Heel pain in runners is a common problem that we see as running physios. Pain is felt underneath the heel and is most commonly caused by a condition called plantar fasciopathy (also sometimes called plantar fasciitis or plantar heel pain). It makes up about 8% of running injuries and can become extremely painful, in some cases stopping runners from training. If you are getting heel pain with running then this blog post will help you to understand what can be causing it, and how you and your physio can work together to best manage it and get your running back on track.
What Is Plantar Fasciopathy?
Plantar fasciopathy means irritation and thickening of the plantar fascia. The plantar fascia is a thick band of tissue that runs along the bottom of your foot, connecting your heel bone to your toes. Its primary role is to support the arch of your foot and absorb shock during activities like running, walking and jumping.
While the foot is in motion during running, the plantar fascia works with the Achilles tendon to store and return energy. It acts like a stiff spring that absorbs energy as your body weight comes down onto the foot during the stance phase of gait, then recoils to release energy as you push off through the toes as your foot leaves the ground. We call this the “Windlass mechanism”. Because of this powerful attachment, the plantar fascia stabilises the inner forefoot as forces peak during push-off at the end of a stride.
Plantar Fasciitis Or Plantar Fasciopathy – What’s The Difference?
Plantar fasciitis is the old term for what is now called plantar fasciopathy. In medical language any “-itis” means that there is inflammation, for example tonsilitis means an inflammation of the tonsils. We used to think that the cause of heel pain was inflammation of the plantar fascia, hence the term plantar fasciitis. However, we now know that is many cases of heel pain there is not much inflammation going on, especially in more longer-term cases (chronic or recurrent pain), so it isn’t really correct to call it fasciitis. Instead, we now use the term plantar fasciopathy. Fasciopathy is a more general term that means damage or degeneration of a tissue, so it is more accurate to describe damage to the plantar fascia when there is not much inflammation present.
Who Is More At Risk Of Getting Heel Pain?
Runners are prime targets, especially those clocking significant mileage or suddenly ramping up their training (a “spike” in training load). In fact, 42% of mid-distance runners and 25% of distance runners experience plantar fasciopathy (1). But it’s not just those pounding pavement; anyone can develop this injury, affecting a total of 4-7% of the population.
Aside from running there are a few other risk factors that have been identified. These include;
- Age: heel pain is most common in 40-60 year olds
- High arches: people with high arches may have a stiffer mid-foot which impacts it’s shock-absorbing ability on landing when running
- Excessive pronation or flat feet (pes planus)
- Sedentary individuals with a higher BMI (i.e. significantly overweight)
- Females are more at risk of developing heel pain than males
- Jobs that involve extended time standing or walking have a higher incidence of plantar fasciopathy. This includes some retail and hospitality workers, factory workers, landscapers, construction workers and teachers.
What Are The Symptoms Of Plantar Fasciopathy / Fasciitis?
The hallmark symptom of plantar fasciopathy is pain on the underside of the heel, particularly during the first steps in the morning or after prolonged periods of rest, for example getting up to walk after a period of sitting. The pain is often described as a sharp, stabbing sensation under the heel or along the arch of the foot. Additionally, the pain may worsen with prolonged standing, walking, or weight-bearing activity, and it generally improves with rest.
If you ignore the pain and continue to run and push through it, the pain will gradually increase. It will be more intense, last longer, and eventually stop going away once you have warmed up. At this point is will get worse if you continue to run, and will start to last longer even after you stop and rest. Eventually, it will reach a level where it will stop you running completely.
What Causes Heel Pain From Plantar Fasciopathy / Fasciitis?
Decades of research into plantar fasciopathy has revealed that many causes can contribute to heel pain in runners. The most common ones that we see that are listed below.
Training Errors
The most common cause that we see as running physios is to do with training errors. For example, suddenly ramping up your mileage, jumping into speedwork or hill intervals, starting back running again after a break period, or new runners doing too much too soon. Researchers have confirmed that mechanical overload is the primary cause of plantar fasciopathy (2), so increasing your running too quickly, before your body has had a chance to adapt to take the increased load, is the most common cause of plantar fasciopathy.
Running Mechanics
Research has shown that your running mechanics may also play a role in developing plantar fasciopathy. The excessive lowering of the arch in flat-footed runners increases tension in the plantar fascia and overloads its attachment to the heel bone, leading to tissue damage, degeneration and heel pain.
Biomechanical Factors
Other biomechanical factors include an inward twisting or rolling of the foot (pronation) and tight tendons at the back of the heel (Achilles tendon) leading to reduced ankle dorsiflexion (upward movement of the ankle). Reduced big toe extension (i.e. less movement of the big toe up towards the shin) also impacts the loads placed through the plantar fascia and can increase the risk of developing heel pain.
Running Shoe Choice
We know that changing your running shoes or the terrain that you run on alters the way force is absorbed and dissipated through your foot, including your plantar fascia. This can also contribute to the development of plantar fasciopathy symptoms. We recommend that if you are wanting to increase your running or training for a target race, then getting a proper running shoe assessment at a running shoe store is a great idea.
