Plantar fasciitis: calf stretching, and other treatments

Plantar fasciitis is certainly one of the most common running injuries. According to research carried out by the Sports Medicine Centre, University of British Columbia, it is 3rd on the list after runners’ knee and ITB (iliotibial band) friction syndrome. Not only is it very common, anyone unfortunate enough to be gripped by plantar fasciitis will know that recovery can lead down a long and very frustrating road.

So why is pf such a difficult condition to treat? Or, to put it another way, why are conventional treatments often ineffective?

To answer that we need to look at the typical treatments for plantar fasciitis which include:

• calf stretching
• orthoses
• steroid injections
• icing
• surgery
• night splints

When we look at research to back up the efficacy of some of these treatments we begin to see why pf is such a stubborn condition.

Calf stretching
A study published in 2007 concluded that ‘When used for the short-term treatment of plantar heel pain, stretching for two weeks provides no statistically significant improvements in ‘first-step’ pain, foot pain, foot function and general foot health compared with a control group. It was also associated with mild to moderate short-lived adverse events. Based upon our results a program of calf muscle stretching, similar to that conducted in this trial, is not recommended for plantar heel pain.’
The full report of the study written by JA Radford of the School of Biomedical and Health Sciences, University of Western Sydney can be downloaded here.

Orthoses
Orthoses (or orthotics) are often prescribed for pf and they can be very expensive. Orthoses are essentially arch supports that fit inside a shoe as replacement insoles. They can be bought ‘off the peg’ or custom built to suit the user. It is commonly thought that supporting the arch removes strain from the fascia underneath the foot. What does the research say about their success or otherwise? In his study — Effectiveness of Foot Orthoses to Treat Plantar Fasciitis — Dr K Landorf, of the Department of Podiatry, School of Human Biosciences, La Trobe University, Australia stated that ‘studies of the effects of orthoses are generally of poor quality, and to our knowledge, no trials have investigated long-term effectiveness’. Dr Landorf and his associates tested 135 participants with plantar fasciitis over a 12 month period with both prefabricated and custom built orthotic devices (there was also a control group allocated sham devices). The study concludes ‘Foot orthoses produce small short-term benefits in function and may also produce small reductions in pain for people with plantar fasciitis, but they do not have long-term beneficial effects compared with a sham device’.

Steroid injection
Steroid injection is one of the least attractive options for a sufferer of pf, mainly to the pain of the procedure. However, what is possibly not completely understood by many are the risks involved; complete rupture of the fascia occurring in 10% of treatments. Nevertheless, it is a widely used treatment. But, how effective is it?
A study by Crawford, Atkins, Young and Edwards (Department of Health Sciences and Clinical Evaluation, University of York and Centre for Rheumatology, University College London, London, UK.) compared the effectiveness of steroid injection with local anaesthetic. Short-term (one month) pain relief was apparent, although ‘This trial corroborates other findings and it appears that a single steroid injection does not offer a therapeutic benefit in the long term‘.

Icing
Ice is the first line of treatment for many injuries and it is no surprise that it is almost universally recommended in treating plantar fasciitis. Icing does seem to offer many sufferers a degree of pain relief, but it should be remembered that plantar fasciitis is not necessarily accompanied by inflammation. Therefore it is important to address the cause of the condition and not just treat the pain. As always, when using ice, care should be taken especially with the soft and sensitive areas of skin on the sole of the foot.

Surgery
As usual with running injuries, surgery should be viewed as a last resort. Many runners I know have been irreparably damaged by possible premature surgery on conditions that are quite treatable without such action. Research tells us that surgery on plantar fasciitis is successful in the range of 70-90%. It is difficult to be accurate because of the various surgical procedures used. What is definite though is that there are risks and many sufferers who have had successful surgery might well have recovered anyway due to the recovery period needed for the surgery itself.

Night splints
Night splints have an appearance similar to an open sided casting for the lower leg, ankle and foot. Typically they hold the foot in a mild, passive, dorsiflexion stretch (foot flexed so that toes are brought closer to the shin). It is not a very comfortable or convenient treatment becaue the splint is worn through the night. However, it does prove to be quite effective; studies have shown that it is effective in around 80% of cases.

It is clear that there is a huge amount of information and advice available to sufferers of Plantar fasciits. However much of this information is simply repeated and rewritten without an understanding of the causes and effective treatments. There is also a lot of contradiction amongst experts about the condition possibly due to a general lack of meaningful research.
All is not lost though; it is quite widely reported that plantar fasciitis does seem to cure itself over a given time, but this can be a very painful and frustrating 2 years or more.
The research does indicate that certain treatments are more successful than others and also there is general agreement that injection and, in particular, surgery should be considered as a last resort (if at all).

But what about anecdotal evidence?
Of course, the internet has made story-telling a much more popular pastime now. Consequently, it is quite easy to find reports of successful treatments, and I think there is much benefit to be had from learning what has worked (or otherwise) for other runners.
Certainly my own condition — which had been very stubborn over a prolonged period — cleared very quickly (significantly better after just 2 weeks) when I addressed the strength (or lack of) in the feet. This was achieved by introducing some barefoot running into my training regime. By barefoot I mean completely barefoot, I think that using minimilist or ‘barefoot’ shoes does not offer the same benefits. Running barefoot demands a very particular way of planting the foot; the heel does not receive any impact, and this is vital. To keep the heel off the ground when running requires strong feet and calf muscles. I am not alone in noticing quite a change in the apparent structure of the foot after just a little barefoot running. It is my firm belief that this strength in the foot plays an important role in maintaining the integrity of the foot and in particular the arch; much like an orthotic device. But, whereas an orthotic will support the foot — much like a crutch will support a broken leg — strengthening the foot seems to be a far more sensible approach.
There are of course, other foot-strengthening excercises that might well help, such as picking up marbles with the toes and/or using the toes to squeeze a towel underneath them on the floor.

Plantar fasciits does deserve more study and it will be interesting to see if some scientific evidence will be produced in the wake of the recent increased interest in running barefoot.