Plantar Fasciitis in Runners: Load, Treatment and the Nerve Version

You're listening to the Restoring Human Movement podcast. Thanks for joining the movement, movement. I'm Sebastian Gonzales, show curator and head clinician at Performance Play Sports Care in Southern California. This show's for active people, those who refuse to let pain and injury get in the way of their life and how they want to live it. Trails and trips, fields and courts, whatever moves you. Each episode features rotating host, expert guest, and real clinical conversations that help you move better and trust your body again. Here we go. All right, this is a special podcast today. This is an interview that Jason Fitzgerald from the Strength Running podcast did an amazing job of interviewing a Dr. Mandy Riehl, also newly Dr. Mandy Riehl, about plantar fasciitis as it pertains to some of our runners and misconceptions that there actually is.

So it was really popular on their show, and so we're going to share it on ours to make sure that there's awareness out there and that there's no reason that heel pain cannot go unsolved, and we can help more and more people. Enjoy the interview. This is episode number 473 with four-year Division I cross-country and track athlete, a doctor of chiropractic, the head coach of the Long Beach Poly High School's girls cross-country team, and a two-time coach of the year, Dr. Mandy Riehl. If you don't know already, I actually used to be quite an injury-prone runner. I've had Achilles tendinopathy, IT band syndrome, SI joint problems, more strains than I can count, and one of my least favorite injuries, plantar fasciitis.

And I can't sit here and blame mileage or crazy workouts. This wasn't my coach's fault. My plantar fasciitis injury happened because I was trying to do too much of my running in minimalist shoes. Hey, it was 2004. But it was an injury that led to a very mediocre cross-country season. I just know how frustrating it can be. You think you're healthy, and then all of a sudden, your PF is just back. And I've worked with dozens of runners over the years with this injury, and today, I'm bringing on a practitioner who treats athletes, as well as a coach, and a former high-level athlete. Dr. Mandy Riehl is going to help us understand the causes of plantar fasciitis, how we can safeguard ourselves from this injury, our best treatment options, and more.

My guest today is Dr. Mandy Riehl, a former Division I track and cross-country athlete, who's now a high school cross-country coach, as well as a doctor of chiropractic, who works specifically with athletes. She also has a Bachelor of Science degree in neurobiology, physiology, and behavior, with an emphasis on physiology. She's twice been named LB Press-Telegram's Coach of the Year in both 2023 and 2024. Today, we're doing a deep dive on plantar fasciitis to help you stay healthy, recover faster, and get back to running if you're currently hurt. Hey, Mandy. Welcome to the podcast. Hey, Jason. Good to see you again.

Of course. I was just on your show, and I'm so happy to host you on mine. We're going to do a deep dive on plantar fasciitis today. This was one of the first major injuries that I ever had, so I'm excited to go back into the trauma memories and talk about all the things I did wrong to get this injury and maybe some of your best recommendations for prevention and treatment. Yeah, totally. Awesome. Where should we start? So let's start with maybe what actually this injury is, because I feel like there is often some confusion on what kind of foot pain actually qualifies as plantar fasciitis. And even just, you know, offline a couple minutes ago, you were mentioning how there's these two different types of plantar fasciitis.

Ultra runner Katie Scheid is dealing with a particular kind of nerve issue related to this injury. So I would love to hear about both types of plantar fasciitis, and then we can get into how to address each. Totally. Yeah. So the differentiation, the way that I usually term it is true plantar fasciitis and fake or pseudo plantar fasciitis. So we'll start with true, because that's what more people are familiar with. True plantar fasciitis has to do with the plantar fascia. So that lies underneath your foot and attaches to the heel and then goes out towards your toes. And it's this thick band of connective tissue called fascia.

So it's not stretchy, really, like muscles or tendons. And it also doesn't contract like a muscle. It has no inherent power that you can squeeze it with. The itis part is inflammation. So plantar fasciitis is inflammation in the plantar fascia itself. Usually this is the kind of classic thing is you step out of bed and it feels like you stepped on a rock in your heel and you're kind of limping to the bathroom until it warms up. It's kind of the classic presentation of it. Yeah, that sounds like the injury that I have had in my running career. It does tend to warm up the more you kind of use it as you go throughout the day.

So when you first step out of bed, you're the least warmed up. You're ever going to be all day. And that's when it feels, excuse me, at its worst. Is there any damage to the plantar fascia in this injury or is it strictly just an inflammation issue? Yeah, that's a great question. There's a lot of debate on if the damage equates to pain versus not. I've seen a fair few cases where there's say like a bone spur in the plantar fascia and on an MRI or an ultrasound it looks super gnarly and like there's fibrosis and little tears and all this crap that you find. And then the person's asymptomatic. So I've had folks with the case I'm thinking of.

It was actually a stress fracture in a different bone in the foot and the images happened to show all of that. They had no plantar fascia pain. So it can be damage related and that can hurt. Obviously, like if you smash your foot with a hammer, that hurts. That's damage. Or it can be inflammation, which usually doesn't show up too much on imaging, which can be really frustrating because then it's, you know, the thought is I'm going to look inside my foot and see what's wrong. And if you don't see anything, it feels like you're back at square one, but it can inhabit either category there. Yeah.

