RB34: Beating Plantar Fasciitis (And Other Soft Tissue Injuries)
Plantar Fasciitis is a runner’s curse. It is also a running injury that I have been battling for over a year now. In this episode, I walk you through my journey from point of injury to rehab. Along the way, I will share what I have learned about this annoying running injury, and share how you can prevent this dreaded injury or other overuse injury you may encounter.
Hi everyone and welcome to another edition of RunBuzz, I am glad to be with you today wherever you are and whatever you are doing. By the time you hear this episode, I will have just undergone my 2nd surgery to address Plantar Fasciitis on my right foot. I would later learn that this running injury was further complicated by the formation of a small bone spur on the bottom of my heel. It is my hope, that you can learn from my experience fighting this injury as well as gain valuable insight into the treatment protocol and process that my doctors and I have used to get rid of it.
I know I have talked about my injury before, but I don’t think I have ever walked you through the complete progression of my injury from start to finish.
When it comes to injury prevention, I know I have preached on this podcast that you should never run through pain and should always stop so you can live to run another day. Usually if you adjust and catch the onset of injury early enough (especially overuse injuries), you have a greater chance to rebound and prevent your injury from getting serious. Not always, but usually.
I hope to use my situation as an example to walk you through what the complete life cycle of an injury rehabilitation looks like as well as share some simple steps you can start with should you develop a soft tissue injury like tendinitis or plantar fasciitis.
So while your injury may be slightly different than mine, the remediation steps I describe should be similar to how you would progress if you had a similar injury. So let’s get started.
First and foremost I want to mention that I am not a doctor and this is just my personal experience of what I went through. My experience is similar to other injury rehab scenarios that other runners I have worked with have experienced. Not exact, but close. So if you are injured, I encourage you to only use what you read here to get a feel for what you may experience and what a typical injury rehab protocol looks like. As always, I am not here to provide medical advice. I will always encourage you to seek out a sports medicine doctor and/or physical therapist to address your unique situation. Getting a correct diagnosis and treatment plan will save you valuable time that could be spent doing other things.
Things I Learned During My Plantar Fasciitis Rehab:
So looking back, one positive benefit I have received throughout this process is learning how my body has responded to various treatments.
Plantar Fasciitis and Heel Spurs
For example, I learned that bone spurs in your heel can complicate things. Early on, I learned that I had a very small bone spur right where the fascia attaches to the bottom of my heel and that this bone spur most likely formed as a result of the tension /irritation/rubbing whatever it was of the fascia where it attached at the heel. Or it was there all along and aggravated once the fascittis developed. No one really knows, but I suspect it formed because I have run for years with no issues at all.
So the theory is, I had tight calves, hamstrings, Achilles and plantar fascia that created this tension. This tension, further came about partially due to my right foot having a higher arch that possibly was collapsing due to years of impact or age in general, thus stretching, or tugging my plantar fascia which caused pain at the heel where it attaches.
An easy way to visualize this is to cup your hand as if your hand was your foot. Your fingers are your toes and the palm of your hand is your heel. Now with your hand cupped, imagine your plantar fascia as an imaginary line that connects your fingers to your palm, or in real life, your toes to your heel. Now in this example, start dropping what would be your arch as represented by the middle of your hand and look at what it does to that imaginary line that represents the fascia, it stretches. That is what we believe is happening with my foot.
Now Plantar Fasciitis is inflammation along that imaginary line I just describes between your toes and your heel. Typically this type of injury is treated by stretching, icing, massaging, and strength building. It is the first advice you will get should you develop this type of injury. And it is a good starting point. But for me, it was not enough.
Stretching, Foam Rolling, And Physical Therapy Is Sometimes Not Enough
I spent the last year with zero running, weekly sports massage, daily foam rolling, daily stretching (sometimes up to 3-4 times per day), sleeping using night splints (early on anyways), strength building the foot muscles doing things like scrunching your toes on a towel, or balance/stability drills, changing shoes, using custom orthotics, not using custom orthotics, frequent icing to try and reduce inflammation, even having a Tenex procedure (which is a minor surgical procedure, I will talk about in a second). I did all these things and these are things that everyone will convince you you need to do. It still wasn’t enough in my case. In fact I exhausted every known treatment ot activity known to get rid of my plantar fasciitis and it still wasn’t enough short of some last resort surgery options.
The good news is that for 80-90% or better of the running population who develops plantar fasciitis, the things I just mentioned usually work. In fact, these are the typical injury treatment protocols for any type of soft tissue, overuse type of injury.
