Plantar Fasciitis Treatment Guide

Copyright © 2014 by Chris Dukarski, PT, Beverly, MA 01915,
info@orthowellpt.com
All rights reserved. No part of this publication may be reproduced, distributed,
or transmitted in any form or by any means, including photocopying, recording,
or other electronic or mechanical methods, without the prior written permission
of the publisher, except in the case of brief quotations embodied in critical
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permission requests, write to the publisher, addressed “Attention: Permissions
Coordinator,” at the email address above.
DISCLAIMER:
The information provided in this book is designed to provide helpful information
on the subjects discussed. This book is not meant to be used, nor should it be
used, to diagnose or treat any medical condition. For diagnosis or treatment
of any medical problem, consult your own physician. The publisher and author
are not responsible for any specific medical or health needs that may require
supervision by a licensed healthcare practitioner, and thus they are not liable for
any consequences from any recommendation, to any person reading or following
the information in this book.

| 3
Table of Contents
Introduction 5
Passion to Learn 7
The Evidence 9
The Right Plan 19
So What Do You Do Next? 25
Appendix 27

| 5
INTRODUCTION
This book turned out to be a labor of love. It has arisen out of
my passion to discover the truth. The truth behind running as
well as the truth behind MY potential as a runner. I hope that you
find my commentary just as insightful as the research and as the
writing has been for me. The references in my paper are from
many on-line as well as off-line sources with an emphasis on the
wealth of information presented by the authors of The Science
of Sport. I have attempted to link all my references for your
convenience. You can access the links on the blog post on my
website at www.orthowellpt.com

PASSION TO LEARN
The more that I read about running, study running technique,
and learn from my own injuries, the more emboldened I am
to become a better runner. Who we consult to determine
the proper path in accomplishing our goals can be THE
determining factor in success or failure. It certainly has
been for me. Every running coach has a different level of
experience. Every physical therapist or trainer has a different
level of expertise. It is up to you to become the educated
consumer, the informed runner, and to advocate for your
own health and wellness. The mantra “you should train to
run, not run to train” will become all the more obvious as
you read this book. What I would like to do is to share my
“education”. I have read the running literature extensively
and wish to consolidate a wealth of information into this
book. I will present current thought and research behind the
evolution of running, the evolution of running shoes, and the
controversy and merits behind different running techniques. I
will summarize the findings of my research by highlighting key
points and strategies for unlocking your potential as a runner.
I have provided references and attached links to as much
information as possible. You can download a FREE copy of
this book from our website in order to activate the links. So
read on!!
| 7

| 9
THE EVIDENCE
In the United States, the running boom was triggered by the
1972 Olympic marathon victory by Frank Shorter. Running
shoe companies blossomed almost overnight. Until that point,
running shoes were very minimalist. The running boom brought
huge financial incentives to the running shoe industry. The
public, to this day, continues to be influenced by various shoe
companies assailing their product as the “next best thing”. By
some accounts, it was the motive of Nike to promote the heel
striking quality of its shoes and hence, the resulting heel strike
generation. This is part the fact, and part the conspiracy theory,
behind the true motives of running shoe companies.
Despite the fact that many studies have been done on
running, that running shoe “technology” has improved over
the years, and that the average runner is much more informed
about running than ever before, the frequency of running
injures has not changed in the past 30 years. The latest studies
suggest that anywhere between 40% and 70% of runners
are injured every year. Regarding the claims of “enhanced
performance”, “improved mechanics”, and “reduced injuries”
made by advocates of different running techniques, there