So let's talk to the runner who doesn't have a plantar fascia problem right now and talk about some of the things that we can do to prevent it from occurring in the first place. I do want to get into some of the tried and true treatment options that exist. But, you know, when it comes to preventing this kind of irritation, this inflammation of our plantar fascia, I'm curious what we can do to prevent it in the first place. And if those preventative steps differ from that, you know, quote unquote, fake plantar fasciitis or that, you know, nerve oriented issue. Yeah, they do differ quite a bit. And this is where people get stuck because they're trying to either treat or prevent one and then they are actually at risk for the other.

And it's really frustrating because you feel like you did everything right. So for a true plantar fasciitis, one of the things that I've seen just anecdotally is big toe extension range. So that's if you're yanking your big toe up towards your face, you should get pretty far. And in trail runners in particular, I'm not entirely sure why this is the case, but trail runners in particular are super bad at that. Like my husband is horrible and he's had plantar fasciitis before, but big toe extension range of motion, passive. So how far you can yank it and then intrinsic foot muscle strength. This is talked about a lot in various circles, whether you're a runner or like, you know, mobility guru or really into barefoot stuff.

So having strength in your foot in the intrinsic muscles, so the muscles that actually start and end within your foot, helps that control so that you're actually using the active tissues, the things that like support your foot and can contract and absorb shock. Using those more than the passive tissues that can't actually squeeze and absorb shock as well. So it's more about offloading the plantar fascia, not letting it take all of the load by virtue of using your foot muscles instead. Yeah, that's super interesting. And I kind of think about it, too, from the perspective of almost any other injury.

You know, like if your muscle tissue is mobile and somewhat flexible and strong, you're less likely to have an issue. But if, you know, you don't have great mobility work, you know, capabilities there and you're unable to do, you know, kind of strong things with those muscles, you're probably at a higher risk of injury. And it seems like our feet are probably one of the areas where we might be at a higher risk of other places in our body just because it's the first point of contact between us and the ground. Is there any impact-related risk to plantar fascia, fasciitis, or is it more like, you know, like this is what our feet are designed for so it can handle that impact.

It's just more of a load and a strength issue. It's almost always a load issue. The classic thing is the too much too soon. But there's a lot more factors in that. The classic thing for runners is, okay, I increased my mileage and now I'm injured. There's a lot more factors in that. Like, say you increased your mileage a little bit or you maintained your training load, but you just started a job where you're on your feet the whole time. I, again, my husband's a great example, but he is a teacher. So in the summer, we go out and we're, you know, out here and doing a ton of trail running. And then in the school year, if we're still going pretty hard on that stuff, he's all of a sudden standing for six, seven hours a day.

So load can also take that type of presentation where it's not necessarily running. It's just life and other stuff going on too. So load is the real kind of like if you're overloading it, that is the highest risk factor. I actually want to like double click on this a little bit because I feel like the stress that we experience outside of running is more pertinent to this injury than, say, IT band syndrome or other types of injuries. Because if we're wearing improper shoes, if we're spending a lot of time on our feet in a very non-strategic way, a way that's just fatiguing for the sake of being fatiguing, then I would think that our risk factor is going to go up pretty substantially.

What are some of those lifestyle risk factors that, you know, if someone were to come in the clinic and talk to you, you might say, well, because you're dealing with this issue, let's try to reduce A, B and C. Yeah, the common things are occupational. So nurses is the classic example. This is actually how Hoka really cracked into the market is, you know, they were running shoes, the clown shoes, but really nurses popped onto them because they have foot pain and started loving them. And now Hoka's are the plantar fasciitis shoe in theory. But kind of the risk factors there is it's a new introduction to load.

So new job or suddenly you're picking up more hours or you are training for a 50 miler instead of a 5k. And even if you increase your mileage correctly, so to speak, you might have way more time on feet. So things like that, just the cumulative load of it is is always the bottom line that is almost invariable for this type of injury. Yeah, I always tend to think, too, that when the load gets too high, whatever your personal weak link is, is probably the piece that's going to start falling apart on you. So, you know, if you tend to have weak feet, you might be at a further risk of plantar fasciitis.

It could be Achilles tendinopathy. It could be one of those types of foot injuries. What are some of those risk factors? You know, is it like someone who might have flat arches or low arches, does that predispose you to plantar fasciitis? And you might be a little bit more wary of spending all that extra time on your feet? Yeah, it can. So both of those can. Flat arches, again, is a little controversial, so to speak. Podiatrists might have a different opinion on this. I've found that people with congenital flat arches, so arches that have been flat their whole life, really don't have too much of an issue.

But especially older runners who have fallen arches, so arches that were fine and then over time have become flat, they have more issues. And I wonder if that's more of the plantar fascia developed in a certain length, and then all of a sudden you're stretching it more when that arch collapses. So I think that is a factor. And other than that, it's kind of a dynamic arch collapse sort of thing. More often, and I mean, you know my bias here, it is strength. So if you lack the strength, that is the highest risk factor. Other things that are just kind of there and not necessarily controllable bone spurs in that area.

So there's a classic bone spur that goes from the point where the plantar fascia actually inserts itself into the heel bone, and it kind of pulls on the heel bone a little bit, and it pulls this little piece of bone out. When you put tension on a bone, it usually builds more bone because it feels threatened, right? So you get this little bone spur, and that's the cases where it's, you might get a ton of benefit from rehab and all of that, but every single time you push on it and really try and dig in it, it still may hurt. Most people still get 90% better, even if they have the bone spur. Many get 100%, but there's a few that just will always have that point tenderness if they have that piece of bone in there.