Physio for Heel Pain With Running
Your First Physiotherapy Session
If you decide that it’s time to see a running physio, the first thing they will do is to take a full history of your symptoms. This will include reviewing your training loads (remember, one of the most common causes of heel pain in runners is training errors), footwear, daily activity outside of running, symptom progression, and any relevant injury history. Previous episodes of heel pain are obviously relevant, but so are other pains or injuries that you have felt in your legs because they may change the way you run and this may predispose you to develop heel pain.
Once your physio has taken your history they will guide you through a thorough physical examination. They will assess your biomechanics, foot position, strength, length and range of motion. They will also palpate (feel) your plantar fascia and may do some functional tests with you, depending on how stirred up your pain is.
After taking your history and completing your physical exam, your physio will take the time to explain what’s happening, why your pain developed, and how you will work together to manage it. We believe this education process is important because it helps you understand the steps you will go through as you work towards returning to your full running training, and how your running program will look during the process. Each person’s case is unique, so your treatment plan will be tailored to your particular history, level of symptoms, rate of improvement, running goals and training program.
Early Management Of Heel Pain
Your treatment will begin in your first physio session, with the primary initial aim being pain reduction. This may include taping to unload your plantar fascia, other hands-on (manual therapy) techniques to reduce pain and muscle bracing, and home exercise such as rolling your foot on a frozen water bottle to help relieve pain. The other big part of your initial treatment is load management, or deloading, which may mean a temporary reduction in your running volume. Whenever possible we keep you running in some capacity, however, if your pain is fairly easy to aggravate, a period of no running may be required. We always try to minimise this, and if it is necessary we will discuss the best ways to cross-train to maintain your strength and fitness.
Although plantar fasciopathy can be a frustrating and, for some, slow-healing condition, there are several things you can do to speed up your your recovery. As mentioned above, load management is a crucial part of your management program. Complete rest is usually NOT the answer, but reducing the load or running volume, and then gradually building back up again once your pain has settled, is an important part of your physio program. Adjusting your running volume (i.e. the frequency and distance/time of your runs), plus the type of runs you do (hills, speed sessions) is a key factor. Your physio will guide you through this process.
The Role of Tape, Insoles and Orthotics For Heel Pain Management
Your physio may tape your foot or prescribe you with heel-lifts. A best-practice study from a mixed-methods study combining systematic reviews (high quality research papers) alongside expert opinions and patient feedback, suggests core treatment for people with plantar heel pain should include taping (3). Over-the-counter insoles can also be helpful, especially for runners with high arches. The American College of Foot and Ankle Surgeons (ACFAS) has published clinical practice guidelines that recommend over-the-counter arch supports and heel cups. Their reasoning for this recommendation is that these devices allow changes in midfoot and arch mechanics that can reduce plantar fascia strain by over 30% in subjects (4). Importantly, only if treatment has failed over the first six weeks do the guidelines recommend custom functional foot orthoses.
Exercises For Heel Pain With Running
Using exercise to address strength imbalances and soft tissue tightness is key in managing your plantar fasciopathy. Your physio will prescribe you with a tailored exercise program suited to the stage and severity of your symptoms. Completing the correct program is essential to managing your heel pain and achieving a successful return to running. It is also a critical part of reducing your risk of future injury and pain.
The exercises below are a small sample of exercises that we often use with our runners. They assist in building strength in your calf, but also putting an appropriate amount of tension through your plantar fascia to increase it’s resilience and ability to withstand the loads associated with running. Begin with an appropriate number of sets and repetitions that keep your pain to a 2/10 level. You can then add or increase the weight and number of repetitions to progress.
Towel Calf Raises
Start by keeping your chest straight, rise on to your toes, and then lower your heels down to complete the exercise. Remember keep your knees straight throughout the exercise.
T-Rex Walk
To perform this exercise step pressing heel into the ground first. Rise onto your toes, then step forward onto heel. Ensure back foot is still in a calf raise. Repeat as prescribed.
Bent Knee Calf Raise Off Step
Stand on a step with heels off the step. Drop your heels lower than the step and bend your knees. Keeping your chest straight, rise on to your toes, and then lower your heels down to complete the exercise.
Can Running Shoes Help with Heel Pain?
Running shoes with a higher heel-toe drop may help in the short-term, especially if you are currently running in a shoe with a low drop (0-5mm) or have recently changed shoes. But, finding the right shoe for you is important.
There is no “best shoe” that is the right shoe for all runners – you need to find what feels good for you. Speaking to a running shoe specialist who can check your foot position and let you try a range of possible shoe options that may suit you is a great idea. Even if you have low arches/flat feet it doesn’t necessarily mean you’ll feel the best in really supportive (anti-pronation or motion control) shoes. What feels great to one runner may feel too low, high, soft or hard to another, even if they have similar foot positions. Going to a specialist running shoe shop where you can try out some different shoes running on a treadmill is an ideal choice.