10 | The Formula For Running Painfree
is NO scientific research to validate ANY of these claims.
Unfortunately, there are pundits in the field who misrepresent
and/or misinterpret the research to validate their own causes.
So you need to be careful before drawing any premature
conclusions. The bottom line is: we need more research!
One of the arguments put forward is that when it comes
to running, we accept that ‘natural’ is best. However, to apply
this “logic” to any other human activity such as swimming,
tennis, dancing, or driving a car would sound totally strange,
but not so for running. This is the running paradox. From an
evolutionary standpoint, some anthropologists state that we
used to run to survive and that each person develops his or
her most comfortable, effective and efficient stride. Those
that were efficient survived and those that weren’t didn’t.
So to apply the logic that we have to be taught to serve a
tennis ball to we have to be taught how to run is the topic
of much debate. The perception that we all run “naturally”
is what advocates of Pose, Chi, and barefoot challenge. The
unfortunate consequence of the debate is that injury rates have

The Formula For Running Painfree | 11
stayed the same despite improved coaching, medical care, and
better running shoes. So where do you draw the line between
what is learned naturally and what is taught technically? That is
the million-dollar question.
So what does some of the research say regarding running
shoes? Interestingly, in 1989, Dr. Bernard Marti published a
paper in which he surveyed 4,358 runners who participated in
a 16km race and found that runners who ran in shoes costing
more than $95 actually were twice as likely to get injured
as runners who ran in shoes costing only $40. Of course it’s
impossible to conclude that “expensive shoes” cause injuries,
but it is certainly a point well taken by the minimalists in the
crowd. In addition, Clingham et al, 2008 found that runners
who ran in the most expensive shoes were just as likely to get
injured as those who ran in cheap shoes. In Kong et al, 2009,
the maximum vertical force and the maximum loading rate
were no different in new shoes versus old shoes. In another
study by Knapik et al, 2010, after controlling for physical fitness

and age, you do no better at reducing injury rates than if you
just give every runner the same shoe. So the idea of prescribing
certain running shoes for certain
motion control features is not
validated by research either.
In a 2008 research paper for
the British Journal of Sports
Medicine, Dr. Craig Richards
revealed that there are NO
evidence-based studies that
demonstrate that running
shoes make you less prone
to injury. Is it any wonder why
barefoot advocates find it easy
to condemn the 25 billion-dollar
running shoe industry?
So what is the rationale behind barefoot running? In Born
To Run, Chris McDougall advocates the Running Man theory
in which humans evolved to be long distance runners. He
points out that homo sapiens evolved the ability to thermo-
regulate via sweating and subsequently exploited their ability
to actually run down and exhaust large game i.e. persistence
hunting. Anthropologically, we are all born to run! From a
developmental standpoint, we tend to think of running as
automatic. We progress from crawling to walking to running. An
innate process, right? However, the day that we start wearing
shoes is the day that our feet start to change. D’Aout et al,
2009 shows that the “natural” shape and function of the foot
changes with chronic shoe wearing. This is a valid argument
for why it would be difficult to go from shoes to barefoot

running. Another argument is that individuals in barefoot
societies are barefoot ALL day. They have time to build the
proper foundation. During barefoot running, the ball of the foot
usually strikes the ground first and, due to the direct sensory
stimulation, immediately sends signals to the brain about
forces and surface irregularities. Take away this direct contact
by adding a cushioned substance and you immediately fool the
system into underestimating the impact.
Footwear manufacturers were well aware that the shock of
impact was the cause of running injuries. What they incorrectly
reasoned was that the way to decrease these forces was to
interpose a soft impact absorbing midsole between the foot
and the ground. In 1988, Hamill and Bates showed that as
running shoes lose their cushioning through wear and tear,
subjects improve foot control on testing. In one of their most
widely publicized studies, Robbins and Waked (1997) examined
the effect of advertising on landing impact. They concluded
that runners who THINK that they are receiving more shock
attenuation in their shoes actually impact harder and may be
predisposing themselves to injury. So how would a normally
shod runner transition to barefoot running? Very carefully. Once
again, you need to train to barefoot run, not barefoot run to
train. Is it possible to rehabilitate the weakened muscles of a
normally shod runner? In a study by Dr. Robbins (1987) he asked
17 normally shod recreational runners to gradually increase
barefoot activity both at home and outdoors over a period
of several weeks and to maintain barefoot activity for about
four months. The runners’ feet were examined, measured and
x-rayed at regular intervals to detect changes. Results showed
marked improvement in the anatomy and function of the arch.