I'd love to go on a little detour and just get some of the differences between what a flat arch is versus a fallen arch versus a congenital flat arch. All these different kind of categories of arch height and dysfunction, I'm really curious about. Yeah, I hope you don't get emails about this. But so the categories I use is high arch, congenital, or just has always been flat arch, or a fallen arch. So high arches are really stiff and they're high. So if you're thinking an arch is a bridge, the higher ones are just taller. They look more like a rainbow rather than a bridge. Those are, the risk factor with that is stiffness in the foot.

So it doesn't share the load when you roll through very well. It's just kind of, it's like a plank of wood. You just move the whole foot at the same time. The trouble, and this is why you might get emails, a lot of people with high arches are put in orthotics, which I'm not an expert in podiatry, but orthotics usually introduce more stiffness. So if you have a stiff high arch and you're introducing stiffness, that may be helpful for a short term, but it may actually increase risk factors long term because you're losing the strength that you do have to shock absorb there. So high arches, pretty common.

If you have high arches, you probably know. So the classic kind of test is if you get out of the shower or get out of a pool or something and you see your footprint. If you see a heel mark and ball of the foot and toes, but nothing in between, more indicative of a high arch. Versus the one that all the shoe companies and all of the, you know, lower limb people talk about is a flat arches. There's a difference if you've always had flat arches, like some of my high school athletes have flat arches and it's like, well, you were, you're in high school, you're growing. That's probably just how it is.

It's not like you had anything cause that. That, I feel like, is not as huge of a risk factor because your body has developed that way and it's already adapted for it. Now, if you have a fallen arch, the arch is made up of bones, basically, and there's this keystone bone at the top. If that bone becomes displaced, the arch falls. So dropped navicular, it's the navicular bone. Those hurt. And you'll know, it's an injury that can happen acutely. So you fall or way overdo it on something and then the arch collapses, but you will not be walking after that and you will be going to the ER or a podiatrist or someone immediately.

But those cases take a lot more legwork if you've had that in the past and then you also have like plantar fasciitis on top of it. Well, I didn't know that the arch was comprised of bones with like a keystone bone, just like a keystone piece to, you know, a stone arch that you might find in architecture. I find that really interesting. Yeah, that's the exact analogy that's used when, you know, when you're in any type of health school. It's like, yeah, it's the arch of like a stone arch. That is exactly what it is. Yeah, yeah. And so, you know, if you're an engineer and you're studying arches, you know that the pressure on the arch is what gives it its strength.

So just kind of a random question. What do you think about the entire idea of supporting the foot with arch support? Doesn't that sort of go against the entire function of what the arch is supposed to do? Yeah, this is controversial. So I'm going to be getting a lot of emails today. Yeah, you are. Hey, if somebody comes with good information, I am happy. I'm open minded. Try and teach me some stuff. That'd be great. But orthotics, I typically am not a huge fan of because of exactly that, unless it is an acute injury that needs it short term. So in my mind, orthotics are kind of like a knee brace where it can help short term if there's instability in the area or pain that is just improved with improved stiffness.

It's a good short term measure for some people. The problem is when people spend 10, 20 years in them, and then they don't have that foot strength because they're not stressing their foot. And unfortunately, with plantar fasciitis in particular, I can't tell you how many patients I've had that not only have had orthotics forever, but they use them inside. Like they literally cannot walk anywhere without their shoes and their orthotics in them. They'll get out of bed and put them on to go to the bathroom. So there's a dependency aspect of that that can be a bit like a bigger hole to dig yourself out of.

I had custom orthotics for about three weeks straight, and they were so uncomfortable and stiff and heavy, and they gave me blisters on my arch, and I hated them. And they're in a landfill now, so we don't see those. They're returning to the earth. Yeah, I'm curious. I'm nosy about this. What happened with your plantar fasciitis? Well, so this was actually during summer base training for cross country. It was my first season of collegiate cross country. You know, and I went from running 40-ish miles a week to 70 miles a week, and I strained my arch. And I went to a podiatrist. They fitted me with custom orthotics.

In hindsight, I really did not need custom orthotics. I just needed to manage load better and strengthen my feet. So the wearing of the orthotics, you know, I'm trying to put them into like, you know, the Nike waffle cross country spikes when I'm trying to do workouts. And, you know, it just didn't work. So it wasn't for plantar fasciitis specifically. That was an injury I got one year later the first time. But it was definitely something that, you know, I have a whole history of foot injuries from my arch to actual plantar fasciitis. Achilles tendinopathy, which I do label a foot injury and all kinds of other minor stuff.

Yeah, you've run the gambit there. Yeah, unfortunately. You know, I am interested in the role shoes play in this entire kind of injury and how we think about it. Because I can certainly see how some shoes could provide relief if you are currently experiencing the injury. But if you're healthy, some shoes might predispose you to an injury like this. So I'm just wondering, maybe we can start with like the casual side of things, then we can move into specific running shoes. What are either some risk factors or specific shoes that you think are maybe, you know, a risk factor for this kind of an injury?

Yeah, I'm actually more of the opinion that it doesn't matter too much. There's a lot of discussion about shoes. My rule of thumb, it's similar to what I tell my athletes for when they're brand new and they're just trying to find running shoes is go try things out and see what feels good. That being said, for people, again, with that bone spur, that's where cushion comes in and is more important because it is just straight mechanical pressure on that bone spur. So if you help take that away with a really, say, cushiony, maybe high stack shoe, that can help. But otherwise, it's kind of what feels good.

