain on the plantar fascia ligament while you’re running. Don’t just stop running, that’s just not a recipe for success.
So the first thing is to figure out what is your real goal. If you have a race you want to do, you have to figure out how you can do that. If you want to train for the Western State 100 or you want to train and qualify for the Boston Marathon, you’re going to have to keep running. You need to figure out how to do that while you decrease the stress and strain on the plantar fascia, and you you have to make sure it’s not plantar fasciitis.
You can check out the course on runner’s heel pain if you’re really worried about this or you really want to keep running, you really want to figure out how to take care of it, everything’s in there. We created this monster course, it’s like two and a half hours of videos, 23 different videos I think, and it walks you through every step of the process of self diagnosis and self treatment of runner’s heel pain.
So, just remember, you don’t have to stop running, you don’t have to have a cortisone shot, you don’t have to have an MRI or an X-ray in order to figure out what to do. It’s very simple. Most runners can treat this at home without any help from a doctor if you just do the right stuff. You just have to understand what is actually causing your heel pain, and then do the things to treat that form of heel pain, and don’t just treat it all like it’s plantar fasciitis. Make sure you have the right diagnosis, make sure that you know what’s causing the problem, and you can fix it, and you can get back to running.
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.
But if you are still confused and think you need the help of an expert, a “Virtual Doctor Visit” is the solution. He has been “meeting” with runners all over the world and providing just that sort of clarity through online consultations for years. He can discuss your injury, get the answers you need and explain what you REALLY need to do to keep running and heal as fast as possible.
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