Plantar Fasciitis

X-ray normal human foot . Lateral view . Invert color style .

Treating Plantar Fasciitis or Heel Spurs

Plantar Fasciitis is commonly known as “heel spurs” even though it’s really not an accurate term. A heel spur is often the result of Plantar Fasciitis, but heel spurs have been seen in X-rays where the patient is completely asymptomatic. The pain can be very intense. It often starts as a painful ache in the bottom front of the heel and can progress to a debilitating level in a matter of weeks. The pain is usually most intense when you first stand up in the morning, and when you return to a standing position after sitting for 10-15 minutes or more.

Most people with heel spurs stand and/or walk on concrete for long periods of time. They are often wearing shoes with inadequate support, and some have fallen arches. This is not an exhaustive list. Your weight is rarely a factor, fully half my foot pain clients are no more than 10 pounds above “ideal” weight and many are quite thin. Plantar Fasciitis will put 20 pounds on you in a hurry, because the pain is so bad, you can’t stand to get up and do anything!

Kay has been doing surveys with plantar fasciitis sufferers from all over the world.  In a decade of asking clients and plantar fasciitis sufferers all over the world about their experiences, there is one thing that more than 85% of them have in common.  They have had a grade 2 or 3 rollover sprain to the same ankle.  When asked if their doctor inquired about their previous ankle injuries, the answer is a resounding no. Fully 85% of my clients with heel pain report having significant ankle injuries in their life, some of them many times. “Turning your ankle” or “rollover sprains”, broken bones, or being in a foot cast, brace, or “walking boot” for a month or more are all significant contributing factors.

Many patients suffer needlessly because they cannot afford surgery or the lengthy recovery time. While properly fitted shoes and orthotics can be very helpful for this condition, I know from decades of personal and professional experience that is it often incomplete.

Manual Therapy Treatment

The treatment Kay uses is not based in Swedish massage, it’s based on decades of clinical experience. It consists of Trigger Point & Fascial Release, combined with neuro-muscular re-education. The success rate is over 80% with just four to six treatments of a half hour per effected foot. The success rate for six treatments is over 90%. A very few take eight to ten weeks, but often they have suffered for many years instead of just a few months.

Kay personally suffered with agonizing and debilitating pain from plantar fasciitis in both feet for three years, so she knows what you’re going through. It’s now been more than ten years since she has had any pain at all. All she did was massage and orthotics. This worked for her, it’s worked for thousands of her clients, it will work for you too!

Traditional Treatments

Traditional treatments include taping, cortisone, night splints, orthotics, ultrasound, shockwave treatment, and surgery.

 

Orthotics – can be very helpful. Good shoes are important for EVERYONE! Proper support goes a long way toward pain reduction. Orthotics do the same thing as taping, but much more effectively. They can also correct for abnormalities in foot structure and gait. However, orthotics alone rarely solve the issue completely, and you often have to try several kinds and styles before getting the best results. The cost ranges from $10 for “Dr. Scholl’s” over the counter insoles (which I don’t recommend) to over $500 for a custom molded model. Quality over-the-counter models tend to run about $40-75. It can add up. A few insurance companies cover orthotics, many don’t. My current favorite is SOLE, they custom mold to your feet within a few days while retaining their support abilities. REI carries them, (REI.com) their website is YourSole.com, and the specific page that compares their available footbeds is http://www.yoursole.com/us/help/compare-footbeds/ Other reputable brands include Aetrex, and SofSole.

Cortisone – Cortisone treatment for plantar fasciitis is an injection. There is debate about the number of injections that can be considered “safe”. Most physicians will not administer more than three to a single area inside a year. How comfortable the shot is depends on the location and direction of the injection, but I have never heard anyone describe it as “painless.” Cortisone reduces inflammation by permanently degenerating tissue. The effects can be immediate, or they may take up to two weeks to fully develop. My clients have reported relief lasting from 2-18 months for the first injection. Subsequent injections appear to give a lower level of relief for a shorter length of time. Some clients report no relief at all. So why is it used? For a few people, cortisone is a “magic bullet”. They get one shot, and they have no further problems from that area. I estimate this is about 10% of the population. If you don’t get good results from an injection the first time, you’re not likely to get results from a repeated injection.

The Mechanics of Foot & Ankle Movement

Basically, the plantar fascia is a broad band of fibrous tissue that begins at the joints of the base of the toes in the ball of the foot, and travels back toward your heel, narrowing as it goes, until a section about as wide as your thumb attaches at the inside front edge of your heel.  The fascial band is very tough, it has the same tensile strength as a piece of steel the same thickness.