And I don't know, it doesn't have to get too complicated. You just go try stuff and hopefully they have a good return policy. But other than that, I think it's pretty much by feel. So what about shoes that tend to be a little bit more restrictive? Because I just know that I feel more sore. I feel like my feet are cramped and just not as healthy as they could be in some types of shoes. And I'm certainly thinking back to another life where I had to wear a suit sometimes and wear dress shoes and walk around a lot. But in this thing, I know my feet are killing me. And if I had to go for, you know, a double session run after wearing dress shoes all day, my feet are sore.

So I'm wondering, like, there's got to be some impact of shoes to the health of our feet. Yeah, so that's a that's a good point. So casual shoes outside of running can get more specific. The biggest risk factor that I know of, and this is less based on my clinical experience, based on who I'm treating, which is mostly trailing ultra athletes and more based on some studies that I've read, wearing heels all the time. It's a lot of pressure. It shortens the foot and it's a lot of pressure on the heels specifically. That has a lot of research coming out that that is a risk factor. Now, suit shoes and the kind of toe box phenomenon, I don't know as much.

People kind of shift to and from the toe box theory. I think personally, I like a little bit of a wider toe box, but I don't go crazy in part because to go too wide, then your foot's sliding around and you can have overused muscle injuries in your foot. But if it's super narrow and you're restricted, it's basically inducing stiffness in your foot, which may cause the same problems as orthotics. So it's kind of on the margins. This is for people who maybe are like just getting into ultra running and they're strong and able to build up their mileage a ton, but are maybe only in one type of shoe and having problems.

That's when you can start experimenting more. But the casual side of things, yeah, I would say if there's extremes, it's more relevant, but pretty much anything in the middle doesn't matter. So suit shoes, I would guess that that's more relevant. Heels, I would, there is empirical data that it is more relevant. Past that, like I wear Birkenstocks all day. I can work barefoot, right? I work in socks in a clinic. So I'm lucky on that sense. Yeah, if you're walking around on socks and all day and you have the ability to like sit down sometimes and the surface isn't really hard, you're probably coming off that feeling as best as you possibly could.

That seems to me like the ideal scenario for healthy, happy, strong feet. Totally. Yeah, totally agree. And lifting barefoot if you're able to and doing it safely. So don't drop a plate on your foot. I'm a fan of anecdotally. I think it helps my feet get strong even without doing specific foot strengthening. So I put it under a prevention category. Yeah, I just actually gave my kids that lesson yesterday when we were in our little home gym. I was like, you know, you can lift with bare feet. And I thought that was kind of crazy. Yeah, I bet they're like, what the heck? Yeah. Now for a quick pause before we keep going.

Hey, everybody. It's Sebastian. If what we've been describing in the show so far sounds very familiar and you've been dealing with some ache, pain, or stiffness that keeps coming back no matter what you do and no matter what you try, we're offering a free discovery call today where we brainstorm with you what has been working for you, what hasn't been working. We also try to unravel what is a critical part of the puzzle that you've actually been missing that's keeping you from full recovery and getting back to full activity. The link's in the description. It only takes a few minutes to fill out the form.

Okay, back to the show. Let's move into prevention because I'm sure this is something that most of us want to avoid and then we'll get into treatment. So it seems like mobility and strength are our front line of defense against this injury. No particular shoe is going to save us. So what are some of the preferred mobility and strength exercises to give our feet that kind of armor to protect it against this injury? Yeah, I'm a big fan of heavy loaded single leg patterns if done well. So like if you're lifting barefoot, this is what I do for prevention. I lift barefoot or as close to it as possible.

I do single leg strength exercises, so single leg RDL or a Bulgarian split squat is usually the pretty good entry points. That produces a ton of foot strength on its own. If you like a little calf auxiliary work, that's great. Like calf raises to failure. Fantastic. That'll help too, particularly if you've had it in the past or as you mentioned, had like Achilles tendinopathy as well. But lift heavy, lift with things that involve your foot. So that does not necessarily mean like a leg press machine. It means foot on ground exercises. And then if you can get a single leg pattern in, that's fantastic.

The mobility side, yeah, that big toe extension is good. In general, the fountain of youth for runners for like almost all injuries is hip internal rotation, which is kind of that knock knee position. It helps with stride and letting your leg go behind you when you're running fast. But bottom line, if you're looking for one thing to do to prevent this, heavy, well done, single leg weighted exercises. In terms of mobility, I really like keeping a golf ball underneath my desk and just kind of massaging the arch, the plantar fascia. I'm under no illusion that I'm like breaking up scar tissue. But I also feel like, yeah, I'm probably not doing that.

But I think I am bringing blood flow to the area, making the tissue a little bit more supple. Do you have any favorite types of ways to massage the foot? Yeah, I think any massage that feels good is good. The umbrella that it falls under, how I educate my patients about it, is it's a novel stimulus. So it's a stimulus that your foot isn't used to. I actually use acupressure boards a lot for people who have had long-term foot pain. It basically resets the signal in your brain. So it makes your brain pay attention to your foot more. That's not to say all of a sudden you're going to be like a orangutan and pick up, you know, pencils with your foot or whatever.

