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Cases of plantar fasciitis can linger for months at a time, with pain increasing and decreasing in an unpredictable pattern. Often, plantar fasciitis discomfort may nearly disappear for several weeks, only to re-emerge full-blown after a single workout. About 10 per cent of individuals who see a doctor for plantar fasciitis have the problem for more than a year.

The plantar fascia is actually a thick, fibrous band of connective tissue which originates at the heel bone and runs along the bottom of the foot in a fan-like manner, attaching to the base of each of the toes. A rather tough, resilient structure, the plantar fascia takes on a number of critical functions during running and walking. It stabilizes the metatarsal joints (the joints associated with the long bones of the foot) during impact with the ground, acts as a shock absorber for the entire leg, and helps to lift the longi-tudinal arch of the foot to prepare it for the 'take-off' phase of the gait cycle.

Although the fascia is invested with countless sturdy 'cables' of connective tissue called collagen fibres, it is certainly not immune to injury. In fact, about 5 to 10 per cent of all running injuries are inflammations of the fascia, an incidence rate which in the United States would produce about a million cases of plantar fasciitis per year, just among runners and joggers. Basketball players, tennis players, volleyballers, step-aerobics participants, and dancers are also prone to plantar problems, as are non-athletic people who spend a lot of time on their feet or suddenly become active after a long period of lethargy. A recent study found that over 50 per cent of people who suffer from plantar fasciitis are on their feet nearly all day, and many cases of plantar fasciitis seem to occur in 'sofa spuds' shortly after they've made their first trip around their garden with a lawn mower in the spring.

The 'red zone of tautness'
Why does the fascia flare up? Although it is a fairly rugged structure, the plantar fascia is not very receptive to stretching, and yet stretching occurs in the fascia nearly every time the foot hits the ground. Studies indicate that the fascia can unkink itself to no more than 102 per cent of its normal length without suffering at least some tearing, but the force equal to almost three times body weight which passes through the foot with each step forces the fascia to come close to this 'red zone of tautness' 90 times per foot per minute during the act of running ('Anatomy and Biomechanics of the Hindfoot,' Clinical Orthopaedics, vol. 177, pp. 9-15, 1983). So, it's not surprising that plantar fasciitis occurs fairly frequently, nor is it a surprise that the damage - and pain - often tend to occur near the heel, where stress on the connective tissue fibres is greatest, and where the fascia itself is the thinnest (it tends to broaden out as it reaches toward the toes).

The heel locus for trouble is one reason why plantar fasciitis is often associated with 'heel spurs'. Those 'spurs' are simply wads of calcium deposited at the site where the fascia suffers most damage. The heel agitations also explain why the clinical manifestation of plantar fasciitis is usually strong discomfort at the bottom of the heel bone. More specifically, the person suffering from plantar fasciitis will often feel a pinpoint, knife-like pain at the 'medial tubercle' of the calcaneus (heel bone), which happens to be the exact location of the origin of the inside part of the plantar fascia. Swelling may occur just in front of the heel bone, and pain can radiate along the whole longitudinal arch of the foot.

Fatties suffer
Why are some people troubled by plantar fasciitis, while others remain relatively pf-free? Research suggests that pf is often associated with a change in activity (like a sudden increase in the volume or intensity of training or a simple expansion of the total time you spend on your feet). Using worn-out shoes, especially while running on pavement or hard ground, also seems to increase the risk Individuals with flat feet are said to be at higher risk for plantar fasciitis, and - somewhat paradoxically - so are people with high arches. A sudden increase in hill training may also spark a bout of pf, and pregnancy and pf go together like hand and glove.

Gaining weight or being obese is also a strong risk factor for plantar fasciitis. A recent study determined that 77 per cent of its sample of 411 plantar fasciitis (heel spurs) patients were overweight. Another study found that 23 per cent of overweight women had plantar fasciitis (heel spurs) compared to 8 per cent of the normal body-weight group. The additional body mass simply places increased stress on the plantar fascia.

