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Two different scenarios of treating a runner with plantar fasciitis

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Craig Payne, Nov 8, 2012.

  1. Craig Payne

    Craig Payne Moderator


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    I have taken the day off work; the wife is at work; the Arena'ettes are at school and given that the lawns need mowing and there is ~40hrs of students assignments to mark .... I can think of nothing better to do and have another rant (here are some previous ones: Chi Running; There is no Barefoot Running debate; The 180 Cadence)

    The shenanigans in the thread on Plantar fasciitis and the anti-orthosis, Minimalist Shoe message inspired this satire:

    Here are two different hypothetical scenarios that I could use to treat a runner that I have just diagnosed with plantar fasciitis. If you were a runner with plantar fasciitis, how would you like to be treated?

    Scenario one:

    Ok, Mr Runner, you have plantar fasciitis. Here is what I think we should do to treat it. I read on a blog that plantar fasciitis is due to weak muscles and minimalism or barefoot is the best treatment to strengthen those muscles and cure your plantar fasciitis. As it was on the internet, it must be true even though it was not subjected to peer review. The author has a large cult following, so it must be true.

    We will not let the inconvenient facts get in the way of getting you to run barefoot or in minimalist shoes. Facts like:

    - There is no evidence that plantar fasciitis has anything to do with weak muscles; and in the zillion cases of plantar fasciitis that I have treated over 30 yrs, I have never seen weak muscles in a single one; but who cares about this inconvenience?

    - I have seen plenty of minimalist and barefoot runners develop plantar fasciitis and you only need to go to any barefoot or minimalist running website and you will see plenty of runners asking for advice on their plantar fasciitis …. But they will still tell you the minimalism is better and leads to less inuries!

    - And even if plantar fasciitis was due to weak muscles, there is no evidence running in minimalist shoes actually strengthened those muscles, but who cares about the lack of evidence if something is written in a blog post! In fact, the evidence is that minimalist running does not strengthen the muscles yet there are others that show there is, so it really far from conclusive to make emphatic statement that it does. But we not worried about that evidence are we? Let’s conveniently dismiss it as there was a typo in the publication.

    - And of course, there is a randomised controlled trial that in the abstract claimed that minimalism was better for plantar fasciitis, so that is good, right? It was randomised, right? We will ignore the fact that several runners in the minimalist group got so bad that they had to withdraw from the study and were eliminated in the analysis! We will blindly accept the results in the abstract and not do any sort of critical appraisal of the study.

    We don’t really care about these facts, so what I am going to do, is divert your attention from them by pointing out that there is no evidence for big bulky running shoes. Who cares that that lack of evidence for big bulky running shoes has nothing to do with proving minimalism is better, it is just a tactic to divert attention from really addressing the evidence. This only works on those who are gullible enough.

    And besides, barefoot or minimalism are "natural" and we are all gullible to believe that because something is "natural" it must be better for you. Who cares that arsenic is "natural", so I wonder if all those who promote "natural" are also taking their arsenic pills? I also wonder what these people do when that get a sever infection - do they actually take "un-natural" antibiotics?

    So what we are going to do is transition you to minimalist running, so let’s talk about your current running program and how we might implement minimalism and transition you to it …. There are a number of sensible approaches to do this. Here is a plan for you to follow…. And here is where you can get some more advice on transitioning properly…

    Do not worry about the plantar fasciitis, it will hurt like hell, but hey, we have to strengthen those muscles as the blog post said minimalism is best for plantar fasciitis. We got to get those muscles stronger. If it hurts too much, we can just give you a cortisone shot to help with the pain. Too bad is that shot increases the risk you will rupture the plantar fascia, but hey, that could be a good thing!

    But, you know that marathon you were planning on running in 4 weeks – forget about it! It way too soon for you to have transition by then and I fully expect your pain will still be as bad then as it is now.

    What you ask? What if it is not better after 6 months? Don’t even think about it. In 6 months your muscles will be so strong that the plantar fasciitis will be ancient history…..but on the off-chance that it is not, then I have a colleague across town who I can get to operate on it as it has now turned into such a chronic problem with degeneration and scar tissue, there is little else that is likely to work. He keeps telling me that I and minimalism is good for his business … don’t figure …. It is all over the internet that minimalism is better for you.

    I will have to check with my insurance policy to see if I am covered for malpractice properly for giving you such bad advice…..but surely a blog post about it claiming its true is more than enough of a good defense!

    Scenario Two

    Ok, Mr Runner, you have got plantar fasciitis. Plantar fasciitis occurs when the load in the plantar fascia exceeds what the tissue can take, so we have only two things we can do. One is reduce the load and the other is increase the ability of the tissues to take the load. Reducing the load is easy and is something we can do today. Increasing the ability of the tissue to take the load is more difficult, takes time and is not something we can do in the short term.