Running Gait Assessment and Correction
Seeing a running physio who can get you on a treadmill, analyse your running gait and then help you improve your running biomechanics is an important part of managing your current heel pain as well as reducing your risk of future problems. It is also one of the most effective ways to improve your running performance! Click for more information on having a running gait assessment at Central Performance.
How Long Does Heel Pain Take To Get Better (Prognosis)?
The prognosis and recovery timeframe of plantar fasciopathy is very variable. Generally, it can settle in 6-12 weeks for most runners, but some may still experience symptoms at one year. Getting on top of it early, seeing your physio and implementing load management strategies can really help with fast/acute pain relief.
Once your initial pain is under control it’s important to clarify the reason why it started in the first place. If it was just due to increasing running volume or intensity too quickly then getting on the right running training program may be all you need to do. When other factors have contributed, for example your running gait or biomechanics, then correcting these issues is critical. If these other issues aren’t addressed then you are at a higher risk of having ongoing pain, or having the pain settle down only to recur again in the future because the underlying issues have not been corrected.
What If Your Heel Pain Isn’t Getting Better with Physio?
Role of Steroid (Cortisone) Injections In Persisting Heel Pain
In severe or recurrent cases of plantar fasciopathy that do not respond to physiotherapy, more invasive options such as corticosteroid injections or surgical intervention may be considered. However, these interventions are reserved for cases that do not improve with physiotherapy alone. Also, we need to remember that cortisone injections don’t cure plantar fasciopathy – they only reduce pain by breaking the inflammatory cycle. So, you still need to correct the underlying problem (for example correct your running biomechanics or increase your strength), but this can sometimes be done more easily and effectively after a cortisone injection has settled the pain and inflammation.
Can You Tear Your Plantar Fascia?
Tears, although not common, can occur in the plantar fascia. These are a completely different injury and are not to be missed because their management is different to plantar fasciopathy. Pain from tears to the plantar fascia will most commonly be more acute (i.e. have a sudden onset) and be more intense. There will usually be a memorable incident or acute onset of pain that you can remember, for example “it just went” on a specific step or stride during a run. Your physio will be able to assess your fascia and if they are concerned about a tear then they can refer you for an ultrasound or MRI to clarify the diagnosis and guide further management.
Physio For Heel Pain – Central Performance Sydney / Surry Hills
If you have heel pain or think you may have plantar fasciopathy, then we’re here to help. Our physios are highly skilled and experienced in accurately diagnosing and managing heel pain in runners and non-runners alike. We provide accurate diagnosis, fast relief and personalised treatment plans to effectively manage heel pain for the long term. With the right approach, runners can return to their full running training and have strategies in place to minimise their risk of future problems. Click below to ask a question or to book a physio appointment online.
Heel Pain With Running – FAQs
Q: What causes heel pain when I run?
A: Heel pain during running is most commonly caused by plantar fasciopathy (previously called plantar fasciitis). IT is damage (+/- inflammation) to the plantar fascia, which is a strong band of connective tissue running from underneath the heel bone (calcaneus) the the underside of the toes.
Q: Can I continue running if I have heel pain?
A: In most cases, stopping running completely isn’t necessary. Load management means reducing your running volume or intensity to a level where your pain settles and recovery can begin, and then gradually increasing your running training again as you improve. However, in more severe or chronic cases, an initial period without running may be necessary.
Q: How can I prevent heel pain while running?
A: You can definitely minimise your risk of heel pain when running. Follow a gradually increasing training program to avoid overloading your fascia, include strength training in your program, and wear shoes that are fitted properly for your feet. Plus, get enough sleep and eat well to significantly improve your recovery between runs, especially in high-volume training blocks for marathon runners.
Q: Is plantar fasciitis common among runners?
A: Yes, plantar fasciitis is a common cause of heel pain in runners. When managed properly and treatment is started early, most cases will resolve well and allow you to return to your long-term running training.
Q: What exercises can help with heel pain?
A: Strengthening exercises for the calf muscles and intrinsic foot muscles are beneficial. See the 3 exercise videos above, or click here for other strength exercise options.
Q: Should I rest completely if I have heel pain?
A: Complete rest isn’t recommended. Instead, load management is the recommended way to manage heel pain in runners. This means reducing your running volume or intensity to allow recovery to occur, but still maintaining some running while working through your rehabilitation program. This reduces deconditioning (i.e. loss of strength and fitness) while you are recovering and unable to do your full running training.
Heel Pain References
1. Di Caprio F, Buda R, Mosca M, Calabro’ A, Giannini. Foot and lower limb diseases in runners: assessment of risk factors. S. J Sports Sci Med. 2010;9:587–596.
2. Cornwall MW, McPoil TG. Plantar fasciitis: etiology and treatment. J Orthop Sports Phys Ther. 1999; 29(12):756-60.
3. Morrissey D, Cotchett M, Said J’Bari A, et al. Management of plantar heel pain: a best practice guide informed by a systematic review, expert clinical reasoning and patient values. British Journal of Sports Medicine 2021;55:1106-1118.
4. Ferber R, Benson B. Changes in multi-segment foot biomechanics with a heat-moldable semi-custom foot orthotic device. J Foot Ankle Res. 2011;
