Physio and runner perspective – having and recovering from a Plantar Fascia injury
Where did it go wrong?
As a runner myself, I’d rank this one the most stubborn injuries of my career. Compared to management of other injuries, the plantar fascia was slow moving in its progress and at times seemed like it was never going to get better. Of course, I’m not alone either, I’ve heard many share their stories on social media and I’ve seen friends and competitors struck down for big chunks of the year, if not several seasons with this condition.
For me, it started as a low key ‘niggle’, so subtle I thought I was just imagining the pain. Surely, it’s just one of those mid run mystery aches that will disappear...hmm?! So, I carried on training regardless and low and behold, before long it had become an excruciating, consistent nuisance and I could no longer continue to run. From that point on, I was stuck in a very disheartening cycle of offload, rehab, disobedient ‘testing it’ and offload again.
I stopped running and started rehab exercises I was given. However, despite consistently putting in effort, I was frustratingly not progressing. After a while I became despondent and started to lose hope. Next came the irrational fears,
“I am never going to run pain free again, this is the end of my running career.”
Time to refocus…
At this point I decided to take a few weeks away from all forms of rehab, cross training and all the failed run attempts. The rest gave me the opportunity to remove myself from the torture of all the unsuccessful rehab attempts and regain the motivation and mental ‘strength’ to give it all another go. Except, this time, I approached my return with a broader view, refocusing on how I could improve as an athlete as a whole and creating structured aims to focus upon. Working on a new version of me – one that would be more resilient and come back stronger!
Establishing some aims…
This time, if I was to successfully return to running, I needed a plan! I started by getting a routine back, so I organised cross training sessions, rehabilitation and strength training into a weekly programme, similar to a typical running plan. This gave me some normality and structure, so I could focus on the additional goals I had set:
Complete my plantar fascia rehab
Monitor activity level outside of rehab (I was curious to see how much additional load I was placing on the foot throughout the day)
Monitor pain levels during activity and in the morning (being honest with myself)
Improve my ability to balance on a single leg
Improve my strength on a single leg
Improve global body conditioning
Improve cardiovascular fitness using non weight bearing methods (swim / aqua jog)
Enjoy the rehab process
Turning the corner…
After a few weeks of sticking to the plan, I began to see some small improvements in my pain. Pain was easing sooner in the morning and walking was becoming pain free. As these improvements became consistent and I could start to complete my rehab without pain, I started to add some walking drills. I monitored the reaction in my plantar fascia to the drills, using this as my guide for when I had to regress my activity and when I could progress. If the pain got better or did not react, I’d progress a little bit more; adding another exercise or a dynamic running drill. This stage was up and down, and sometimes the pain response would not seem to align with how much or little I had done. This part required small and patient steps. But as a general trend, I was making improvements. On reflection, this was one reason that the monitoring was important, because when it felt like I wasn’t making improvements, I could look back and see how much progress I had made and keep up my spirits.
Starting to run again…
After a few months I had progressed to some very small jogs, approx. 2 minutes to begin with. A few weeks of consistently managing these small runs began to fill me with confidence and my fear of running was beginning to ease. I gradually built up the length of my runs, monitoring any reaction in the plantar fascia and progressing or regressing accordingly. First it was to 5 minutes, then 5 minutes turned to 10, 10 to 20. Eventually I reached 30 minutes pain free running, which was a great achievement at this point. As a physio I view 30 minutes as somewhat of a threshold for introducing some changes in speed etc. So, at this point I began to add subtle changes of paces to my runs, first introducing short tempo efforts and eventually progressing to faster strides.
At about 6 months after I had naively brushed off my plantar heel pain as a mere mid run suspicion, I was back into normal training! It was less volume and intensity than ever, but it resembled a normal training week that was pain free. I continued to carefully focus on getting consistency back to my training and went on to compete the next season, picking up an England representation and to be honest, just really enjoying running pain free again!
The Physio perspective: What I learnt from my Plantar Fascia injury and recovery
When I take time to reflect on this injury and my recovery it is perhaps more obvious why this is a notoriously difficult injury to manage for runners. These are some of my thoughts and a few ideas of how to overcome difficulties:
Offload from running early.
Getting runners to offload is often quite difficult, especially if the injury isn’t seriously painful. As I found out, it is possible to keep running through minor pain for some time without too much of a problem. But eventually the minor pain can turn into a chronic and stubborn injury. Often by the time I see a patient with a plantar fascia complaint, it has been lingering around for some time.
On reflection on my own experiences, reducing running and offloading early on could have been advantageous to the healing process. Allowing the pain to settle and tissue to recover, rather than struggling on and causing the pain to become more locally and centrally sensitised. The acute, reactive phase was probably the time to stop, allow the tissue to recover and address the underlying factors driving the injury.
My hard lesson learnt: Get your heel pain checked sooner, rather than later.
Managing load, that isn’t loading.
One thing we often fail to consider, is how our daily activities outside of running and rehab could be influencing our recovery. For example, consider doing your rehab in the morning and then walking your dog/ commuting to work or doing the shopping, all these activities could significantly increase the load on the plantar fascia beyond what we realise. It is important to consider how much our additional activities are also having an impact on our recovery and whether the sudden relapse of symptoms could be explained by the extended dog walk in the hills.
My suggestion: In order to get a better idea of the load outside of your prescribed loading, use a daily step count on your watch or phone to guide how much extra demand you’re putting on the plantar fascia. This can help guide when you might need to put in some additional recovery time between loading sessions.
Looking away from the foot.
When the pain is so obviously in the heel, it can be hard to comprehend or even be motivated by exercises targeting other areas. But for my recovery, a big factor was focusing on improving my overall strength and stability on a single leg, which historically I’ve not been good at. I first retrained my ability to balance on one leg and then lift weights on a single leg, following a program including Bulgarian split squats, double leg squats and balancing on a BOSU. Improving single leg strength makes sense when you consider running is just continually switching from one leg to the other while trying not to fall.
Take home message: work on your weaknesses, strengthening your weakest link ensures your body ready for when you can run again.
It’s more than just the physical pain.
Any injury is upsetting to runner but this one seemed to have a grip on me more than others. Perhaps the heel to brain connection is stronger than others? As runners, running quickly becomes a big part of our identity, shaping our social life and acting as a tonic for our mental health. These and so many other psychosocial factors drive our need to run and our frustrations when we can’t. Despite knowing what I know as a Physio, I pushed running too soon. Repeatedly “tested” the plantar fascia, out of desperation to get back to being ‘me’. Only when I removed myself for a while and concentrated on other areas that make up my self-identity did I move from being frustrated with the injury, to a problem-solving mindset. In turn I was able to avoid making irrational decisions like I did early on (pushing too soon / training in pain / ignoring my pain). Consequently, I began to feel happier, and despite being injured, I could make honest progress.
My learning: use the time that you are not running to enjoy other areas of your life; meet up with friends, take up a new hobby and come back to your rehab with a rational brain.
Thanks for taking the time to read this blog, I hope my insight can help another runner to overcome this injury and get back to pain free running.
written by @jacqfairchild