Could Barefoot Running Fix my Plantar Fasciitis?
By: Rhys Burton
Tags: Fitness, Lifestyle, Life, Running, Health

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Plantar Fasciitis develops due to an insidious overload through the Plantar Aponeurosis (Plantar Fascia) and is characterised by plantar heel pain; usually reported during the first steps taken in the morning or after a long bout of inactivity (Grieve & Palmer., 2017). In coordination with the intrinsic foot muscles, the structure provides support to the arch of the foot, as well as deliver sensory feedback and motor control of the foot. This pathology is described as a sharp sensation developed in the heel and radiating into the arch of the foot (Huffer et al., 2017). Excessive load to the Plantar Fascia leads to a strenuous stretch of the tissue — which in turn leads to the development of microtraumas and subsequent alterations to the architecture of the connective tissue. Ultimately resulting in a degeneration of the Plantar Fascia (Ribeiro et al., 2015).

From a sample of 3500 runners, across 8 studies, Plantar Fasciitis was highlighted as the third most common running-related musculoskeletal, meaning the pathology is still affecting a large proportion of runners (Grieve & Palmer., 2017; Lopes et al., 2012). Meaning that alternative treatment and prevention strategies may need to be explored. This research also alluded to the potential detrimental effects of utilising a rearfoot strike (RFS) running technique. However, it was concluded that risk factors for Plantar Fasciitis are multifactorial and there is limited evidence to identify a selection of factors that leave more susceptible to Plantar Fasciitis.

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Within this article, we’re going to explore and challenge the traditional approaches to treating this pathology. Whilst also highlighting how some physical factors MIGHT be exposing particular runners to a higher risk of developing Plantar Fasciitis and how modified barefoot running MIGHT be a welcomed change for their bodies.

The Risk Factors:

Ankle Dorsiflexion

Riddle et al (2003) concluded that the lack of passive dorsiflexion in the ankle, demonstrated by participants diagnosed with Plantar Fasciitis, supported the hypothesis that the reduced range of movement, played a role in the etiology. However, due to these participants being collected after being diagnosed with the pathology, there is not a clear way of identifying if this reduction is dorsiflexion was as a result of acquiring Plantar Fasciitis; or if it was a factor which led to the onset of the pathology. The study incorporated rigid inclusion criteria of symptoms, which was mirrored by case reports in runners (Francis et al., 2017; Saxelby et al., 2017). But, despite eight subjects reporting being recreational runners, there is no way of matching their specific risk factors to the rest of the running population. Bias was also accounted for between examiners, by blinding them from the knowledge of which group the subject came from, as well as which side was affected and the identity of the participant. The role of a shortened Achilles tendon was also considered, and the further biomechanical consequences it could have led to. The proposed mechanism for a reduction in ankle dorsiflexion is linked to a shortened Achilles tendon — which would cause compensatory foot pronation (Irving et al., 2007).

Despite the authors stating that the findings should not be generalised to athletes/competitive runners, it could have been argued that the same mechanical principles could still be applied to runners. Ribeiro et al. (2015) demonstrated those with unilateral Plantar Fasciitis (in both acute and chronic stages) conveyed a higher plantar load when striking with their rearfoot (landing heel first). This adoption of an RFS by runners did not carry a clear causality; although it’s a foot strike pattern used by ~75% of runners (Larson et al., 2011). The data extracted from this study demonstrated high levels of ecological validity, due to the sample consisting of 286 sub-elite runners (predominantly recreational). Furthermore, external risk factors, particularly fatigue were accounted for, by recording foot-strike patterns within two points in the race (10 km and 32 km). This highlighted whether recorded fore-foot strikes adopted an alternative RFS pattern during the latter stages of the race. Four runners changed from forefoot striking (FFS) at 10km to RFS at 32km.

High Impact Peaks & Rear Foot Strike

RFS can produce a significant impact transient, which has been associated with higher loading rates when compared to alternative strike patterns (Altman & Davies, 2015). For example, an FFS, which is classified by the ball of the foot making initial contact with the ground, prior to the heel (Lieberman et al., 2010). FFS is associated with barefoot running, and RFS predominates in shod runners (Larson et al., 2011; Lieberman et al., 2010).

The research has shown that these high impact transients were significantly higher in the shod runners who struck the ground with their rearfoot. Which only increased further as the shod runners were placed into the barefoot condition, and maintained their usual strike pattern. An RFS pattern may have predisposed the sample to a repetitive and excessive load through their proximal plantar region (Altman & Davis, 2012). Additionally, between the shod and unshod group, it was indicated that the use of trainers facilitated the use of an RFS, due to the thickest portion of cushioning being underneath the heal. Perhaps the constant use of trainers by shod runners could be another predisposing factor, leaving them at a higher chance of acquiring Plantar Fasciitis. Maybe an intermittent use of barefoot running, which could’ve encouraged an alternative footstrike pattern, and impact transient could alter this. Potentially offering a chance to load the Plantar Fascia structure directly and increase the surrounding intrinsic foot musculature (McKeon et al., 2014).

