Running Injury Series: Plantar Fasciitis
Jul 17, 2023
Plantar Fasciitis is one of the most common running injuries with 42% of middle distance and 25% of long distance runners being affected. With many of these runners seeking medical services to remedy their pain there is a variance among clinicians in evaluating and treating these patients. Emerging evidence points towards the use of a running gait analysis to better resolve symptoms. Here is a typical evaluation and treatment plan for a runner with Plantar Fasciitis.
Evaluation Findings of Runner With Plantar Fasciitis
Below is an example of evaluation findings you would see on a running gait analysis and physical therapy examination. For reference take a look at the YouTube videos below of the patient’s slow motion running.
Running Gait Analysis Lateral View
Running Gait Analysis Posterior View
History:
Patient is a 45 year old female runner that presents with right plantar fascia pain that started 3 months ago while running. She notes she only gets pain (4/10) when running over 3 miles at a 9 minute mile pace.
Posture analysis:
Pes planus bilaterally (B)
Moderate arch height in non-weight bearing → Minimal arch height in weight bearing
Genu valgum B
Running gait analysis findings:
Foot progression angle R>L
Overpronation B
Subtalar joint valgus collapse B
Heel strike B
Genu valgum B
Hip drop B
Narrow base of support (feet crossing midline)
Cadence: 170 steps per minute
Running shoe during analysis:
Minimal arch support
Minimal rigidity in outer sole
Minimal heel cup
High cushion
Moderate heel drop
Objective findings:
Gluteus medius R 4/5, L 5-/5
Quadriceps: R 4+/5, L 5-/5
Tibialis posterior: R 4-/5, L 5-/5
Gastrocnemius: R 5-/5, L 5-/5
Soleus: R 4/5, L 5-/5
Single leg heel raises: 21 R, 24 L
Single leg squat R 10x w/ valgus collapse, L 15x
PROM and AROM: WNL
Findings To Address For Runner With Plantar Fasciitis
To address this patient’s Plantar Fasciitis they would benefit from a plan of care including changes to their running gait. Assuming the patient’s R Plantar Fasciitis developed from their running form the focus of this treatment plan will be to fix the patient’s running. As with all runners it is important to identify the most urgent running gait deviations to address. In this patient’s case they include the following.
- Excessive overpronation
- Subtalar joint valgus collapse
- Narrow base of support
- Genu valgum
- Hip drop
The objective findings supporting addressing the above gait deviations include…
- Moderate arch height during non-weight bearing with pes planus during weight bearing
- Muscle weakness of the gluteus medius, quadriceps, tibialis posterior
- Valgus collapse during SL squat (R)
- Hip drop B
Clinical reasoning: With Plantar Fasciitis one of the main treatment goals is to reduce the inflammation in the plantar fascia. The research points towards inflammation to the plantar fascia developing from overstretching the plantar fascia resulting in small microtears. However, in some individuals with Plantar Fasciitis their symptoms developed from excessive external pressure on the plantar fascia from insoles or footwear. In this patient case their plantar fascia is being overstretched from excessive pronation and narrow base of support. These issues are compounded by the patient's arches collapsing into pes planus during weight bearing and poor muscle strength in the tibialis posterior. Additionally, the patient presents with genu valgum and hip drop which increases medially driven pressure onto the patient’s plantar fascia. Again these issues are compounded by weakness of the gluteus medius and quadriceps along with an inability to perform >10 single leg squats on the RLE.
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Gait Retraining Techniques For Runner With Plantar Fasciitis
“Keep your knees apart while running” OR “Don’t let your knees touch”
“Turn your feet inward while running” OR “Don’t let your feet turn outward”
“Push off with your big toe at the end of each stride”
Clinical reasoning: As mentioned above we want to limit the patient’s overstretching of their plantar fascia. Keeping the patient’s feet inward limits the excessive foot progression angle and the plantar fascia overstretching in overpronation. Keeping the patient’s knees apart limits genu valgum and medial momentum over the plantar fascia. Lastly, pushing off terminal stance with the great toe limits foot progression angle and helps reduce overpronation.
Corrective Exercises For Runner With Plantar Fasciitis
Ankle Inversion with Theraband (3 sets of 10x)
Lateral side stepping squat walks with theraband (3x10)
Single leg bridges (3x10)
Arch raises with tibialis posterior activation (2x10 with 3 second holds)
Squat progression:
Double leg squat into chair → Partial single leg squat → Full single leg squat into chair (2x10)
Clinical reasoning: This patient will benefit from strengthening their supporting arch musculature with resisted ankle eversion, inversion and arch raises. Additionally, they will benefit from single leg bridges and a squat progression to strength quadriceps and gluteal muscles.
Additional Treatment Considerations For Runner With Plantar Fasciitis
Footwear prescription (if necessary)
- Moderate arch support with moderate heel drop and moderate stability
Insoles (if necessary)
- Moderate arch support, soft to moderate flexibility
Manual Therapy (if necessary)
Reduction in training mileage (if necessary)
- Once cleared by running expert initiate a return to run program
Clinical reasoning: Emerging research supports a minimalistic approach to changing running gait. Often this means practitioners are keeping the patient's original footwear preferences, refraining from insoles, performing limited manual therapy and not changing training mileage. When changing footwear it’s important to consider low to moderate arch height shoes for this patient to prevent excessive external pressure to their collapsing arches. Additionally, while utilizing manual therapy extra consideration should be taken to not increase mobility in overpronation or valgus collapse. Lastly, training mileage adjustments can be useful for high mileage runners who benefit from an initial reduction in training mileage and subsequent implementation of a return to run program.
How To Become More Confident In Your Running Gait Analysis
Performing a running gait analysis can be intimidating for many clinicians. If you are interested in learning more about providing a running gait analysis and starting your own running gait analysis clinic check out our continuing education course “The Essentials of Running Gait Analysis”. Lastly, if you have questions about this content or the course feel free to reach out to us to discuss and we will personally respond to your questions.
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References:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8477898/
https://www.nature.com/articles/s41598-021-88883-4