But it does kind of disrupt that chronic pain signaling and let it reassess, do I actually need to send those signals there? So golf ball is a great way to do that. Acupressure board. I used to do lacrosse ball, which is pretty gnarly, like right in the middle of the arch and flex my toes. That's good for healthy, non-problematic feet. If it is problematic, then that really gets down into what your diagnosis is, if it's helpful or not. Yeah, another thing that I was reading that's particularly helpful for the foot is whenever you're doing a particular weighted exercise, like you were talking about, Mandy, a simple cue to really help you get a lot out of it for the foot in particular is just to make sure that your big toe is pressing down on the ground.

And, you know, I'm a big fan of the MOBO board, which is a Jada Sherry product. I love it. I was using it yesterday in the gym with my kids. But, you know, it's one of these things where it really reinforces that big toe kinetic chain, kind of starting at the big toe, driving that toe into the ground. Is that a cue that you also like to use when you're barefoot? And what do you think of the MOBO board? I, the cueing, I love that. There is a lot of good information about distal cueing. So distal means away from the center of your body. So for the upper extremities, the cue, like say you're doing a pushup, the cue is to dig your pointer finger knuckle into the ground and it allows everything to work better together.

So for your foot, pushing your big toe into the ground, not only does it have effects at the foot, your big toe muscle is working and your arch muscles are working better. But also it allows your lower leg to work better together because you're creating that tension at the bottom. It's a whole study of biomechanics into that. But I use that all the time. If someone's doing something weird, even like if their deadlift form looks weird, sometimes you're just like, yeah, press your toes into the ground and it fixes everything up the chain. It's weird. It's freaky. But I use it all the time. Those cues are fantastic.

Yeah, it seems like a kind of, not that it centers you, maybe it grounds you. It helps you kind of like use your muscles in the correct order of operations, if that makes any sense. Like it's a very intuitive, kind of ephemeral, subjective type of feeling when you're actually doing it. But like you said, it's incredibly effective. Yeah, if you want to get really, really in the weeds to anyone listening, go look up joint centration. It gets really fun and technical, but that is part of that concept. Talk to me a little bit about just the general topic of variety when it comes to our feet. And I'm thinking about, you know, like I put on my coaching hat and I'm trying to help someone who might be predisposed to plantar fasciitis prevent this injury.

I'm probably going to tell them to wear a couple different types of shoes just to expose their feet to different stimuli. I'm going to tell them to run on a whole variety of surfaces. Just again, just to get different stimulus, because if you are particularly risk, you know, if you're if you're at a higher risk for this injury, my thinking is that we've got to just reduce the repetitive nature of your foot strike as much as possible. And that loading pattern, because that is, you know, arguably the reason why you're getting this injury. But, you know, the front line defense against that is is manipulating the load in a certain way so that it's a little bit different from run to run, different shoes, different surfaces, different paces, different types of workouts that we're going to be running.

How much value do you see in this as a clinician? Yeah, variety is the spice of life. So I the end stage for my patients before I kick them out the door and tell them, you know, I'll see you at a race sometime is strength training variety. So it's exactly what you're talking about. Having options in the gym and fulfilling the major movement patterns, which push pull for upper body, squat, hinge and carry and single leg movements. If you're fancy, fulfilling those and having options within them is what creates resilience. So you can be really strong like you can have a let's even say like a 300 pound deadlift, but you might be really crappy at single leg RDLs if you never train it.

It's the same concept as running. Like if you're doing road miles at eight minute pace all the time, you're really good at doing that. You can bang out six miles, eight minute pace any day of the week, and then you go try and run a VK. Like it's just not going to work because you haven't created that resilience or that movement variation. So I even my colleague when he goes to the gym, he works with a personal trainer and works with them, I think, two times a week. But when he goes on his own for that third day, he just picks machines and he's like, I haven't done that for a while. Let me just do that.

There's a lot of value in that. Just being able to adapt to basically whatever force your body's going through. You've just introduced a really interesting concept to me, like the idea of an adventure day where you kind of just don't follow any formal training progression or workout, but it's more an opportunity to explore and experience things that you don't normally get to experience on a normal training day to day basis. I think that's really fun. And, you know, probably it probably seems fun to me because I was always the guy who was like, yeah, I want to run the steeplechase. Yes, I want to do an obstacle course race.

Yeah, let's do a triathlon. I was always sort of interested in doing something a little bit different rather than doing the same race over and over again. So, yeah, that kind of variety can be super helpful. Yeah, I was the opposite, actually. So when I ran in the NCAA, I was a 1500 specialist. I ran cross country, but it was like 1500, 1500, little 800s in there for spice, but pretty much always just running 15. And then outside of college, when I started trail running and ultra running, I'm like, this is so much better. I can do whatever I want. If I go out for a long run and I'm prepared for it, I can go eight miles or I can go 15.

I'll just decide on the day. Like having that freedom to do that, I think, is something that's unique and special to trail running. Yeah, it also sort of reminds me of like, you know, when I'm working with an athlete and I encourage them to race a road mile or a 5K. And they're like, but I don't run those distances and I don't think I've ever tried to race them. I'm like, well, let's let's create some of that opportunity, some of that. I think resilience is a good word there to exposing the body to all kinds of different stresses. I mean, we can talk about surfaces. We can talk about shoes, workouts, races that you're training for, exercises you're doing in the gym.

I mean, there's value in a whole variety of variety, I might say. Yeah, yeah. The more things that you can do, the more things you can do. It sounds stupid, but it's true. If you do lots of things, then your body is capable of doing lots of things. So I like doing that. There was a time in my life where it was metronome and train for one specific thing and there's no variety there. That's fine. That's a circle of running for sure. But I mean, having the variety to basically do whatever you want whenever you want it is awesome. And a lot of my patients, that's their ultimate goal. So, Mandy, let me ask you one more shoe question, and then I want to get into a little bit of the treatment side of things.