If you have heel pain at the front and bottom of your heel, especially when you first wake up in the morning, it's quite likely that you have pf. If it is indeed pf, putting about an inch of folded paper under your heel or stretching out your calf muscles will usually help diminish the pain. However, other problems sometimes mimic pf discomfort; X-rays and a bone scan can help rule out the possibility of stress fracture, and a nerve study (using electrodes) can eliminate tarsal tunnel syndrome. A bit of arthritis in the heel may resemble pf, but blood tests can help make the diagnosis (there is no blood test for pf, but there is for arthritis). Your doctor may want to perform an MRI to confirm the presence of plantar fasciitis.

The traditional remedies for plantar fasciitis are - at best - quite weak. Stretching the calf muscles is often recommended, as are massage, decreasing one's training, losing weight, purchasing better-fitting shoes (with a raised heel and arch support), using special insoles, relying on thick heel pads, icing the sore heel, and gulping down prescription-type doses of ibuprofen.

The trouble with most of these nostrums (e. g., stretching the calf muscles, getting a massage, cutting back on training, hitting the non-steroidal anti-inflammatories, and icing) is that they don't really address what's going on. Stretching out the calf area is often a step in the right direction (tight calf muscles put extra strain on the plantar fascia), but there are many other strengthening and stretching routines which work more effectively (we'll describe them later). In addition, you can refrain from training, employ ice packs, and wash down dozens of ibuprofen caps over a period of many months, but when you get back into full-fledged training again, pf is very likely to recur with full fury. As is the case with any injury, you have to understand why plantar fasciitis cropped up before you can really rehab yourself and make the impairment a distant memory. You also need to increase the strength and resiliency of the plantar fascia and the other muscles and connective tissues of the foot - and stabilize and strengthen the entire leg - before you can expect to stay away from plantar fasciitis in the future. The exercises outlined below do just that.

Exercises to recover from and prevent plantar fasciitis
Our pf routines are divided into two types - those that emphasize stretching and those that stress strengthening:

I. Stretching Routines
A. The Rotational Hamstring Stretch
To carry out this stretch, stand with your weight on your left foot and place your right heel on a table or bench at or near waist height. Face straight forward with your upper body and keep both legs nearly straight. As you stand with your right heel on the table and your left foot on the ground, rotate your left foot outward (to the left) approximately 45 degrees, keeping your body weight on the full surface of your left foot (both heel and toes are in contact with the ground). You are now ready to begin the stretch.

Lean forward with your navel and shoulders until you feel a steady tension (stretch) in the hamstring of your right leg.Don't increase the stretch to the point of pain or severe discomfort, but do maintain an extensive stretch in your right hamstring while simultaneously rotating your right knee in a clockwise - and then counter-clockwise - direction for 20 repetitions. As you move the right leg in the clockwise and counter-clockwise directions, stay relaxed and keep your movements slow and under control.

After the 20 reps, remove your right leg from the table and rest for a moment.

Then, lift your right leg up on to the table and repeat this clockwise and counter-clockwise stretch of the right hamstring, but this time keep the left (support) foot rotated inward (to the right) approximately 10 degrees as you carry out the appropriate movements. Perform 20 repetitions (clockwise and counter-clockwise) before resting.

Finally, repeat this entire sequence of stretches, but this time have the right foot in support and the left foot on the table for the repetitions (do 20 clockwise and counter-clockwise reps with the left foot on the table and the right (support) foot turned out 45 degrees, and 20 more reps with the right foot turned in).

Why is this stretch valuable? Tight hamstring muscles (which cross both the knee and hip joints on the back of the leg) can lead to limited extension and exaggerated flexion of the knee during the running stride (they tend to pull the lower part of the leg backward). This over-flexion at the knee actually increases the amount of dorsiflexion at the ankle during the landing phase of the running stride (remember that the entire leg functions as a kinetic chain; change one thing, in this case hamstring flexibility, and that change will 'ripple' right down the leg to the ankle joint). Increased flexion of the ankle creates an inordinate amount of stress on the Achilles tendon (the Achilles tendon's 'job' during running is to control dorsiflexion of the ankle), which in turn pulls on the heel bone (calcaneus) and plantar fascia. The rotational hamstring stretch ensures that hamstring flexibility is developed in the transverse (rotatory) plane as well as the sagittal plane. The hamstrings undergo movement stresses in both of these planes during the running motion and therefore must have flexibility in both planes to avoid overstressing the plantar fasciae.

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