    I know you have a marathon to run in 4 weeks. Is the plantar fasciitis interfering with your preparation for that? If it is, then we will use low dye strapping today to get a more acute effect of reducing the load. At least that will help the symptoms and start the healing process while we keep an eye on that marathon preparation. We are also going to use foot orthotics to reduce the load. I know you have read on a blog post that orthotics are evil (and minimalism is the second coming of the messiah), but the reality is that every single outcome study on foot orthotics says they work (except for one when used to treat bunions in kids, but that obviously does not apply to you). It is irresponsible to not do what the evidence says. Not all foot orthotics are created equal and there are specific design features that they need to ensure that they do lower the load in the plantar fascia (if they do not achieve that, then the chance of a failure is increased). I know you read on a blog post that orthotics weakened muscles, but the all the published research (3 studies now) have shown that this is not the case, in fact, two of the studies actually shows foot orthotics strengthen the muscles, so would you rather believe the scientific evidence or an anonymous blog post from someone who has no clinical experience?

    We also going to get you to do a lot of stretching for the calf muscles and plantar fascia. You are going to do it 4-5 times a day, without fail! It is extremely important! I am also going to mobilize your fibula to make sure there is no inhibition there and if your calf muscles are tight, probably use a heel raise in the very short term. As soon as possible we want to get rid of the heel raises, but they important now to overcome the tightness until the stretching kicks in. The evidence also tells us how effective stretching is and we want to give you the best chance to get through that marathon.

    Keep up with the ice applications after running.

    I expect this to get you through the marathon in 4 weeks. If after a couple of weeks it is not improving as fast as we would like, then we may add some night splints to further stretch and even consider a cortisone shot (if you did not have the marathon coming up, maybe would not do this). At that stage we may also consider some other things to help the tissues heal (eg Graston, trigger point therapy; deep friction; or even shockwave). However, most of those types of treatment do not reduce the load in the plantar fascia or improve the ability of the tissues to take the load; all they do is facilitate the healing of the damaged tissues. We still need to get load down and/or increase the ability of the tissues to take that load.

    Say what? You read on a blog post that minimal running is the best treatment for plantar fasciitis as weak muscles is the cause of plantar fasciitis!! What would you rather believe, a blog post or the evidence. There is no evidence that weak muscles are related to plantar fasciitis (I have never seen it). There is even evidence that minimalistic running does not strengthen the muscles. One randomised control trial reported that there was no statistical difference between minimalist shoes and regular shoes for plantar fasciitis, but there was a trend to the minimalism group doing better. But, if you read the actual paper rather than the abstract you will see that they left out of the analysis several in the minimalist group who got so bad they had to withdraw from the study. Having said that, if you want to go down that pathway, it is your choice and we will assist you with the transition etc.

    You asked about running form and plantar fasciitis? Running form or technique is extremely important, not only for injury prevention and performance. There is no data linking plantar fasciitis to any particular running form or foot strike pattern. It appears to me to occur in all different running forms and foot strikes, so changing your running form is probably not going to help or hinder your plantar fasciitis. There are other injuries that do benefit from changing the running technique one way or another. Having said that, when I watched you run, there were a couple of issues you might want to consider addressing over the longer term. If you are interested I can refer you to some people who know a lot more about running technique than me. They are sensible in their approach and do not promote a nonsensical agenda.

    You asked about stengthening exercises? Strength is important for running, but there is not one shred of evidence linking muscle weakness to plantar fasciitis (apart from blog posts by people who have no clinical experience actually treating people with plantar fasciitis). What those bloggers seem to miss is that a weakness of the intrinisic muscles of the foot actually lead to a higher arched foot and not a flat foot that they claim. I can give you some exercises if you inclined to do them. Even if plantar fasciitis is due to weaker muscles, we need to fix your plantar fasciitis now; strengthening exercises will take many many months to have an effect, even if they have any effect on this! And besides, we know from the evidence that foot orthotics can strengthen the muscles, so why not use those?

    Now we got you through the marathon, what are we going to do in the long term? It is really up to you. There is nothing wrong with continuing to wear the foot orthotics if you want to and they make you more comfortable. There is no evidence that they do any harm. The evidence is that they do not weaken the muscles and they actually make the muscles stronger. Plenty of people wear them long term and never have problems, but also plenty of people rant about them in forums and on blogs, but they ignore what the evidence says which does their credibility no good. If you look at all the outcome studies on foot orthotics and there success rates, they are no different than any other medical intervention for almost any other medical condition. Of course there will be failures. There are failures in knee replacement surgery; in using antibiotics for strep throat; etc. Should we not use knee replacement surgery or antibiotics because sometimes there is a failure? Sometimes foot orthotics fail. This could be due to the wrong design being used or the runner not following the proper advice. The overwhelming evidence from all the outcome studies is that they work. The problem is that when a foot orthotic fails, the runner goes on to a forum to rant about it. No one rants about a knee replacement surgery failure or antibiotic failure … don’t figure!