However, in my case, super tight hamstrings, tight calf muscles, tight Achilles, and tight fascia combined with that bone spur made my case particularly challenging.
So when it comes to super tight muscles, all you need to do is stretch right? In my example, the goal was to build stabilizing muscles to help support the foot and absorb impact, along with stretching to release that pressure on the heel. The bone spur was small enough that they thought if I could maintain good flexibility, the irritation of that spur would be relieved.
Well, another thing I learned from my orthopedic surgeon and sports doc is that stretching only works to a point. For people with chronic Plantar Fasciitis, stretching doesn’t have that good of a track record in helping. I believe it helped some, as I felt a little better on those days where I stretched multiple times, but it never resolved. That tension was always there.
What I learned is in the best of cases, you can only add/improve your muscle stretch to about a 4% in best cases. So in my case, stretching was not enough to release the tension/pressure on that bone spur which was too small to operate on, but enough to still cause pain. More about this in a minute.
So that covers the why the fasciitis was particularly difficult to resolve. What about the mental aspects of injury?
Mental Aspects Of Plantar Fasciitis Injury Rehab
Through out the year, I learned that falling out of shape and dealing with time off from running is much harder than you might think. I had people telling me, “It must be relaxing having a break from running”. Ummmmm. NO!
I can’t describe how frustrating taking time off due to injury is. If you have had an injury that has resulted in significant time off you probably know what I am talking about.
This can be especially frustrating when you run a running club or a website/podcast about running. I can’t just walk away. I am constantly around my fellow runners and watching them head out for their runs, while I have to stay back is depressing. When you coach you have to be there for them so you learn to deal with it.
Despite all these challenges, things are progressing along so before this turns into a full blown pity party, let’s take you back a year and see what other lessons we can pull out of my experience.
So to start, let’s make sure everyone knows what Plantar Fasciitis is.
What is Plantar Fasciitis
The Plantar fascia is a flat band of tissue that connects your heel bone to your toes. It is there to support the arch of your foot and the muscles in your feet. It is harder than muscle and therefore does not have a lot of access to blood capillaries like your muscle fibers do. This is a bad thing when it comes to healing as it can’t heal as fast. Chronic injuries withthese harder tissues can take upwards of 1-2 years to fully heal. Keep that in mind, if you suffer from heel pain and want to keep running through the pain.
Plantar Fasciitis is when the fascia becomes inflamed and painful and pain usually presents itself after a run, or first thing in the morning when you wake up. It can be in the middle arch of the foot, or right on the heel (which was the case for me). Early morning pain when you first step out of bed is the classic symptom of Plantar Fasciitis. After a few minutes it loosens a bit and gets less painful.
How I Got Injured In The First Place
I got injured last year in August, so it has been exactly a year for me, I was training for the Columbus marathon and was up to my 16-18 mile long run, I can’t remember exactly. My training had been going well, although volume wise, I was lower than where I would have liked to be.
I remember work travel and some excruciating hot days of 94-95 degree humid days, prevented me from getting in some of the runs I wanted to. My training wasn’t horribly bad just not where I wanted to be. I had been progressing well as my long runs increased in distance with no issues. I remember my heel was a little sore after my latest long run, but pretty mild and it just felt like it was bruised. It did not feel like full blown Fasciitis. After a day or so of rest, it went away (well at least for a day or two). I mostly wrote it off as post long run soreness.
The following weekend I had a half marathon scheduled.
Well that mid-week between my long run and my race, I had Hill repeats scheduled with my running club and I remember putting in a great workout. I had pushed hard, but not too hard. I remember being a little sore afterwards, but again nothing too bad.
Until the next morning.
The next morning I woke up and could barely put weight on my foot. It felt badly bruised, but after a few minutes, the pain eased and I was able to walk normally. I suspected I might have strained my Fascia, but since it felt 100% better, I went on about my day. Over the next few days, this would be repeated although each day, it would be slightly less painful and I assumed since I took a few days off I would still be good to go racing that weekend.
For the half, I felt good, there was minimal heel pain that morning and once I got moving there was no pain until about half way through the course. That is when I knew I was injured. But the pain wasn’t that bad, so I completed the race and went home to ice. From that point on, I have been unable to run other than a few easy test runs to see how it felt in the coming weeks.
Every morning I went through a painful wake up routine until it loosened up. Any attempt to run, made it get worse the following few days. At this point, I decided to drop out of my training and just rest for a few weeks. Even walking a mile or two would be followed by several days of severe heel pain.
