Plantar Fasciitis and All Its Glory – Part 2

Part 2

Plantar Fascia -photo credit: visible body
In the previous post (Plantar Fasciitis… and All Its Glory-Part 1) I covered the biomechanics which can be responsible for causing plantar fasciitis. This included certain restrictions within musculature and joints which can cause overloading of the plantar fascia. This, in my opinion, is the actual reason for plantar fasciitis. In this post, I will talk about the strength side of plantar fasciitis which can also be a part of poor foot biomechanics and contribute to the pathology. 

In order to get a clear picture of the plantar fascia and its relation to foot mechanics, it is important to know its composition. The plantar fascia is a tendinous sheath. In other words, it is a dense fibrous structure with hardly any flexibility. This means that all though it is strong and durable, it does not have the ability to stretch like a muscle. This inability to stretch is what makes it very good at its job but also puts it at risk for injury if other supporting structures are not doing their job (aka muscles of the foot). 

What weakness are we talking about? Foot weakness can be narrowed down to two issues. The first of these is inactivity. We as a population do not move as much as we should. Our bodies are created to move and move a lot. Generally speaking, we as a population spend the majority of our time sitting;  not walking, running, jumping and being physically active. This inactivity leads to weakness in our entire body, including our feet.  The second issue is our footwear. Modern-day footwear is very supportive. This is a good thing, right? Absolutely not, and I’ll give you an analogy to prove it. 

Suppose we lived in a world where we never walked but rode around on little powered vehicles. In fact, we never got off these vehicles except for maybe a couple times a day. In other words, we had them supporting us all day and never had to use our own strength to walk. Well, suppose we did this from an early age. Our entire life, we used these little vehicles to ride on, rarely getting off because we could do everything we needed to while on them. I would assume you understand that our legs would be very weak and incapable of supporting the weight of our bodies. Now, replace “little powered vehicle” with the word shoe and now you understand why our feet are so weak. Highly supportive shoes, which we wear the majority of our day, do not allow our feet to use their own natural strength to support themselves. And since we use shoes from a very early age, our feet fully develop with the inability to support themselves.  

Now, this may raise a few questions about why some people develop foot issues and others do not. This is a hard question to answer since every person’s circumstances are different but as a general rule, we can look back at foot mechanics and strength to determine why someone has an issue or not. If your foot and ankle flexibility is good and your foot strength is on par, chances are that you will not have any issues. If one of these factors is lacking, you have a higher probability of developing a problem.

Activity is also a factor in having plantar fasciitis. Let us reference our analogy once again. If we are riding around on our little vehicle all the time, our legs are very weak. The few times we get off per day to do tasks puts stress on our unconditioned legs which is fine if that is all we do. Now say someone has a revelation and decides to go cold turkey and start walking everywhere. His very atrophied legs are not going to be able to take these new stresses and will develop joint and muscles injuries. It is like telling a person who has never run to go run a marathon. Injuries will happen.

The same is true with our current lifestyles. We tend to be fairly sedentary with limited time spent on our feet. We then have a day where we walk 5 miles and then wonder why we develop a foot issue. It is too much stress for the conditioning of our feet on top of poor mechanics probably being present.

So why do active people get plantar fasciitis? 

Not to sound like a broken record but, once again, I will reference mobility and strength. Even very active people can have foot weakness and poor foot/ ankle mechanics. In Part 1 we talked about dorsiflexion (the motion of bringing your toes toward your shin) and its importance. I’ve known many long-distance runners who have problems with plantar fasciitis, obviously not because they are inactive, but because of poor ability to dorsiflex their ankle due to chronically tight calf muscles, thus putting too much stress on the plantar fascia. 

So, obviously, plantar fasciitis can affect anyone which brings us to our final subject. Shoes. Modern-day shoes are made in such a way that creates the utmost support and comfort. Truly, shoe manufacturers have mastered this. However, this support is a huge culprit when it comes to foot weakness. Once again, if we are walking around for the majority of our lives with ultra-supportive footwear, our feet are not going to be able to support themselves. As time goes on, our feet become weaker and weaker leading to more support being needed (aka arch supports and custom orthotics). It is only a downward cycle which will feed itself. 