    We do need to put in place a strategy to increase the tolerance of the plantar fascia to the loads that are placed on it, so we will give you a plan for that. It is really up to you how much effort you want to put into this. Hopefully as the orthotics bottom out, your plantar fascia is adapted to the load and does not become a problem again and you do not need the orthotics. However, sometimes the magnitude of the forces on the tissue are so high that the tissues cannot adapt and you may need foot orthotics over the longer term to keep the load on the plantar fascia down to a level that the tissues can tolerate. That is not a problem and it won’t make you infertile, blind, or go bald or anything like that.

    It is up to you. If you want to transition to minimalism running, that is fine, it will probably not impact on your plantar fasciitis. There is nothing wrong with minimalism; there is nothing wrong with maximalism. It all depends on your choices and what tissues you need to offload over the longer term. Different running forms load different tissues. It also depends on what feel you want under your feet. If you want to feel something soft, then that is fine. If you want to feel the ground more, then that is fine. Just do not fall for all the rhetoric and propaganda and the misuse of science.
    Last edited by a moderator: Jan 13, 2013
  2. Craig:

    You are soooooo old school......everyone knows that plantar fasciitis, and death, are caused by Rothbart's foot!!:rolleyes:
  3. RobinP

    RobinP Well-Known Member

    You could have mown the lawn, marked the assignments and made dinner for the family in the time it took you to do that post.

    Loved it though - Barefoot/Minimalist running is rare in the Isle of Man but this is going to get handed out to the next runner that comes in with plantar fasciitis, even if he/she doesn't want to go minimalist
  4. CraigT

    CraigT Well-Known Member

    Craig- Well said!
    Another scenario you didn't mention-

    I know this story is on PA somewhere else, but I thought this was interesting-

    (from the article)-
    Perhaps going minimalist treats the problem the same way??? Smashes it until there pathological tissue tears...
  5. Craig Payne

    Craig Payne Moderator

    lol! No sooner than I write the above, this piece of idiocy appears an a running site from someone who obviously has no clinical experience, yet alone even read the evidence on what works in plantar fasciitis:
    If they really believe that, they need to answer:
    1. Why all the evidence shows just how effective stretching is for plantar fasciitis?
    2. What evidence is their on the strengthening of the foot muscles in plantar fasciitis?
    3. Why is it that those who treat a lot of plantar fasciitis never see any with weak muscles?
    4. Why is it that so many minimalist/barefoot runners get plantar fasciitis if this is the best thing for it?
    5. Why do so many of those with plantar fasciitis get more pain when they go barefoot?
    6. Running shoes do not weaken muscles and neither do foot orthotics (that is what the evidence says!)
    7. How come all the zillion cases I have treated in the last 30 yrs got better without strengthening? Certainly not "strengthening the feet is critical for PF sufferers"

    Funny how all these facts and inconvenient bits of scientific evidence get in the way of advice from non-clinically qualified people try to tell people how to treat clinical conditions..... these idiots need to be held accountable. Plantar fasciitis is generally actually easy to treat and its easy to see why the runner who wrote the post ended up with a chronic problem! What makes it harder to treat is runners who follow the idiotic advice on that blog before coming in for treatment.
  6. William Fowler

    William Fowler Active Member

    I hope none of your students are reading this. :hammer:
    Scenario 2, of course.
  7. toomoon

    toomoon Well-Known Member

    Honestly Craig.. this is now just starting to depress me.. it is just nuts!

    What about the poor runners reading this.... just terrible..
  8. Craig Payne

    Craig Payne Moderator

    I have been reflecting more on this; it really is insane. Obviously the person that wrote that blog post has never actually treated a single person with plantar fasciitis! They obviously have not read, let alone understood, let alone appraised all the research on plantar fasciitis. They need to be held accountable for their claims and answer the questions:
    This is not about defending orthotics and the $; it is because of bloggers like that one I am making more money now! If it was really about the money, I should be encouraging more to write like them!

    Reminds me of a tweet from IanG a couple a days ago when a blog full of misinformation would not publish my comment:
  9. Griff

    Griff Moderator

  10. When I read blogs like this, I feel sorry for the poor, uninformed masses that believes that what they read on these blogs is true.:sinking:

    Do you really think that most people believe the information being written by these ignorant bloggers about their medical conditions?:confused:

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