The authors concluded that the normally shod foot is capable
of rehabilitation of foot musculature. So, yes, it is possible to
strengthen the foot.
As I dug deeper to find validation for proper foot striking, I
came across a study in the journal Nature by Harvard’s Daniel
Lieberman entitled “Foot strike patterns and collision forces in
habitually barefoot versus shod runners“. The study found that
habitually barefoot endurance runners most often land on the
forefoot, sometimes land with a flat foot (mid-foot strike) or,
less often, on the heel (rear-foot strike). In contrast, habitually
shod runners mostly rear-foot strike. His study found that
heel striking generates a significant impact transient, a nearly
instantaneous, large force. In forefoot striking, the collision of
the forefoot with the ground generates a very minimal impact
force with no impact transient. He also demonstrated that FF
striking decreases the eccentric load on the knee yet increases
the load at the ankle due to the plantar-flexed position of the
foot at impact. The author is also quick to confirm what others
have said in that there is “no evidence on injury prevention or
cause with heel or fore-foot striking”. Dr. Lieberman has a very

informative website to learn more. You can also watch a video
of Dr. Lieberman explaining and demonstrating the results of
his study. Barefoot running has inspired people like Barefoot
Ted and Michael Sander to share their enthusiasm as well.
So what about the Pose Technique and Chi Running? The
fundamental principles of Pose and Chi Running are taken
directly from their respective websites. Regarding the Pose
technique, “The Running Pose is a whole body pose, which
vertically aligns shoulders, hips and ankles with the support
leg, while standing on the ball of the foot. This creates an S-like
shape of the body. The runner then changes the pose from one
leg to the other by falling forward and allowing gravity to do
the work. The support foot is pulled from the ground to allow
the body to fall forward, while the other foot drops down freely,
in a change of support. ??This creates forward movement, with
the least cost (energy use), and the least effort. The end result
is faster race times, freer running and no more injuries!” The
idea behind Pose is that you create forward momentum by

falling forward like a pole, hence, using the pull of gravity. You
pull your foot from the ground as you begin to fall and then
let gravity return your foot to the ground. You move the legs
by PULLING up instead of DRIVING your legs forward. The
inventor of Pose, Dr. Romanov, states that the “fall and pull
is the essence of the running technique”. He demonstrates
the technique in this video and performs an analysis of Haile
Gebrselassie in this video.
Regarding the Chi Method, “The Chi Running program
teaches people biomechanically correct running form that is in
line with the laws of physics and with the ancient principles of
movement found in T’ai Chi. Chi Running technique is based
on the same principles and orientation as Yoga, Pilates, and
T’ai Chi: working with core muscles; integrating mind and
body; and focused on overall and long term performance and
well-being.” Here is a video on Chi Running. So what’s the
difference? Not much. Chi seems to be a re-packaging of Pose
philosophy with a “holistic” twist. They both advocate leaning
to engage the pull of gravity. Chi encourages a mid-foot strike
and Pose a forefoot OR mid-foot strike. Chi purports to be
more “holistic” and to rely more on your lean than the “fall and
pull” with Pose. Subtle differences, for sure.
So what does the research say about running technique?
Can you guess? There is NO research that correlates any
reduction or any increase in injury to a specific running
technique i.e. Pose, Chi, barefoot, or running shoes.
Anecdotally, you hear about elite African runners who grow
up barefoot, but choose to use running shoes. Abede Bikala
won the 1960 Olympic marathon running barefoot, but went
on to break the world record in 1964 with running shoes. If