As we walk, each part of the leg and foot takes part of the movement load. When the ankle can’t move properly, the metatarsal and tarsal bones (which are right behind the toes) have to take a lot more weight and force. This causes them to splay forward and outward in a spreading motion, transmitting extra force out through the toes, where the plantar fascial band attaches. Remember, the job of a tendon or fascial band is to concentrate all of the force of the muscle or connective tissue in one place to create movement. Basically this extra outward force is “pre-loading” the band, tightening it significantly before you even roll off your toes. As you roll forward and off of your toes, it tightens even further. The force is transmitted along the length of the band to the heel. The force is so great that it pulls bits of the band off at its connection to the heel, taking little bits of bone with it. These are called micro-avulsion fractures.

It is also important that we consider how the ankle heals after an injury. Eighty-five percent of Kay’s PF clients have had serious sprains to the ankle of the effected foot. When this happens, your body swells up at the ankle in an effort to keep you off it, and sends building materials like proteins to the site of injury or pain in an effort to stabilize it while it heals. Understand that a truly complete healing process means that you have regained full mobility, stability, and strength. This rarely happens with ankle injuries. Most of the time, the healing process just stiffens everything up in an attempt to stabilize it, and prevent further injury. Too often it stops there, and your ankle winds up being like a major construction zone abandoned half-way through, with NO clean-up. The peroneal tendons (on the outside of the ankle) are often severely damaged or outright torn, and provide no counter-balancing force to the flexor tendons (on the inside of the ankle). This tends to make the foot roll toward the outside (inversion).

Then, Wolff’s law kicks in. Wolfs Law states that your body will lay down new tissue in the manner in which it is used most often. What this means is that it will lay down tissue to allow you to be in whatever position you are in the most often with as little effort as possible, and it will resist going back to its original position. It has two affects here;

First – it will adaptively shorten the flexor tendons, which will increase your chances of re-injury.

Second – Because the plantar fascial band is being torn and overstretched, pulling little bits of bone off the heel, it grows new bone at the site of damage. Over time this forms a spur.

Wolff’s Law and the body’s healing process create greatly reduced mobility, adding strain to tendons that already have too much of it, which obviously causes more pain. The crude analogy is that the adhesions in and around the tendons are like spaghetti that someone threw into a pot and didn’t bother to stir.

Several Things That Can Cause Excess Stress on the Plantar Fascial Band

Damaged ankles – Bad sprains, strains or breaks: In a bad sprain or break, its not just the ligaments of the ankle that are damaged, so are the tendons. Remember that a tendon is how a muscle concentrates force to move a joint. In a rollover sprain/strain, the tendons of the outer muscles of the calf are damaged, and there is no counterbalancing force for the flexor muscles, whose tendons run along the inside of the ankle. This is a major yet unsung underlying cause, and responsible for a large percentage of cases. In this type of injury, the flexor muscles adaptively shorten. Add this to the necessary wound healing mechanisms affecting the whole ankle, and you get significantly reduced mobility. In the healing process, the scar tissue and fascial restrictions that your body uses to stabilize the ankle so the ligaments can heal doesn’t always break up. It radically changes how the bones in the ankle move and distribute weight. It limits the ankle’s range of motion, sometimes severely. If the ankle cannot move properly, more of the load is shifted to the ball of the foot, increasing pressure on the toes, which adds tension to the plantar fascial band, and viola, you have plantar fasciitis.

Fallen arches – This causes the longitudinal arch to stretch further than it should, pulling on the tendon. It pulls when weight comes down, and pulls some more when you roll forward onto your toes and step off onto the other foot.

The foot taking more weight than it should – If you’re in a boot because the other foot or leg is damaged, the good foot will be taking a great deal more of the load than it is accustomed to.

Stiffened inflexible fascia – If you have plantar fasciitis, and had severe or repeated ankle injuries, the healing process has probably created scarring and stiffened fascia. The primary culprits in this scenario are the tibialis posterior, flexor hallicus longus, and flexor digitorum longus. The tendons for these muscles all run to the inside of the ankle, and will adaptively shorten after an ankle sprain, which rolls the ankle outward, and turns the foot inward, increasing the chances of another rollover sprain. The secondary culprits are often the muscles in the front of the calf, which are the extensor digitorum, and the tibialis anterior. In my experience, releasing the muscular and fascial limitations, and re-training the muscles to their proper length restores proper ankle movement, and ENDS THE PAIN.

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