Running Distance, Ankle Eversion and Heel Pain: what the 4HAIE cohort tells us

Plain English summary of the study

A 1‑year prospective study of 1,206 people looked at who developed plantar fasciitis or plantar heel pain. The main findings were twofold: runners who logged more than 40 km per week had markedly higher odds of plantar fasciitis than runners who did 6, 20 km per week, and greater maximal ankle eversion during stance was associated with higher risk. The overall incidence was low, about 2.3 percent. The paper used three‑dimensional motion capture to measure biomechanics and weekly reporting to catch injuries. What we see In clinic we see a spectrum. Some people are the classic morning first‑step sore, others complain of sharp, localised heel pain after long runs or hard training blocks. Parents bring us sporty kids who tip into heel pain after adding extra sessions. Recreational joggers on the Central Coast, weekend trail runners and netball players who increase volume quickly are common. Exam findings range from tight calves and weak foot intrinsics, to a foot that spends too long on the inside edge during stance. Why it's happening Two drivers stand out from the study and match what we see on the ground: load and how the foot is exposed to load.

• Load: piling on weekly kilometres above a moderate volume raises risk. The study shows a clear jump in odds above 40 km per week compared with a 6, 20 km baseline. That fits with the load tolerance model. The tissues tolerate a steady, progressive load; spike the volume and the plantar fascia becomes the weak link. Sudden increases in training, back‑to‑back hard sessions, or adding extra sport without gradual build up all do the same thing.
• Loading pattern: greater maximal ankle eversion in stance was linked to higher risk. Eversion keeps the medial arch lower for longer, increasing tensile stress through the plantar fascia. It is not a single villain , strength, range, and timing elsewhere (calf, tibialis posterior, hip control) all influence that eversion and how loads are distributed.

What we test in clinic We focus on tests that change management, not just a tidy checklist.

• Load history and training diary. We map weekly km, hard vs easy sessions, sudden increases and other sports (netball, school sport). That tells us if load tolerance is the main issue.
• Gait and movement assessment. We watch running on the road or treadmill for foot progression angle, step rate, and how long the foot spends in pronation. The study used 3D motion capture to measure eversion; we use careful video gait analysis and, when needed, pressure mapping to quantify where the load sits under the foot.
• Strength testing. We assess calf strength, tibialis posterior and foot intrinsic strength. Weak calf or intrinsic strength changes how force is absorbed and transferred. We often use objective strength measures where appropriate to track progress.
• Palpation and functional tests. Pain location matters. Plantar fasciitis is typically local to the medial plantar heel or insertion. We check first step pain, pain after prolonged loading and a single‑leg heel raise as a crude tolerance test.

What actually changes it

Management is about raising tissue tolerance and shifting load, logically and slowly.

1. Immediate load management. If someone is above 40 km per week and symptomatic, we reduce or alter running volume. That might mean cutting weekly kilometres by 20 to 40 percent, swapping runs for cross‑training, or inserting more rest between hard sessions. The aim is to stop the flare while preserving base fitness.
2. Progressive loading for the calf and plantar fascia. A graded heavy slow resistance programme for the calf, paired with exercises to load the plantar fascia (controlled single‑leg calf raises, progressive step work), improves tissue capacity. We prescribe a structured plan and re‑test strength to guide progression.
3. Foot intrinsic training and load distribution. Short‑foot exercises and toe curl progressions help the foot control pronation and reduce strain on the plantar fascia. These are not quick fixes; we build them into weekly training.
4. Footwear and simple aids. Supportive shoes with a firmer heel counter and reasonable midsole can reduce excessive movement. Heel cups or silicone pads redistribute peak pressures and can reduce pain enough to allow rehabilitation. We do not recommend soft, unsupportive shoes when someone is load sensitive.
5. Targeted orthoses where indicated. For people with excessive eversion and persistent symptoms despite load management and strengthening, a contoured prescription orthosis can alter pressure patterns and reduce tensile load on the fascia. We only move to custom devices after gait assessment and pressure analysis to ensure the orthosis will change the relevant loading pattern.
6. Gait retraining, cautiously applied. The study suggests more toe‑out relative to the shank may be protective. Gait changes can reduce plantar load, but they also shift load to knees and hips if done poorly. When we retrain, it is specific, gradual and monitored with video or pressure metrics. What people get wrong

• Blaming one thing only. People want a single cause. Rarely is it only footwear or only pronation. Load history plus mechanics interact.
• Rest without a plan. Complete rest may remove pain but erodes tissue capacity. Without progressive loading the same pain returns when they resume training.
• Aggressive gait fixes. Drastically changing foot angle or cadence overnight can create new symptoms. We make small adjustments and reassess.
• Overreliance on stretching alone. Calf stretching helps some people, but stretching without strengthening and load control often leaves the plantar fascia vulnerable.
• Waiting too long. If pain limits training for more than 4 to 6 weeks, or if walking tolerance drops, the tissue deconditions. Earlier targeted intervention shortens recovery.

Practical examples for Central Coast runners and parents

• A weekend trail runner who pushes from 30 to 50 km a week over a three‑week block with two back‑to‑back long runs is at risk. We would reduce the long run, insert an extra recovery day, start calf loading twice weekly and use a heel pad temporarily.
• A teenage netballer who develops heel pain after a tournament may have both load spikes and weak foot intrinsics. We work with coaches to reduce match load, add intrinsic strengthening, and monitor return to play.

When to seek help from us Make an appointment if pain: is local to the plantar heel, hurts on first steps in the morning or after rest, increases with running volume, or stops you doing training you need for work or sport. Early assessment lets us map load tolerance, check biomechanics and start a targeted plan rather than a string of temporary fixes.

Study citation and how it fits our practice Jan Plesek, Joseph Hamill, Michal Burda, Steriani Elavsky, Jiri Skypala, Jan Urbaczka. Running Distance and Biomechanical Risk Factors for Plantar Fasciitis: A 1‑yr Prospective 4HAIE Cohort Study. Medicine and Science in Sports and Exercise. 2025 Apr 1. doi:10.1249/MSS.0000000000003617. PubMed: https://pubmed.ncbi.nlm.nih.gov/39629715/

The study reinforces what we use in clinic: track load carefully, look at how the foot spends time in eversion, and treat by raising tissue capacity while adjusting load. For many Central Coast runners and active families a modest, structured reduction in training plus a targeted strength programme and measured changes to footwear or orthoses gets people back to sport with less recurrence.