the Pose and Chi methods are valid, then one would expect
that elite runners would tend to be more mid-foot or fore-foot
strikers. Studies actually show the OPPOSITE. In Hasegawa et
al., it was found that the vast majority (75%) of elite runners
land on their heels. So what happens if you try to change a
runner’s technique? In a study performed in Cape Town in
2002 on 20 runners, one week of intensive Pose training was
able to change a great deal of biomechanical variables. The
stride length, stride rate, knee joint angles and rate of loading
were all changed. What happened next is that more than half
of the runners broke down with calf muscle injury, Achilles
tendon strains and other injuries of the feet. As always, the
consumer has to be careful when they “buy” the product.
The biggest problem may not be the instruction as much as
the timing of implementation. How much time is required for
proper adaptation? An interesting side-note is that nobody
has yet done a study that changes a runner’s technique and
then tracks him or her over many months, or years, to see how
his or her injury rates change. Although this would be a very
difficult study to control due to all the potential variables, it
would certainly provide substantial evidence in the running
technique argument.

| 19
THE RIGHT PLAN
The idea that one single technique should be applied to
millions of genetically distinct runners may not be realistic.
What is realistic, is applying the sound fundamental arguments
made by advocates of the different running techniques as
well as from the science of running biomechanics. Much of
the running technique debate is based on the biomechanical
analysis of elite runners – and with good reason. The authors
of the Science of Sport blog eloquently state that “good
running technique is first learned naturally, then refined
through practice, and then subtle changes can be taught
through instruction on a case by case basis…Finding a BETTER
way to run is not the same as only ONE way to run.” An
informed coach or even an intuitive runner can modify his or
her technique in subtle ways. Just as in the golf swing, small
changes can produce noticeable results. So where do we begin
to make changes? There are so many factors that need to be
considered in answering this question such as the results of the
gait analysis, the presence of pain or injury, the experience of
the coach, the goals of the runner. What I attempted to do was
to list several key points for consideration based on the merits
of all the research that I have done up to this point.
1. We want to minimize the energy expenditure to create
the forward momentum of running. Therefore, it seems
advantageous to utilize the pull of gravity and the

concept of controlled falling as proposed in Pose and
Chi. We should keep our center of mass forward instead
of backward. Lean forward from your hips, not from the
shoulders. Remember that you fall like a pole with inertia
created at your center of mass i.e. hips/pelvis. If you are
suffering from low back pain, maybe you are running too
upright or even leaning backwards.
2. The foot strike is one of the most controversial issues. It
makes sense that if you lean forward and keep your center
of mass forward, that your forefoot would naturally land
directly under your body. Jumping straight up and down
is an example of keeping your center of mass directly over
your base of support.
3. If you strike your foot too far out in front of your body, you
are essentially “putting on the brakes”. Efficient running
should mean minimal shock at impact with minimal effort
to maintain our forward momentum i.e. inertia. As stated
earlier in the Lieberman study and video, heel pain or
knee pain may be the result of the 4x greater impact load
that occurs with heel striking. So try forefoot or mid-foot
striking instead.
4. Maybe we shouldn’t be concerned at all about how our feet
strike the ground. Increasing tension at impact may lead
to repetitive stress injury. One strategy would be to simply
have the runner land in a “relaxed” manner on whatever
part of his/her foot they choose, but to land more directly
under his/her center of mass. If you ‘reach’ for the landing,
then you will land more on the heel (unless you plantar flex,

which is a BAD idea!), whereas if you allow your foot to land
under the body, then you land more mid-foot. And maybe
that’s all we need to know about foot striking!
5. We need to focus more attention on foot strengthening
and proprioceptive (sensory) retraining. You can accomplish
this via intrinsic foot muscle training or simply walking
barefoot. As stated earlier, we CAN “strengthen our arches”.
6. You may want to consider switching to a lightweight shoe
that provides less cushioning and no arch support. Racing
flats are one example. Inquire at your local running shoe
store about minimalist running shoes like the Nike Free.
Start using these shoes at home, during your gym workouts
and then progress to a walk-run program.
7. We need to stress that the only research validated reason
for injury is improper training. A study by van Gent states
that shoes and running technique are factors, but the only
factor that is KNOWN to cause injury is training too long,
too hard, too soon, or a combinations of all three.
8. We need to become less quad dominant in order to
prevent the overuse that occurs from muscular imbalance.
We need to add posterior chain, hip strengthening, and
core stabilization exercises to our weekly routines. The link
between hip weakness and faulty biomechanics can be read
at Powers and Ferber.
9. Remember that over-striding causes deceleration. Instead,
you may want decrease your stride, increase your turnover
rate, and LEAN as advocated in Pose.