Minimalist shoes. I feel like these are a useful tool for healthy runners, but could be a risk factor for those predisposed to the injury. What are your thoughts? Yeah, there's a large range of minimalist shoes. So I used to run in the Saucony Freedoms, which is fairly low stack. I ran in them for six years, I think. And then they discontinued them. So sad. But fairly low stack, fairly narrow toe box, actually. But I could feel the ground, which I really liked and made my feet feel strong. There are people who go really hard into it and go basically straight barefoot running. The Vibram, like, five-finger shoes were popular for a while, like mid-2010s.

Those are, you can handle it if you work up to it. But the problem is if you do have those risk factors and you just jump into it, that's tough. That's overloading. It's the same thing as overtraining, but for your foot. So it can be beneficial. You can get a good amount of strength if you're just exposing your foot to higher loads like that. But jumping straight into it or doing it for a really long distance, like, I'm not a fan of super minimalist shoes for, like, ultra distances. Some people can handle it. That's awesome. More power to you. But I have not found many people who can. So as with most things, there's a middle ground and the extreme sides can work really well for a small population.

But the middle ground is usually people's happy spot. Yeah, totally, totally. I mean, I remember after the Born to Run surge in about 2009, look, did I buy a pair of Vibram Five Fingers and go on some hikes in them? Sure. I didn't run in them. But, yeah, I took it a little bit overboard. I kind of found it fun. But unless you're making it into your personality and you want to be, like, you know, barefoot Jason. The Teva's guy, yeah. Right. You want to rebrand yourself to barefoot Mandy or whatever. Right. Then, you know, thinking of it, think of it like a tool. Like, you wouldn't do a long run every day.

You wouldn't deadlift every day. You wouldn't do a VO2 max workout every day. You wouldn't do barefoot training every day. So it's just a tool that you can use to help accomplish a job. I think that's the safest way to go about it. Yeah, totally agree. It's funny you mentioned that, too. In the run this morning, we went out to Little Lakes Valley in the Eastern Sierra. Just gorgeous. And I actually saw somebody for the first time in, I don't know, two years with the kind of Tarumara style, like, basically tread in a string type shoes running up. And it's a rocky trail. It's like, wow, I haven't this funny because I knew we were going to talk about this stuff today.

Like, what are the odds here? It was the ghost of Caballo Blanco. Right. Yeah. Seriously. Well, let's talk a little bit about treatment, rather. Treatment. So we've talked a lot of different ways to prevent this injury, strength, mobility, shoe choices, kind of living in the middle and not being too extreme about really any of these issues that we've talked about. But if you do come down with plantar fasciitis, what are we going to do about it, Mandy? Are we sitting on the couch? Are we doing more of the foot strength and mobility work, just like if we were healthy, but we're doing it as treatment now?

What's the general consensus on how we approach this? Yeah, I'm very, very biased against sitting on the couch. I am very much a practitioner who keeps people running unless it's dangerous. So basically, unless you have a stress fracture, you're running. But soft tissues in general respond really well to load if applied correctly. So if you sit on the couch all day and you're just like, it hurts. I'm not going to do anything. I'm going to see if it gets better. That might work for a few days. But past that, if you're in a phase of like, okay, I've been resting for two, three weeks, a couple months, all you're doing is deconditioning it.

And now the tolerance for load is even lower. So it is strengthening, but it is also exposing it to a load that is correct and adaptable. There's a lot of concepts about what the body can adapt to. Wolf's Law is commonly kind of cited as it's for bones, but it applies to soft tissue as well. If you apply a load to something, it will become stronger if the load is appropriate. So this is kind of in the running analogy for it. If you say you're a 10 minute mile pace aerobic runner, if you do an interval session every week, that's maybe at eight minute pace for a few reps, you get faster because you're applying a load to your body that it's not used to, that it is able to adapt to.

Overuse injuries, you're applying too much load. It can't adapt. It just breaks down. So you don't really want to rest it more than you have to, unless there's something else going on. Like the bone spur case, if there is an actual fracture within that, like say the plantar fascia actually pulls the chunk of bone off, then yeah, you need to rest bone stuff. Don't mess with it. Rest it. But for almost all soft tissue stuff, you need to be strengthening and you need to be loading it. But you need someone, frankly, you need someone to guide you on how to do that correctly. So you don't just break it down more.

Yeah. Yeah, of course. I mean, if you're dealing with significant pain, don't try to self-treat it. I do think that runners need to learn how to self-treat minor injuries. Yeah, totally. But if you're dealing with any kind of substantial pain, assuming it is a minor case of plantar fasciitis, is there anything runners can do at home to kind of, you know, let it rest, but then also apply some kinds of appropriate loads? Yeah, actually, the thing that comes to mind is something not to do that a lot of people do, and that's stretching it. I would not stretch it. Plantar fasciitis, inflammation of the fascia, sometimes can be an overstretch injury.

So if you're stretching an overstretch injury, that's not great. It'll feel like you, it will really feel like you want to stretch it because it's stiff. Don't stretch it. At least not for a long time. Other than that, general kind of single foot strengthening stuff works really well. Honestly, and maybe this is horrible and put me out of business, Dr. Google has a lot of good stuff on just straight plantar fasciitis. It's a fairly well-known condition and fairly straightforward to treat if it is plantar fasciitis. So like, you can slice it a ton of different ways, foot strengthening, up the kinetic chain strengthening, so calf and hip is really high payoff, and then loading it heavy, but appropriately.

