Despite its complicated name, the majority of runners can pronounce plantar fasciitis because they’ve had the misfortune of personal experience. I’ve heard it called the ‘M.E’ of sports injuries because it’s so hard to pin down what triggers it and equally hard to find a way to get rid of it. It’s not uncommon for the condition to last 6 months or more. Part of the problem with defining the cause and solution is the fact that there’s little agreement on what PF actually is. The ‘itis’ in the name suggests it is a condition that involves inflammation but this has been challenged in recent years and some podiatrists and sports medicine experts have called for it to be known as plantar fasciosis instead. An ‘osis’ is degeneration of tissue, rather than inflammation – and as such, requires a different approach when it comes to treatment.
(That might explain why the usual remedies, such as rest, ice and anti-inflammatories - or even corticosteroid injections provide little more than passing relief.)
In one study, tissue biopsies were taken from people suffering from severe PF and then assessed. There was no evidence of inflammation in the plantar fascia, but there were numerous microscopic tears and signs of degeneration (necrosis) both in the plantar fascia itself and within the intrinsic flexor muscles of the foot.
Caused by what? Well, you may not need to look further than your own footwear. A lot of running shoes (in fact, a lot of shoes in general) don’t have enough space – or the correct shape - in the toe box, causing the big toe to be drawn towards the other toes (adducted). Then there’s the common shoe feature called ‘toe spring’ which pulls your toes into extension because the front end of the sole curves upwards (shown below). Add this to the fact that in most shoes, your heel is raised higher than your toes, and you end up with toes being forced into both extension and adduction. (Incidentally, given that the pads of your toes are essentially receptors, they don’t like to be away from the ground, and one frequent result of toe spring in shoes is hammertoe, toes that curl under in an attempt to feel what’s happening beneath them.)
To get a sense of the position in which the foot is held in most footwear, push your toes together, raise the heel and pull your toes into extension. If you now feel along the medial side of the heel, you may well find you recreate your pain symptoms. This position will greatly increase tension in the flexor muscles on the bottom of the foot as well as the PF – an effect magnified by the forces of running.
So what’s to be done? You need to allow the toes to sit properly. That means a shoe with enough space in the toe box, but more specifically space for the big toe to sit straight, not curving in towards the other toes. Correct Toes toe spacers are designed to be worn inside footwear to help realign your toes back to their correct anatomical position. I found these invaluable in getting over my long-standing PF (and that’s why, unashamedly, I now sell them through my natural running store, The Emperor’s New Shoes).
You also want a shoe that doesn’t have your toes lifted way off the ground at the front, court jester style, and one that is flexible enough to allow the foot to bend where it’s designed to bend – across the metatarsal heads. (Pick up a pair of Converse, or suchlike and you’ll find when you try to bend it, it will bend in the middle. Whose foot ever did that?!)
And finally, you need to get those feet mobile again. Any kind of movement is good – but stretching the tight toe extensors is the best starting point.
The toe extensor stretch
This stretches the toes at the metatarsophalangeal (MTP) joint – the ‘knuckle’ of the foot (level with that bit where bunions form). You can do this sitting or standing (sitting is easier to get to grips with). Extend one leg back behind the body and place the upper surface of the toes on the floor. This should bend the toes at the MTP joint. Then, plantar flex the foot fully by pressing the heel down toward the floor. The stretch should be felt across the top of the foot and front of the lower leg. As the muscles become more flexible, bring the foot further forward, relative to the body, to increase the stretch. There’s a great video on how to do this here.
I’ve also found stretching the muscle that pulls the big toe away from the other toes (abductor hallucis) very useful. Try placing a wide elastic band midway up the two big toes and gently pull the feet apart.
Deep tissue massage was also helpful in mobilizing my feet and improving blood flow when rehabbing from PF. I regularly use a soft golf ball to stretch and ‘iron’ out the connective tissue on the soles of my feet. But for guidance on a more big toe-specific massage, check out this clip Abductor Hallucis stretch
There will undoubtedly be physios, podiatrists and the like who will dismiss outright the notion that modern footwear and its effect on foot structure/alignment causes plantar pain. Indeed, people suffering from PF are often given MORE cushioning, MORE support in their shoes when they actually need less. But the huge number of runners with ongoing, stubborn plantar pain that doesn’t respond to the usual bag of tricks might be more open to suggestion. That’s how I felt after I’d had a corticosteroid injection, two different pairs of orthotics made, done copious stretching, icing and resting and was still on the bench nigh on a year later. Why not free your feet and see what happens?