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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Isometrics in tendinopathy – a wonder weapon to decrease pain?

Isometrics in tendinopathy – a wonder weapon to decrease pain?

Are isometrics the wonder weapon to decrease pain in tendinopathy? In this blog we will discuss where the isometrics “trend” came from and what the evidence says about it!

In 2015 Dr. Ebonie Rio and colleagues started a bit of trend when they conducted a cross-over trial in 6 volleyball players with patellar tendinopathy. Their results were astonishing with all players experiencing an immediate decrease in pain from an average of 7/10 on the NRS to 0 with only one of the 6 reporting a remaining pain of 1– for at least 45 minutes after the isometric contractions.The protocol they used were 5 sets with 45 seconds contraction in a leg extension machine and an effort of 70% of the maximal voluntary effort. They also found that isometrcis were able to decrease cortical inhibition and an increase in strength of 19%.They compared the isometric intervention with an isotonic intervention and the effects seen in the isometric group could not be achieved in the isotonic group:

Figure from Rio et al. (2015)

The same authors did a follow up in-season study with jumping athlets two years later in which they compared an isometric programme and an isotonic programme to each other. In this study the results were a bit more heterogenous with both groups with a greater immediate pain decrease in the isometric group:

Figure from Rio et al. (2017)

A recent study by Holden et al. (2019) looked at the effect of isometrics in patellar tendinopathy as well and did not find any analgesic effect:

Holden et al. (2019)

However, a high percentage of women and a relative high average age is untypical for patellar tendinopathy, which is usually a disease of young jumping men. So it could be that the diagnosis of patellar tendinopathy was no correct in some cases.
Now while those two studies were conducted for patellar tendinopathy, let’s look if we can transfer these results to other tendons.
Looking at the Achilles tendon, Seth O’Neill and colleagues did a study in 2018 in which they had a group of patients with Achilles tendinopathy performing isometric contractions of the plantar flexors. They found no immediate pain relief nor improved motor output in patients with Achilles tendinopathy:

Figure from O'Neill et al. (2018)

A study of Riel et al. In the year 2018 examined the effects of isometrics, isotonics and walking on pain for plantar fasciitis. They found that there was no change in pain for any of the groups before to after the exercises:

Riel et al. (2019)

At last, Coombes et al. In the year 2016 looked at isometrics on lateral epicondylalgia. In their study, isometric contractions above the patients’ pain threshold actually increased their pain levels after the exercise, while isometric contractions below the patients’ pain threshold had no effect compared to a control group:

Figure from Coombes et al. (2016)

Another study from Stasinopoulos et al. In the year 2017 compared three exercise groups in the treatment of lateral epicondylalgia: One group performed eccentric training, another eccentric-concentric training and the third group combined eccentric-concentric training with isometrics. The authors argued that most grip activities require isometric contraction of the wrist flexors and extensors, so adding isometric exercises for LE makes absolute sense. They found that adding concentric led to superior results at pain, function and grip strength at 4 and 8 weeks:

Table from Stasinopoulos et al. (2017)

However, the follow up time of the study was rather short and should at least have been 12 weeks. On top of that the combined isometrics group performed a higher exercise volume with more time under tension which could explain the superior results.

So while isometrics are certainly no magic bullet, what role do they play in tendinopathy rehab? First of all,  isometrics are a great option to start exercising if everything else is too painful – and this is not only limited to tendinopathy but other conditions as well. Be aware that they must progress to isotonic exercises, because you want to recover muscle function over the full range of motion instead of just 1 angle. So move on as soon as a patient is able to tolerate isotonic loads.
What can be derived from all of those studies is that isometrics do seem to work really well in some subjects and can actually make things worse in other subjects. To keep it simple, give them a try with the patient in front of you and if they respond favourably, keep doing them, if they don’t move on.
While 45 minutes of pain relief might not be a goal that is important in the average patient, this might be useful for athletes as a warm-up to decrease pain during the ensuing exercise session or competition. Isometrics are also less tiring for athletes in-season as they are less tiring than isotonic exercises. One can surely argue if it is desirable to achieve short-term pain reduction in order to load a painful tendon during sporting activities and if this might actually lead to detrimental effects.

Alright, this was our blog on isometrics for tendinopathy. If you were surprised by the results, you will love our blog on 7 facts about tendinopathy you didn’t know! Thanks so much for reading. 



Coombes BK, Wiebusch M, Heales L, Stephenson A, Vicenzino B. Isometric exercise above but not below an individual’s pain threshold influences pain perception in people with lateral Epicondylalgia. The Clinical journal of pain. 2016 Dec 1;32(12):1069-75.

Holden S, Lyng K, Graven-Nielsen T, Riel H, Olesen JL, Larsen LH, Rathleff MS. Isometric exercise and pain in patellar tendinopathy: A randomized crossover trial. Journal of Science and Medicine in Sport. 2020 Mar 1;23(3):208-14.

O’Neill S, Radia J, Bird K, Rathleff MS, Bandholm T, Jorgensen M, Thorborg K. Acute sensory and motor response to 45-S heavy isometric holds for the plantar flexors in patients with Achilles tendinopathy. Knee Surgery, Sports Traumatology, Arthroscopy. 2019 Sep 1;27(9):2765-73.

Rio E, Kidgell D, Purdam C, Gaida J, Moseley GL, Pearce AJ, Cook J. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. British journal of sports medicine. 2015 Oct 1;49(19):1277-83.

Rio E, Van Ark M, Docking S, Moseley GL, Kidgell D, Gaida JE, Van Den Akker-Scheek I, Zwerver J, Cook J. Isometric contractions are more analgesic than isotonic contractions for patellar tendon pain: an in-season randomized clinical trial. Clinical Journal of Sport Medicine. 2017 May 1;27(3):253-9.

Silbernagel KG, Vicenzino BT, Rathleff MS, Thorborg K. Isometric exercise for acute pain relief: is it relevant in tendinopathy management?.

Riel H, Vicenzino B, Jensen MB, Olesen JL, Holden S, Rathleff MS. The effect of isometric exercise on pain in individuals with plantar fasciopathy: a randomized crossover trial. Scandinavian journal of medicine & science in sports. 2018 Dec;28(12):2643-50.

Stasinopoulos D, Stasinopoulos I. Comparison of effects of eccentric training, eccentric-concentric training, and eccentric-concentric training combined with isometric contraction in the treatment of lateral elbow tendinopathy. Journal of Hand Therapy. 2017 Jan 1;30(1):13-9.


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