10. Keeping in mind all the stated research, the best approach
to running technique may be a mixed approach. Respected
running coach Vin Lananna has his runners perform part of
their workouts in bare feet and stated, “When my runners
train barefoot, they run faster and suffer fewer injuries”.
(Born to Run, p.169). Gerard Hartmann,PhD,PT, who treats
the best runners in the world, believes that the best injury-
prevention advice that he’s ever heard is to “run barefoot
on dewy grass three times per week”.(Born to Run, p.177)
11. In terms of barefoot training, being conservative is the key.
Per the authors of The Science of Sport, you may want to
start once a week at first. Limit the length of each run to
50% of your normal distance and break it up into intervals
of about 5% with walking in between. For example, if your
average run is 60 minutes, you should head out for 30
minutes, run for 2 minutes, walk for 1 minute, 10 times.
Gradually increase the running from there; if you feel your
feet, ankle and calves are up to it.
12. We need to realize that motion control shoes and foot
orthotics may only have to be a temporary solution. I have
fabricated custom foot orthotics for 20 years and can
unequivocally say that they can reduce tissue stress, re-
distribute pressure, and alleviate pain. The weaning away
process is determined by the time and effort that the
patient or runner puts into proper re-training.
13. Only change ONE variable at a time when modifying your
training. Do not change the distance, frequency, and /or
intensity simultaneously. Don’t get too excited. Make sound
and safe decisions.

14. Lastly, whatever change you implement, remember to
listen to your body, use sound training principles such as
not increasing your speed or distance by more than 10%
per week, allow adequate recovery time, and protect your
body-Your Temple-at all costs.
Good Luck!

| 25
SO WHAT DO
YOU DO NEXT?
If you need help, then give us a call! Our clinic specializes in
biomechanical evaluation. We can perform a thorough gait
and running analysis in the clinic. We can utilize videotaping to
analyze your technique frame-by-frame.
Check out our website at www.orthowellpt.com

| 27
APPENDIX
Suggested links
http://www.sportsscientists.com/
http://orthowellpt.com/
http://ajs.sagepub.com/content/16/3/285
http://www.ncbi.nlm.nih.gov/pubmed/17932096
http://bjsm.bmj.com/content/43/3/159.short
http://borntorun.org/
http://uahost.uantwerpen.be/funmorph/kris/
http://journals.lww.com/acsm-msse/abstract/1987/04000
/running_related_injury_prevention_through_barefoot
.14.aspx
http://www.nature.com/nature/journal/v463/n7280/full
/nature08723.html
http://www.barefootrunning.fas.harvard.edu/3Running
BeforeTheModernShoe.html

http://www.barefootted.com/index.php?q=/
http://posetech.com/
http://www.chirunning.com/
http://journals.lww.com/nsca-jscr/Abstract/2007/08000/Foot
_Strike_Patterns_of_Runners_At_the_15_Km_Point.40.aspx
http://journals.lww.com/acsm-msse/Abstract/2004/02000
/Reduced_Eccentric_Loading_of_the_Knee_with_the.15.aspx
http://sportsscientists.com/
http://www.jospt.org/issues/articleID.2396,type.1/article
_detail.asp
http://sph.sagepub.com/content/1/3/242.abstract
Suggested Videos
http://www.youtube.com/watch?v=_xUT5QLZDgk&
feature=player_embedded#%21
http://www.youtube.com/watch?v=JcX4CDhqo04&feature
=channel
http://www.youtube.com/watch?v=PUJhnEmx8Do

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