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One of the biggest limiting factors of this research was the conditions in which they were conducted. Due to the tests being conducted on a treadmill, which provides a constant flat and stable surface, unlike the frequent alternations in surfaces, distance runners may face.

An FFS pattern has been shown to increase the tensile load through the Plantar Fascia (Chen et al., 2019). Because of this, it could be suggested that moderated loading and lengthening of the structure, could reproduce similar results to that of an eccentric loading intervention to treat an Achilles tendinopathy (Alferdson et al., 1998). When the calf muscles were loaded eccentrically, patients reported reduced pain levels and a return to pre-injury activity levels after a 12-week intervention (Mafi et al., 2000). The Achilles tendon and Plantar Fascia, demonstrate similar physiological properties (Orner et al., 2018). This could imply that a similar, moderated loading protocol could reproduce similar results for Plantar Fasciitis, as it has for Achilles tendinopathies (Murphy et al., 2018). This could be achieved through inducing an FFS, via barefoot running. Additionally, reduced intrinsic foot musculature has been associated with Plantar Fasciitis (Chang et al., 2012). It could be suggested increasing the surrounding musculature, could facilitate decreasing tensile loads on the Plantar Fascia and other passive structures that form the foot and ankle. Developed intrinsic foot musculature has also been implied to have occurred as a result of barefoot running (McKeon et al., 2014).

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Current Treatment

Recent studies have indicated that “Advice”, “Education on Plantar Fasciitis” and “Self-management” are methods of treatment that are heavily utilised by Physiotherapists within the UK. This is understandable given the multifactorial considerations and poor understanding of Plantar Fasciitis risk factors (Grieve & Palmer., 2017; Irving et al., 2006). However, the data hasn’t highlighted the effectiveness of these treatments and the success rate of the plans — which is incredibly hard given that the general population’s rehabilitation goals are vastly different from that of a seasoned runner.

After suffering from Plantar Fasciitis for 40 years, a 62-year-old male runner was put through 8-week load management and biomechanical alteration intervention (Saxelby et al., 2017). To monitor fluctuations in pain, a numeric rating scale (NRS) was used to convey how the runner responded to the intervention. After identifying the participant had an RFS pattern, he altered that to a midfoot strike (MFS) pattern, which was tracked with a 9-axis inertial sensor. Post-8-week intervention the runner reported a significant decrease in pain levels — but obviously, this does not show that this treatment plan would have the same effect on another runner of different age, sex, or injury history.

Similar findings were indicated from a 27-year-old female triathlete who had suffered from left-sided medial calcaneal pain for 12 months. A similar NRS was adopted by the therapist to measure pain levels in the morning and post-session. 6-weeks post-intervention the athlete’s symptoms dropped from 6/10 to 2/10 in the morning, but then increased back up to 4/10 after completing a 15-minute jog in her normal running shoes. The triathlete was then prescribed barefoot running on the same surface, after an observed alternation to an MFS and reduction in pain the following morning, was reported (Francis et al., 2017).

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Clearly, there is an argument to be made for the potential of barefoot running to be applied to a treatment plan for a runner with on-going Plantar Fasciitis. However, it does need to be made clear that this article isn’t advocating that you go and run 10km barefoot on your usual road route. Or if you are suffering from Plantar Fasciitis this doesn’t mean start running in your local neighborhood barefoot and expect to make a good recovery. Firstly, if you don’t suffer from Plantar Fasciitis, but you do use an RFS, this article isn’t saying that you will develop it. Don’t try and fix what isn’t broken. Secondly, if you’ve only just started feeling Plantar Fasciitis-like symptoms then PLEASE consult with a Healthcare Professional (HCP)for advice and management. They will guide you in a direction that they see fit for you. That may be a load management program similar to the ones that didn’t seem to work for the previously mentioned case studies — which may work for you. It may even incorporate a small dose of barefoot running on grass or sand — which may also work. No one model fits all!

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Let's summarise all of this:

Can barefoot running help fix your Plantar Fasciitis? Yes. It most definitely has the potential to. Has barefoot running been an integral part of previous rehabilitation programs that have helped people recover in the past? Absolutely. Should I go out and run barefoot on concrete on my next run? No. Too hard, too soon. Try some loops of your local field or lengths of the beach. Can I damage my feet from barefoot running? Yes. If you’re going to run barefoot anywhere, make sure you’ve checked the area or are very familiar with the surroundings and what wildlife will surround it. Be VERY careful that you don’t step on glass. Should I try switching to barefoot running even though I am not injured? I would not advise it, because you should be enjoying the fact that you’re running as you are with no problems. But if you want to try integrating it into your life then PLEASE do as much research on it as you can beforehand. Will I enjoy running barefoot? Yes. I do, but I also enjoy doing a long run down the country lanes on a Sunday, with my Nike Zoom Flys on. It’s about balance.

If you are currently suffering from Plantar Fasciitis then seek advice from an HCP; don’t throw yourself too deep into a brand new form of running too soon; be open-minded with your rehabilitation and try new things later on. Finding things that work further down the line are what makes it fun.