Yeah, I mean, it all comes down to this like appropriate loading of the tissue. And it's also funny to me, like no matter what injury we're talking about, the treatment is somewhat similar, you know, like for these kinds of soft tissue running injuries. You know, of course, there's edge cases, there's stress fractures, there's all kinds of that stuff. But the application of appropriate load without really bothering the tissue is tried and true number one treatment approach for most injuries. I love that you told us what not to do, stretching it. And I feel like one of the things that most runners often do is they go and they get that nighttime splint spook thing.

Oh, the sock, yeah. Yeah, the weird sock that keeps your foot in that dorsiflexed position with your toes. You know, kind of pointing up towards the ceiling if you're lying on your back. So I'm going to assume that you do not recommend that. I don't love it. Man, you're going to get so many. Sorry. Well, if you don't have a point of view, you're not really saying anything at all. That's a good point. Yeah, no, I have plenty of points of view. I don't love it. I think both for true plantar fasciitis and fake or nerve plantar fasciitis, it can be pretty aggravating. But the problem is it can feel pretty good in the moment.

And then like you feel like you're being productive because it's like, oh, I'm stretching it out. It feels tight. But in reality, it's just prolonging it. I have not found a single case where I would recommend it. Very interesting. Okay. All right. Well, we can move on from the nighttime boot. I guess that's not the move. Not so much. Now, if we're not supposed to stretch it, can we mobilize it in other ways? I mean, it sounds like the strength work is hands down a good idea, provided it doesn't bother you. You know, again, under the direction of a PT or a good strength coach, if your pain is a little bit more severe.

But how can we mobilize the tissue? I mean, is this something where, you know, rolling that golf ball under your desk, standing up on it, is that too aggressive or is that something that you recommend? Yeah, that's a great question. For chronic cases, I would say soft tissue mobilization is more productive. Chronic being more than, let's say, a couple months. For acute cases, like you ran a hundred miler and now a week later you're in agonizing pain, I wouldn't. And only because creating that pressure may just create the inflammation cycle more. But for chronic cases, a lot of times it is that pain signaling error, almost, where the signal is stuck in a loop.

And if you have, again, like a novel stimulus of making your brain pay attention to your foot by virtue of, you know, a little bit of pain with a golf ball, it can help break that loop. But for acute cases, I wouldn't really recommend it. The thing you can do otherwise, other than mobility and strengthening, really, is you can get in tissues that are not at the plantar fascia. So most people find that when their plantar fascia is painful, they're tight, their calves get really tight because it's trying to make up for it. So working that out can help. And frankly, it just feels productive. So it's a good kind of mental thing to do as well.

Yeah, that's another thing I wanted to ask you about, which is the stretching of the calf and the soleus often is really helpful with symptoms, but you're not really working on any of the tissues that are actually affected. Is that an example where stretching is going to be OK and might provide some relief? Yeah, stretching things that are not overstretched can work. Again, and I know we're foreshadowing here, if it's true plantar fasciitis, if it's nerve plantar fasciitis, it'll really piss it off. But for true plantar fasciitis, if you're creating flexibility, so flexibility is passive stretch, mobility is what you can do actively.

If you're creating flexibility in the areas around the plantar fascia, again, it can kind of help share bending load a little bit better. OK, now you have mentioned this nerve-related plantar fasciitis, and I'd love to differentiate between the two. But first, what percentage of people who have plantar fasciitis pain might have this more nerve, quote-unquote, fake plantar fasciitis? That is a question that research has not answered yet. Anecdotally, I will say there is a selection bias for what I've seen. So my patient population is ultra-run trail runners who usually have seen a few people or they have a long history of pain, and nothing's worked yet.

Most people have tried other rehab for plantar fasciitis and failed it. For me, 80% of my plantar fasciitis, quote-unquote, cases are nerve-mediated, and that's why it hasn't worked. So what exactly is it? Yeah, there's a few different ways to slice it. So the kind of general term for it is nerve irritation, which sounds very throwaway, but there's different branches of that. Usually the irritation is actually in the nerve root in the spine. And this is where it sounds really woo-woo, because I'm like, there's a problem in your spine that's affecting your foot. If there is nerve irritation there, the whole line that that nerve supplies, so nerves kind of go down into your leg kind of like a big rope, that whole line is more able to be irritated with a lower amount of load or stress to the nerve.

So for the foot, it's kind of like the end of the rope. So let's say the irritation's up there, and now the rope can't really move. And all of a sudden you're, say, in a sock that's stretching it a ton. Nerves really don't like stretching, so it can hurt in the foot. But overall, without getting really into neurodynamics and weird stuff like that, it's irritation in a nerve. It's not necessarily nerve damage. So it sounds scary, but it's actually a way better boat to be in. Those cases respond much quicker than a true plantar fasciitis, because nerves, like their sensation ability can change so much faster than an actual fascia injury.

Might you have this type of issue instead of your tried and true classic plantar fasciitis if you're also experiencing like SI joint issues or that, you know, that kind of sacroiliac nerve-related pain on like one side of your pelvis that is often very common among runners? Yeah, there's several kind of, if I'm taking a history of someone having a consult and just getting an idea of their story, there's a few things like that that pop out if there's pre-existing low back or SI joint stuff. If they've, say they have quote-unquote plantar fasciitis, but like two months ago they had piriformis pain, and like last year they had IT band syndrome.

