Heel Pain in Runners

Heel Pain in Runners – More than Just Plantar Fasciitis!

Heel Pain in Runners - More than Just Plantar Fasciitis!

Heel Pain is a common overuse injury in recreational runners. There are multiple causes of heel pain in runners and the most common cause is plantar fasciitis or plantar fasciopathy. Plantar fasciopathy is an appropriate description since this condition is not inflammatory. Risk factors include limited ankle dorsiflexion, increased body mass index, standing for prolonged periods of time, and a recent increase in training volume or speed in runners. Plantar fasciitis is common in both the athletic population and sedentary people. With appropriate treatment, 80% of patients with plantar fasciitis will improve within 12 months. The peak incidence is between the ages of 40 to 60.



The classic signs and symptoms of plantar fasciitis are pain to the medial tubercle at the insertion of the plantar aponeurosis, pain worse upon standing in the morning, and standing after long periods of inactivity. The incidence of Plantar Fasciitis in runners ranges from 4.5 to 10% and represents the third most frequently experience running-related musculoskeletal injury in this systematic review by Lopes et al. (2012)

The high incidence of PF in runners is not surprising, if one considers the role of the plantar fascia and the longitudinal arch, in the force absorption, associated with long-distance running.


Physical Examination:

On palpation, the patient will be tender to palpation on the proximal plantar fascial insertion at the anteromedial calcaneus. The windlass test is a useful test for this condition and is described  in the following video:

A positive result is heel pain reproduced by forced dorsiflexion of the toes at the metatarsophalangeal joints with the ankle stabilized. The windlass test has a specificity of 100% and a sensitivity of 32% as shown by De Garceau et al. (2003).


Differential Diagnosis:

There are multiple causes of chronic heel pain in runners and it is important to be aware of other pathologies in this area, as outlined in the picture below:Heel Pain in Runners

Key Differential diagnoses in the running population, include fat pad contusion in the heel, calcaneal fracture, and retrocalcaneal bursitis. Calcaneal fractures may present with localized tenderness and usually occurs after trauma or a spike in training volume or speed. Retrocalcaneal bursitis presents with insertional Achilles tendon discomfort and is located in a more posterior position. In the following 5-minute video, I will go more in-depth about the differential diagnosis:



In the case of uncertain diagnosis or when a patient presents with persistent heel pain, for more than 3 months or if symptoms are worsening, diagnostic imaging is recommended to confirm the diagnosis and to rule out other differentials.  As a therapist dealing with runners, it is important to be aware of the multiple causes of heel pain and key differential diagnosis, other than plantar fasciitis.

This blog article is taken from our Running Rehab - From Pain to Performance Online Course. To learn more about the management of running-related foot and ankle injuries, including plantar fasciitis, check our comprehensive online Running Rehab Course with access to all information on initial assessment to management of all running injuries.
If you would like to watch another free webinar about hip pain in runners, feel free to sign up below!

Thanks a lot for reading!

Benoy Mathew,

Lower Limb Specialist Physio

Creator (Running Rehab Course)



De Garceau D, Dean D, Requejo SM, Thordarson DB. The association between diagnosis of plantar fasciitis and Windlass test results. Foot & ankle international. 2003 Mar;24(3):251-5.

Lopes AD, Hespanhol LC, Yeung SS, Costa LO. What are the main running-related musculoskeletal injuries?. Sports medicine. 2012 Oct;42(10):891-905.



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10 Mistakes Why ACL Rehab Regularly Fails

10 Mistakes Why ACL Rehab Regularly Fails – Are You Making These Mistakes?

10 Mistakes Why ACL Rehab Regularly Fails - Are You Making These Mistakes?!

The aim of this blog is to summarize the key aspects why we may fail to achieve optimal results after ACL injury and/ or ACL reconstruction. Note that this summary is not meant to blame anyone. But just to make sure we can do better in the future.

10 Mistakes Why ACL Rehab Regularly Fails

1) Lack of clinically applicable guidelines

The first limitation we are currently dealing with is that there are  only a limited amount or there is a lack of clinically applicable guidelines for rehabilitation after ACL injury and ACL reconstruction. Some guidelines have been published but these guidelines remain very general and non-specific.

2) Gap between research and practice

Secondly, there is clearly a gap between what we know from research and what is typically done in clinical practice. This can be due to many reasons. For example for many of us physical therapists, it can be very challenging to keep up to date. Given the fact that a lot of research remains behind a paywall and that we often have minimal time to dig into the individual studies while working all day in the clinic. Our ACL Rehab online course might offer of course a good opportunity to get up to date again. Furthermore, as mentioned in my first points the research findings are often too non-specific to apply directly in clinical practice.

3) Most patients are not ready when RTS

A third important barrier to achieve optimal results of ACL injury is that a lot of patients are not ready when they return to sport. A lot of patients just return because they think they can return based on no test, no criteria or just based on time after injury or reconstruction. They often lack the physical, psychological and physiological capacities to return successfully to sport and performance. Hereby increasing the chance for a second ACL injury or other lower extremity injuries or reduced performance and lower quality of life.