MEDICAL DISCLAIMER: The following information is intended for informational purposes only. Consult an HCP to help you diagnose and treat injuries of any kind.

References:

Alfredson, H., Pietilä, T., Jonsson, P. & Lorentzon, R. (1998) Heavy-Load Eccentric Calf Muscle Training For the Treatment of Chronic Achilles Tendinosis. The American Journal of Sports Medicine, 26 (3), pp.360–366.

Altman, A. & Davis, I. (2012) Barefoot Running. Current Sports Medicine Reports, 11 (5), pp.244–250.

Altman, A. & Davis, I. (2015) Prospective comparison of running injuries between shod and

barefoot runners. British Journal of Sports Medicine, 50 (8), pp.476–480.

Chang, R., Kent-Braun, J. & Hamill, J. (2012) Use of MRI for volume estimation of tibialis posterior and plantar intrinsic foot muscles in healthy and chronic plantar fasciitis limbs. Clinical Biomechanics, 27 (5), pp.500–505.

Chen, T., Wong, D., Wang, Y., Lin, J. & Zhang, M. (2019) Foot arch deformation and plantar fascia loading during running with rearfoot strike and forefoot strike: A dynamic finite element analysis. Journal of Biomechanics, 83, pp.260–272.

Francis, P., Oddy, C. & Johnson, M. (2017) Reduction in Plantar Heel Pain and a Return to Sport After a Barefoot Running Intervention in a Female Triathlete With Plantar Fasciitis. International Journal of Athletic Therapy and Training, 22 (5), pp.26–32.

Grieve, R. & Palmer, S. (2017) Physiotherapy for plantar fasciitis: a UK-wide survey of

current practice. Physiotherapy, 103 (2), pp.193–200.

Huffer, D., Hing, W., Newton, R. & Clair, M. (2017) Strength training for plantar fasciitis and

the intrinsic foot musculature: A systematic review. Physical Therapy in Sport, 24, pp.44–52.

Irving, D., Cook, J. & Menz, H. (2006) Factors associated with chronic plantar heel pain: a systematic review. Journal of Science and Medicine in Sport, 9 (1–2), pp.11–22.

Irving, D., Cook, J., Young, M. & Menz, H. (2007) Obesity and Pronated Foot Type May Increase the Risk of Chronic Plantar Heel Pain. Medicine & Science in Sports & Exercise, 39 (Supplement), p.S69.

Larson, P., Higgins, E., Kaminski, J., Decker, T., Preble, J., Lyons, D., McIntyre, K. & Normile, A. (2011) Foot strike patterns of recreational and sub-elite runners in a long-distance road race. Journal of Sports Sciences, 29 (15), pp.1665–1673.

Lieberman, D., Venkadesan, M., Werbel, W., Daoud, A., D’Andrea, S., Davis, I., Mang’Eni, R. & Pitsiladis, Y. (2010) Foot strike patterns and collision forces in habitually barefoot versus shod runners. Nature, 463 (7280), pp.531–535.

Lopes, A., Hespanhol, L., Yeung, S. & Costa, L. (2012) What are the Main Running-Related Musculoskeletal Injuries?. Sports Medicine, 42 (10), pp.891–905.

Mafi, N., Lorentzon, R. & Alfredson, H. (2000) Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis. Knee Surgery, Sports Traumatology, Arthroscopy, 9 (1), pp.42–47.

McKeon, P., Hertel, J., Bramble, D. & Davis, I. (2014) The foot core system: a new paradigm for understanding intrinsic foot muscle function. British Journal of Sports Medicine, 49 (5), pp.290–290.

Murphy, M., Travers, M., Gibson, W., Chivers, P., Debenham, J., Docking, S. & Rio, E. (2018) Rate of Improvement of Pain and Function in Mid-Portion Achilles Tendinopathy with Loading Protocols: A Systematic Review and Longitudinal Meta-Analysis. Sports Medicine, 48 (8), pp.1875–1891.

Orner, S., Kratzer, W., Schmidberger, J. & Grüner, B. (2018) Quantitative tissue parameters of Achilles tendon and plantar fascia in healthy subjects using a handheld myotonometer. Journal of Bodywork and Movement Therapies, 22 (1), pp.105–111.

Ribeiro, A., João, S., Dinato, R., Tessutti, V. & Sacco, I. (2015) Dynamic Patterns of Forces and

Loading Rate in Runners with Unilateral Plantar Fasciitis: A Cross-Sectional Study. PLOS ONE, 10 (9), p.e0136971.

RIDDLE, D., PULISIC, M., PIDCOE, P. & JOHNSON, R. (2003) RISK FACTORS FOR PLANTAR

FASCIITIS. The Journal of Bone and Joint Surgery-American Volume, 85 (5), pp.872–877.

Saxelby, J., Paya Gamez, J. & Heller, B. (2017) A Holistic Approach to Managing a Runner with Recalcitrant Plantar Fasciitis outside the Clinic. Podiatry Now, 20 (8), pp.8–12.