The Treatment Protocol
I was injured. My next step, was to see a sports medicine doctor. My club works with a couple of sports medicine doctors so I went and had an appointment where I had a x-ray and ultrasound done. I was officially diagnosed with Plantar Fasciitis. I had all the classic symptoms so it was pretty easy to diagnose.
The X-ray showed a small bone spur on my heel but nothing of the size that seemed like it would impact the pain much. It could have developed, or could have been there my whole life. There was no way to know and it wasn’t big enough that we though my issue couldn’t be resolved through normal treatment protocols.
Nothing in the ultrasound seemed to indicate a rupture or tear either which despite hurting probably would have been a good thing looking back as it would have naturally resolved my problem. With full blown Plantar Fasciitis release surgery that is basically what they are doing. Creating a man-made tear instead of a natural one.
First Steps Of Treatment
The first steps in my injury rehabilitation protocol was no running, frequent icing, rest, daily exercises and lots of stretching. I used a frozen ice bottle to roll my feet, a tennis ball or lacrosse ball to help massage and break up scar tissue in addition to lots of stretching.
It was also around this time, I decided to see a massage therapist to help loosen up my hamstrings, calves and feet.
I was told to continue all these steps for about 6-8 weeks and if it did not get better come back to see my doctor again.
Ouch That Hurts!
After 6 weeks or so, with little to no improvement, I was given a cortisone shot to help settle the inflammation and started physical therapy. The cortisone shot was not to cure anything, but to help relieve inflammation and help sooth the pain a bit.
Having a 2-3 inch needle shoved up the bottom of your heel is an experience like no other, let me tell you. After a few days, the shot really helped relieve my pain but it was short lived and the pain came back after a few weeks.
On a scale of 1-10 with 1 being barely noticeable and 10 being something like childbirth (not that I have any experience with that), that shot was a 9.
Afterwards, I felt great with little to no symptoms during this time, but I also knew my injury was still there, so no running during this time despite really wanting to.
After several weeks of physical therapy my pain dropped to about a 5 out of 10. When I started it was maybe a 7. So physical therapy and everything I had done to date helped, but certainly did not resolve my issues.
Time To Escalate My Treatment Options
At this point I am about 6 months into my recovery, but still having problems, I went back to my sports medicine doctor. We decide to kick up my treatment a notch and get a little more aggressive. I had a procedure known as Tenex.
Tenex is a mildly invasive procedure that uses a specialized needle with a blade on the end of it. An incision (or a couple in my case) is made, and the doctor uses the apparatus to cut and flush the area with saline rinse to remove scar tissue. In a way it also re-injures the fascia in that area to promote new healing to occur.
Tenex was done as an outpatient procedure in my doctors office with local anesthesia. I was awake the whole time and never felt any pain or discomfort. It only took 15 minutes. The only part that was slightly uncomfortable was the initial shot to administer a nerve block. And the first few weeks afterwards as your heel heals.
After the procedure, I was placed in a walking boot for 2 weeks and I was able to walk on it immediately after the procedure. After it healed enough I could walk on it, I went through another 2 rounds of physical therapy to help rebuild the tissue as well as work on building strength, maintain flexibility and focus on good walking and running form. In addition to the strengthening and stretching routines, they added a newer type of eStim routine which was showing good results that created a small electrical shock in my feet to help strengthen those intrinsic muscles in my foot to help build foot strength. So basically lots of balance and strength drills combined with getting 20 minutes of small electrical shocks in my foot while doing basic strength and balance drills.
Tenex gave me my biggest improvement to date as it literally brought my pain down from a 5 to like a 1 after the latest round of physical therapy. Since I made so much progress, we decided to add one more round of PT. (Each PT session was about 6 weeks). We just wanted to wait it out another session to make sure we weren’t just in some final stage of healing.
The Final Stretch?
Between all the PT, massage and stretching, my fascia and calf/quad muscles were as loose as they ever were going to be. But one spot, one tiny little spot right where the fascia attached to my heel (you guessed it that bone spur), was still painful. There was no pain in the surrounding area like I had prior, just this one little spot when I pressed on it, or tried to walk and run on it. My therapy had progressed to where I was doing full squats, jumps, calf raised, plyometrics, and so on, and my foot was not getting worse. That was the good news. I was tolerating the increase in weight and impact, but if I tried to run a few minutes, or go on a long walk, BAM it started hurting again. Not as bad as before, but certainly not enough to start running again. I could mostly walk around the house or work with no pain, I just couldn’t exercise. That little bit of pain which was a 1, would jump up to a 3 or 4.