4) No criteria-based progression

Number four is related to the previous point actually. A lot of therapists progress the athletes during the rehab continuum based on no criteria or criteria that might not be sufficient to deal with the demands of the following phase or return to sport. A rehab based on criteria based progressions can be very helpful to set clear goals and guide your exercise prescription according to the functional level of your patient.


5) Low quality rehab
Point 5 is also really essential and is focused on the quality of the rehabilitation. Without optimal rehab, you will not go for results you are achieving or you wish to achieve. However, we see that the rehab quality is often relatively poor in general (Dingenen et al. 2021), not for everyone, but in general. And even though it might be very difficult to define high-quality rehab, there are some key points to pay attention to. First, I think we often fail to achieve the full potential of an athlete. This can be due to the fact that there is in general not enough knowledge on all aspects that need to be trained. Or a lack of knowledge and skills to be able to target all the aspects that need to be addressed in your rehab program to return to sport and to return to performance. In addition, we are often not specific enough in our exercise prescription. A detailed exercise prescription is important to achieve desired training goals. One of the points here that we also addressed in this online course is the fact that often rehab is underloaded. We need to train hard and smart to get the results that we want to achieve, especially if you really want to return to sports performance.

6) Rehab is often rushed
In point six, I want to remind you that there is no need to rush during rehab.There should be no such things as skipping a few steps or phases to speed up recovery. However, in reality we often progress too quick during rehab. We know that both from a functional but also from a biological perspective, you need time to achieve the maximum potential after this kind of serious injuries. In my online course we use a combination of criteria focusing on the functional status of the patients in combination with time after injury and potentially the reconstruction as well.

The take-home message here from this sixth point is then: don't hurry. Be patient. Take your time to improve and to achieve your goals. From a patient perspective rehab after ACL injury can be very tough journey.

7) Poor compliance & motivation
Studies have shown that patient compliance with the rehab program and motivation to do rehab are key points in the prognosis of the outcome. You can have the best rehab program in the world but an exercise therapy program can only be effective when it's effectively done. Patients who have a lower compliance and patients who don't follow the program as it should be and patients who have a lower motivation to do the rehab typically have less optimal outcomes after ACL injury and reconstruction. We as physical therapists play a key role in motivating the patients and keeping the compliance as high as possible. For example, by setting realistic expectations, having an open communication with your patients, setting goals both on the short and on the long-term. Provide feedback and engage the patient in the rehab program. Remember to progress your program, make it challenging and don’t forget to have some fun.

8) Rehab is not targeted to the individual
A scooping review of Linda Truong et al in 2020 reported that a lot of psychological, social and contextual factors are present and influence all stages of recovery following a traumatic sports-related injury. A better understanding of these factors and both at the time of injury, but also throughout the whole rehab, could assist in optimizing injury management. Or to achieve the desired results of the patient for example promoting return to sports but also promotes long-term quality of life and long-term joint health. What we often do wrong is that we don't target the intervention enough to the individual person in front of us. No two rehabs will be exactly the same. Not only because of the physical impairments associated with ACL injury or reconstruction but also because of the psychological, social and contextual factors having a strong influence on the recovery process.

Take home messages here: treat the person not only the knee.

9) Poor communication
Across the whole rehab process, a clear and open communication between all stakeholders involved is crucial. Depending on the level and age of the athletes different persons can be involved. As first of course, we think about the person himself. We use a patient-centered approach. It's not you as a physical therapist who should be important. It's all about the patient. You're working over long period of time with this patient so take care that you build a strong patient therapist relationship. In addition, communication with the orthopedic surgeon in case of an operation with the physician, athletic trainer, parents, maybe strength and conditioning coaches in some cases; all other people potentially involved are important. Everyone involved in the process should be on the same line. All of them should know what the specific goals and phases are What the patient can do or not to do. Personally, I think we as a physical therapist can have a leading role in this whole process. However this might also change over time in some circumstances where for example strength and conditioning coaches might take over when heading the patient back to performance training and on-field retraining. Especially on a higher level, getting a player back to performance It's really teamwork. On a lower level, it can be that the physical therapist takes the lead across the whole rehab process.
Take home messages: Work together. Share decisions and use an open communication with a patient in the center.

10) Regulations & Limitations of the healthcare system
The regulations and limitations of the healthcare system also play a role. Depending on the county where you working in, the insurance company of the patient, or the financial situation of your patient. The number of physical therapy visits might vary substantially. Some patients might only have a few sessions to complete this whole rehab program, which can hamper the quality also of the program, of course. And this can also lead to more difficult progressions across all the levels that are needed to return to performance. In this case, patient education very clear exercise prescription formulation, and trying to achieve very high patient compliance with the program and motivation with the rehab program will be even more important.


If you click on this link you can also find a summary of these 10 points in the infographic I made for you. I hope you enjoy reading and can learn some lessons from these points to improve the quality of your rehab program. 


Thanks for reading!


40% of Physios are not confident to get patients back to cutting sports!

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