If you will, partake in a little experiment for me. Go walk around in your most comfortable shoes. I assume this is a pair of running or tennis shoes which have a good amount of arch support and heel padding. Notice HOW you walk. You probably have a decent amount of heal strike followed by rolling on to your forefoot and then onto your toes. Okay, now take your shoes off and walk with bare feet. Notice how different you walk. That heal strike is probably a lot more gentle and your toes should raise up as you put your foot down allowing for more pressure on your forefoot. A bit different than with shoes huh? This is the reason why ultra-supportive shoes are not good for your feet. They actually force your feet to walk or run in an unnatural way. This conditions the feet to have poor mechanics and truly alters the way our body moves. 

So what can we do?

I believe that natural is always the better option. In the perfect world, we would all walk around in bare feet. This is obviously not going to happen and should not happen for a couple reasons. First, we need footwear to protect our feet from our environment (concrete is not foot friendly). Second, and more important, our feet are very deconditioned and if we all went cold turkey we would certainly end up injuring our feet and causing more harm. 

The answer to this is to start re-conditioning our feet. Start by walking barefoot for a few minutes per day and slowly progress by increasing the amount of time spent barefoot.  If walking on hard floors is uncomfortable, start by walking in your backyard, using the soft grass and dirt as padding. Certainly, if you have or have had plantar fasciitis you will know how uncomfortable it is to walk barefoot. If plantar fasciitis is present, this re-conditioning will need to be preceded and paired with proper mobilization and mechanics of the foot, as I previously wrote about, in order to fully help the pain.  Once you have the correct function of your feet, walking barefoot should actually feel normal and become part of our everyday norm.

Once strength is gained back in the feet and you are able to walk barefoot with ease (which can take weeks), our footwear can be changed to help maintain proper foot mechanics and utilize our foot’s natural supportive abilities. Footwear should allow for our feet to function in a natural way; not do the opposite and change our feet to the parameters of the shoe. I will premise this by saying that every foot is different and you will need to find what is best for you. However, there are some characteristics that are important to look for in good shoes.  

  • Low Heal Drop – This is the height of the heal in the shoe. Usually, this is fairly high in running shoes to create padding when the heal strikes. As we said before, this is unnatural for the foot and should not be in a shoe we wear for good form. Look for a shoe with little to no drop. 
  • Wide Toe Box – The toe box is the part of the shoe where your toes rest and should be wide enough for your toes to spread out when your foot lands. This toe and forefoot “spreading” is a natural function of the foot and important to correct foot mechanics. Most shoes are too narrow and do not let this happen. 
  • Average Arch Support – Just because there is a huge arch support in a shoe does not mean that it is good. If the foot is operating correctly the arch should support itself. Having an average height arch support will give gentle support while still allowing the foot to function correctly. 

Once the proper strength, along with foot mechanics, is gained, plantar fasciitis should be eliminated. Of course there are always circumstances where the condition can prevail, but certainly, this will give the foot the best chance at fully healing and staying that way.

If you would like to delve more into the foot strengthening, please visit this resource. They are awesome!

Also, If you are interested in shoes which have all of these characteristics visit my Footwear resource page for my recommendation

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Plantar Fasciitis…and All Its Glory

Part 1


Plantar fasciitis is a very common pathology which seems to plague a diverse population of people. I have seen it everywhere from high-performance runners, putting 50 miles per week on their feet,  to your average individual who sits at a computer most of their day. To say that it only affects certain people because of one specific reason underplays this pathology’s complexity. For this reason, I would like to attempt to break down the involved anatomy in order to clarify what structures are involved. Then, we will adventure into how biomechanics plays an important roll in this problem. Lastly, I will attempt to give a few tips on how to treat the issue.

