Plantar fasciitis: running from the ground up

Athletics – Berlin Marathon – Berlin, Germany – September 16, 2018 Kenya’s Eliud Kipchoge celebrates winning the Berlin Marathon and breaking the World Record REUTERS/Fabrizio Bensch TPX IMAGES OF THE DAY

With the recent setting of a new world record for the marathon by Eluid Kipchoge, runners everywhere will be stepping up their game. With that renewed intensity often comes new injuries. To help you with the athletes that limp into your clinic, we begin our newsletter series on running injuries and performance. Most running injuries are due to training errors. Some factors that result in injury include:

• Increased distance
• Increased speed
• Change in terrain
• Hill running
• Overused shoes

Starting from the ground up, we’ll look at some common injuries, and pull a few uncommon ones from our previous series, to arm you with up-to-date knowledge on how to treat runners. Many runners struggle with plantar fasciitis (PF). Part of the difficulty in its resolution, as Chris Mallac explains, is the fact that the strap of fascia-like tissue contains little elasticity and histologically resembles a tendon. With little blood supply to the already rigid tissue, any degeneration due to chronic strain or corticosteroid injection may weaken the fascia and cause it to rupture. Physio Tracy Ward investigated the pros and cons of corticosteroid injection and found it increases the chance of fascial rupture by two to four percent.

Interventional treatments

Surgeons in Istanbul recently conducted a randomized controlled trial to evaluate the effectiveness of four different interventional strategies for the treatment of PF (1). They enrolled 158 patients with a diagnoses of PF along with a symptomatic bone spur, in one of four groups. Each group received a particular treatment for the PF, either extracorporeal shock wave therapy (ESWT), prolotherapy, platelet-rich plasma, or corticosteroid injection, all popular treatment strategies.

All interventions appeared effective when administered within the first three to 12 months of injury. However, at the time of follow-up 36 months later, it seemed all treatments lost their treatment effect. The mean visual analog scale (VAS) score was nearly the same at follow-up for all four groups as prior to treatment! Most studies only follow patients for six to 12 months, such as demonstrated in a recent meta-analysis conducted in China (2). While this literature review found ESWT to be more effective than placebo in treating PF, the VAS scores were only followed for six months after the intervention.

Malloc advocates strengthening the intrinsic muscles of the foot to relieve some of the tissue strain in both inflamed and ruptured fascia (see figures 1 and 2). In a separate article, Ward recommends looking up the kinetic chain for deficits that may translate to added strain on the plantar fascia. She gives recommendations to remediate key areas of weakness and other training modifications. In short, PF isn’t an isolated issue, but usually a symptom of training error or kinetic chain deficits. As much as athletes want an easy procedural fix for PF, it appears exercise is the best treatment plan. For more on treating and preventing running injuries, take a look at the compilation of running expert authored articles in our Running Injuries: Prevention and Treatment book.  

Figure 1: Towel scrunches

Begin in sitting and scrunch a towel with both feet. Progress to standing scrunches with both feet, then standing on one foot. 

Figure 2: Cup exercise

Pick up a cotton ball with one foot and place it into a small cup. Begin in sitting and progress to standing sets of 10 reps. 

Reference

1. J Foot Ankle Surg. 2018 Sep – Oct;57(5):913-918.
2. J Cell Physiol. 2018 Aug 4. doi: 10.1002/jcp.26907. [Epub ahead of print]