If there's weird like concurrent injuries like that, there's usually a common link, and that means it's usually nerve-mediated. There's always, like you said, fringe examples. And then if it changes sides, that is like the biggest flag. Or if it's on both sides at the same time. But if it changes sides, that is super weird. Like if you blow out your right knee, your left knee is never going to hurt. If you tear your plantar fascia on your right foot, your left foot is never going to hurt. But nerves, since they originate in the spine, they're very close together. So if there is a nerve irritation, it can send pain to either side or both, and it can feel like it switches randomly.

So that's like a huge flag for a might-be nerve. Yeah, it seems like this is definitely maybe easier to treat and doesn't have the potential to become chronic, but also—or does it? I would argue nerve plantar fasciitis can be more chronic. Nerves, they're great, and they also suck. So their irritability threshold, if it is lower, like less load pisses it off, rather than like a healthy individual, that can become pretty chronic if you're not actually dealing with the source of the problem, because there's no like natural history that takes it away. Natural history is just the body's way of healing itself.

That's the term that we use. Whereas if it's a fascia problem, there's already other processes that kind of take care of itself over a certain period of time that you would expect. But nerve stuff doesn't really do that as much. So what is the origin of something like this? Because, you know, it makes sense that if you apply too much load, you could have a soft tissue failing. It gets irritated. It gets inflamed. But how do you do that to a nerve? What's the actual mechanism of what's going on when we do too much volume too quickly? Yeah, it's very much the same. So it is a load problem. But what people don't necessarily realize is that nerves swell a little bit if they're irritated.

So the most common things, almost all nerve stuff originates in the low back. There are always examples otherwise. But the common things are if you have a disc problem, so the kind of squishy stuff between each vertebra, that abuts, it kind of pushes on the nerve root. Or if the hole where the nerve root kind of comes out of, the hole is made of the vertebra above and below the nerve root. If that hole is smaller, which happens as we age, that hole becomes smaller. It's arthritis technically, but it's just age-related changes. If that becomes smaller, or if the nerve is swollen and taking up more space in the hole, or both, you get in this cycle where it just, it keeps pinching it.

And then it becomes irritated. And then the nerve swells more. And then you pinch it easier. And it just like cascades like that pretty quickly. Sounds like that's something I definitely want to avoid. Yeah, yeah. I mean, it's not fun. I've had injuries that kind of fall into that category. It's really irritating. Yeah, I've had some like SI joint, nerve-related discomfort. I don't know if I'd call it a full-blown, quote-unquote, injury. But it's a little bit of an unsettling feeling. You're not quite sure what's going on, what actually hurts. Because it's a very different type of feeling than a muscle or a tendon or a ligament having some pain.

So, yeah, that's definitely something. Go see a specialist. You don't want to mess around with those kinds of nerve-related issues. So, Mandy, what did I miss about plantar fasciitis? I feel like we talked about causes. We talked about all kinds of different prevention and treatment options. First line of defense is strength and mobility. Shoes definitely contribute here. But really, it's a load management issue. And if our weak link is our feet, then that's certainly going to be one of those links that break. But any other aspect of this injury or dimension of prevention or treatment that we didn't cover that you wanted to get to?

Yeah, I think we may have talked about this on the podcast that I hosted with you. But there's a general rule of thumb that I give my patients of if something isn't working over a span of weeks, like you're treating something and it's not working, then you're missing a piece of the puzzle. So, I want to put that out there because a lot of the patients that I have seen have tried a certain type of treatment for a long time and it doesn't work and they're still stuck on it. So, I think just general blanket injury advice. If it's not working, something needs to change. Same thing as running. If your training is not making you faster, something needs to change.

But I don't want people to keep getting in this loop. I would rather, you know, people deal with their injury quickly and get back to running. But plantar fasciitis especially, it just seems like one that sticks around unless you get it right. Yeah, I mean, that's great advice. Not just for this injury or any injury. That's life advice right there. Yeah, what's the Einstein quote? It's like, insanity is a thing doing over and over and no change. Something like that. Yeah, doing the same thing over and over again and expecting a different result. Exactly. Yes, yes. Well, Mandy, where can folks follow up with you if they have a specific question, follow you on social media?

Do you have a website? Yeah, so I work at Performance Place. We're a clinic in Southern California, but we do telehealth. So, I actually, I work with athletes around the U.S. and help them out with things like this over telehealth, which seems crazy. But it's a treat for me. So, we have a really big YouTube channel. So, there's actually a lot of information. If you do want to try and use Dr. Google to treat yourself, we have a whole ton of videos on information about these sorts of things. So, you can just look up Performance Place Sports Care on YouTube. Or, probably in the show notes, there's a link to talk to me directly if you just want some advice or need some one-on-one help.

Awesome. I'll have some resources in the show notes so people can find you. Mandy, appreciate you. Thank you. Yeah, thanks for having me on. It was a blast. If anything in today's episode resonated with you, visit the link in your podcast player. There, you'll find any free resource that we mentioned in the show, any guest links, and a link for a free discovery call with us. We're licensed to work with our outdoor active people via telehealth across many states in the U.S. at this point. In fact, we cover almost half of the population in the U.S., and we add more states every year. Thanks for listening.

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