Before we get into the well thought out, stringent plan that I just put before you, let us ignore it for a second and touch on a condition that plantar fasciitis can be mistaken for.

Bone Spurs

Bone spurs are probably the most commonly mistaken pathology when it comes to diagnosing plantar fasciitis. The two conditions can present with very common symptoms and, thus, misdiagnosed. The only way bone spurs can be truly diagnosed is with x-ray, so commonly plantar fasciitis is misdiagnosed first when an x-ray has not been done but pain symptoms are present. If symptoms of plantar fasciitis do not improve after standard treatment, usually diagnostic testing will then be done to see if there are further issues (such as bone spurs). I will note that both plantar fasciitis and bone spurs can be present at the same time making diagnosis even more tricky. Also, bone spurs can actually be a result of chronic plantar fasciitis making these two conditions even more interconnected. You can now understand why the two are mistaken easily.

Okay now that we have that out of the way, let us get to the good stuff.

Plantar Fascia Anatomy
Plantar Fascia   Photo Credit: Visible Body
The Plantar Fascia is a strong sheath of dense tissue on the bottom (or plantar) of the foot. It originates from the tuberosity of the calcaneus (front of the heel bone) and fans out over the bottom of the foot towards the toes. It is responsible for creating support for the arch and absorbing shock as we run, walk, jump and generally live out our daily mischief. It works in unison with muscles of the calf and foot to create the ability to move in a smooth effortless motion. Without this unique structure, the foot would not have the support it needs to maintain its arch and function as the efficient spring that it mimics. This would lead to a host of other joint alterations which we will not get into.  Generally speaking, you really need your plantar fascia.

Now that we, as I like to say, have our anatomy doctorate after that 1-minute lesson, let us continue on.

So what is plantar fasciitis and why does it occur?

True plantar fasciitis by definition is the inflammation of the plantar fascia. This occurs due to minor tearing of the plantar fascia and the build-up of scar tissue as a result of these tears. This causes pain on the bottom of the foot, usually where the heal and arch come together. It can present in other parts of the arch and bottom of the foot but those areas are not as common. The pain is usually described as a burning or tearing sensation. This occurs because the sensation felt is actually the re-tearing of the newly formed scar tissue. Pain is usually worse in the morning with symptoms improving as the day goes on. This is because the time spent off one’s feet while sleeping allows for minor healing to happen. However, once weight is put back on the feet in the morning, that freshly laid down scar tissue gets re-torn and the process begins again. It is a vicious cycle which can be tough to break. When this has occurred long enough, actual tearing can occur at the periosteum (where the plantar fascia actually connects to the calcaneus). This is usually when the pain becomes much worse and inflammation increases. 

It is important to realize that the treatment of plantar fasciitis is usually not done correctly. The common treatment of NSAIDS, ice, steroid injections, and stretching are not going to correct the reason why this occurred in the first place. They may help with the symptoms but the chances of the pain returning is high and the likelihood of a chronic issue developing is very high. The realization needs to be made that these kinds of treatments are simply a way of treating symptoms; not the root cause. In other words, we always need to find the cause of why this happened in the first place, not just treat the pain.

The root cause of plantar fasciitis is ankle mobility and great toe biomechanics. This involves the muscles of the lower leg and foot. As we walk, the foot and ankle need to be able to move freely in order to operate correctly. This freedom allows for proper stride length when we walk. If there is not enough flexibility in the ankle and foot, these mechanics can be altered significantly. First, if the great toe does not have the ability to extend (bend back), the entire motion of one’s stride is disrupted and the foot is forced into an altered motion. This presents with the great toe using more with a side to side motion and not using its natural ability to extend. When this occurs, the foot and ankle compensate with either eversion (turning out) or inversion (turning in). This compensation, in turn, puts increased load on the plantar fascia. 