So that brings me to a few weeks back, it was time to look at that heel spur much closer and see what other options we had to deal with it. We decided to bring an orthopedic surgeon into the picture to decide whether or not surgery was the next option to possibly eliminate that bone spur.
Gastroc Recession Surgery
After more X-rays, we decided that the bone spur was still small enough that another option was available. It was an option that made sense in my case if you think back to how tight my muscles are, despite all the stretching. If we could lengthen the gastroc tendon which connects the calf muscles to the Achilles and ultimately down to the Plantar Fasciitis, it could release that pressure off the bone spur, and essentially get rid of the heel pain and get me back to running. The only other option was to do a full plantar release and grind off the bone spur which would have a much longer recovery.
So that brings me to where we are at today.
I just had the Gastroc recession surgery. Basically, they put you to sleep, and then there is a 30 minute procedure to cut and lengthen the tendon to release tension. If all goes well, this should be my permanent solution. As you can expect, I am crossing my fingers and hoping this does the trick.
Recovery should take a few months and right now I am 100% non weight bearing in a walking boot so lots of time on my butt or using crutches. My post surgery pain has not been bad at all, but my calf sometimes charlie horses, or spasms at night when I sleep. All this is a normal part of the recovery process I have read. I was given some muscle relaxers but have been avoiding using them as they make me sleepy.
I’ll keep you updated about how it goes and the next few weeks should be an strong indicator as how successful this procedure was. If I come out of the boot and the pain has subsided in my heel, that will be a great sign. I’ll also need at least another round of physical therapy, maybe two to get me strong enough to start running again.
If this doesn’t work, I’ll be pretty disappointed because I am running out of options. There is one last hope and that is having a full plantar fascia release surgery as well as removing that bone spur but I hope that doesn’t happen because that surgery is very invasive and has a very slow recovery. It would probably add another year before I could run, based on how long it will take to see if this surgery worked and prep and recovery for a new one.
I know I just spent a lot of time, talking about me. However, there are a couple things that I want to point out that can help you.
Final Lessons And Thoughts
1) More procedures are available now that can help fix things like I have. The Tenex procedure is a relatively new procedure and it can also be used to help fix issues like I had, along with Achilles Tendinitis, Tennis elbow and other soft tissue type injuries. Not all doctors do it, so you have to find one that does to see if you are a candidate or not. It really helped in my case, and I believe would have solved it completely if not for that pesky bone spur. Prior to that I had pain in a 2-3 inch wide path across my heel to mid arch, afterwards, just that tiny spot.
One lady in my running club had Tenex done on her Achilles which she let get pretty severe rather than dealing with it early on. She had a severe case and she is almost fully recovered 3-4 months post operation. Her post surgery treatment is still in progress but it looks promising for her so far. Our sports doctor said it was the worst case of Achilles Tendinitis he has ever seen. Her Achilles was very thick and scarred.
2.) Tendons and Fascia type injuries are extremely slow to heal. Because they are harder tissues and do not have a lot of blood flow to them, they heal much slower than muscles. You have to be patient with these types of injuries as they will not heal overnight and your best treatment is prevention and dealing with any indication of injury early.Continuing to run through these types of injury will make your injury worse, or delay healing at best. I know runners who are close to race day and choose to just manage the injury to “get them through the race”. They usually can, but the trade off is that it may add weeks, or even months to their recovery so take that into consideration as to whether or not you want to take on that risk. Is it worth it? I try to discourage runners doing this as much as possible.
3) Injuries have a unique ability to sneak up on us and by the time we realize it, it is too late. You can’t always turn it around by taking time off to rest. Taking a few days off when it comes to Achilles, or Plantar Fasciitis or knee pain usually isn’t enough. Still that is the first thing you should do and hit the ice and time off hard as early as you can.
4.) While stretching can help, in many cases, it simply isn’t enough. No amount of stretching would have solved my issue. It required medical intervention in the form of surgery. I am not against stretching, but you can’t stretch or exercise your way out of some conditions.
The sucky thing about insurance is that you have to kind of work your way through the allowed treatment protocols and can rarely jump ahead. With soft tissue type injuries time goes hand in hand with the treatment protocols. Damage takes time to heal.
Thanks again for listening I appreciate each and every one of you and if this has been helpful, please let me know. The best way is to leave feedback for the podcast in iTunes.
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Steve is a RRCA / USA Track and Field Certified Running Coach who has helped thousands of runners since 2010. He coaches online as well as locally in the Columbus, Ohio area. He is host of RunBuzz Running a top rated running podcast with 150+ episodes available for free on all major podcast apps. Steve resides in Lewis Center, Ohio with his wife, kids, and dog.