Adding to this, the ankle needs to have enough ability to dorsiflex (the motion done to bring the toes toward the shin) to function correctly. Without this ability, the mechanics of walking are changed by forcing the heal to come off the ground prematurely. This causes increased pressure to be put on the plantar fascia leading to overloading, overuse, and potential injury. THIS is what causes plantar fasciitis. 

So what do we treat? The primary theory of treatment as far as mobility is concerned relies on increased dorsiflexion for the ankle and increased extension for the great toe. By doing this we can decrease the overloading of the plantar fascia which in turn will  break the cycle of re-injury and allow it to heal properly

 

Tibialis Posterior Photo Credit: Visible Body
The primary structure that is involved with ankle motion regarding plantar fasciitis is the tibialis posterior muscle. Yes, there are plenty of structures that limit dorsiflexion and should also be addressed, but this muscle in my experience is a primary culprit which causes chronic misalignment of the foot and the inability to have a correct stride due to improper dorsiflexion. When this happens, extra load is then put onto the plantar fascia; creating the potential for overuse and injury. On top of it limiting dorsiflexion it can also lock the foot into inversion which coincides with the inability of the great toe to extend. This muscle can also mimic plantar fasciitis by causing inflammation on the inside of the arch by the calcaneus. As the tibialis posterior courses around the ankle, it passes underneath the flexor retinaculum which can become adhered and cause inflammation and discomfort. Coincidentally, this location is where most plantar fasciitis symptoms occur.  By treating the tibialis posterior your truly allowing the ankle and foot to move correctly and in the process, taking pressure off of the plantar fascia which will allow it to work less and begin to heal.

 

Flexor Hallucis Brevis Photo Credit: Visible Bod
The next important structure is the flexor hallucis brevis. This muscle contributes greatly to the inability of the great toe to extend. By treating this muscle we are, in effect, allowing the great toe to extend, and also the rest of the foot to function properly by not needing to invert (turn in) or evert (turn out) in compensation. Although a simple motion, being able to easily extend the great toe can greatly affect plantar fasciitis by taking the load off the arch of the foot.

This muscle is also located very close to and runs parallel to the plantar fascia. Any shortening or adhesive tissue laid down in this area can affect the flexor hallucis brevis and limit its ability to extend. 

The flexor digitorum brevis and longus can also be involved due to their close proximity to the plantar fascia in the bottom of the foot. When these muscles are involved, it is more because of overuse due to the poor foot mechanics we have just discussed than being a root cause.  

Plantar Fasciitis Stretch

In order to truly gain lasting increased dorsiflexion of the ankle and thus recreate proper foot mechanics, we must incorporate a stretch which will pinpoint the distal part of the calf. If we look at the anatomy, the gastrocnemius muscle crosses the knee and the ankle joint. Due to its unique anatomy, it limits the ability of the ankle to dorsiflex completely when the knee is straightened due to Achilles tendon tension. In other words, any stretch with dorsiflexion as our primary goal needs to eliminate the gastrocnemius’ tension in order to fully stretch the rest of the structures to their full length. This can be done by simply bending the knee when we stretch the calf. Below is a demonstration of a correct stretch to increase dorsiflexion and help plantar fasciitis.

 

Plantar Fasciitis Stretch
  1. Bend the knee to slacken the gastrocnemius muscle.
  2. Place your foot on the edge of a chair or bench with pressure placed on the forefoot.
  3. Stretch the calf by allowing your heal to drop toward the floor as you lean your body forward.
  4. To deepen the stretch, rest your elbow on your knee in order to use your body weight to force the heal downward.
  5. Hold the stretch for 15-30 seconds in order to allow for maximum release.

It is important to note that after all of these structures are treated, plantar fasciitis takes some time to heal once the foot and ankle is working properly. This is especially true if this has developed into a chronic issue over a long period of time where the periosteum has begun to pull away from the calcaneus as mentioned before. However, this can still heal if given the right environment and functionality.

 

For more on this topic, read  Plantar Fasciitis… and All Its Glory- Part 2.


 

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