Plantar Fasciitis (PF) can be a rather debilitating condition. It doesn’t matter if you have flat feet (pes planus) or high arches (pes cavus). If there is added stress to the bottom of the foot that occurs quickly, it can result in plantar fascial pain.
What exactly is the plantar fascia? Consider the plantar fascia to be similar to a ligament. It runs from the heel (the medial calcaneal tubercle) to the heads of your metatarsals (point at about where you see the webbing of your toes). Despite what you might have been told, its function is NOT to hold the arch of the foot. Rather, the PF more-so holds the muscles under it together so that they can suspend your arch.
My take on things, with over 18 years into treating foot injuries, is that the extrinsic sling muscles (some of muscles from the leg that go to the bottom of the foot) weaken, essentially ‘sag’, and that puts stress on the plantar fascia. As this continues, the PF gets injured. This process can also include some of the intrinsic muscles (muscles that start and end in the foot) of the foot that lie beneath the PF as well. These muscles also help to hold the arch.
We don’t want arches that are too high or too low. Somewhere in the middle tends to be the best to avoid plantar fascia pain
Whether we have good arches or no arches, if the muscles we are referring to weaken, there is stress put on the plantar fascia and this creates the pain. I find flaws with traditional methods of treating plantar fascia. Let me give you a comparison…if you were to break a bone, would you pull it apart or put it together for it to heal properly? If you rip a muscle, do you stretch it hard or put it together to allow the fibers to stitch back together? Well, the answers to these questions is rather simple: you have to approximate torn tissue to get it to heal properly. So, why is it that with the plantar fascia, all too many practitioners go ahead and stretch the foot, put it in a Strassburg sock (to stretch it), stretch the Achilles, etc? To me, this makes no sense.
Let me see…you have pain when you first get up in the morning because all night the foot has been relaxed and shortened. Then you put it on the ground, it stretches and by doing so, it hurts. This, alone, indicates that it is a stretch injury. Yet, the treatment involves stretching it? Many therapists will tell you that it will heal in time no matter what you do. That’s a load of, well, untruth. Sure, it will continue to tear and heal and tear and heal, and you’ll ultimately be left with scarred up and permanently over-stretched plantar fascia. That is something we do not want. In addition, the cause of the problem has never been identified. If PF goes on for too long, spurs can form and those are no fun either!
The cause, as I alluded to earlier, is weakness of the extrinsic and intrinsic foot muscles, not of the plantar fascia itself. In fact, the PF injury just tells us that other things are wrong and treating the PF alone will not yield the results that we need.
Proper treatment for PF involves reducing the stress on the PF for the short-term and then figuring out what is putting so much pressure on the PF that is causing it to tear. Sometimes we need orthotics to help and sometimes we do not. Proper joint mobility of the ankle and feet is a must. Many times we tape with functional tape to support the arch to reduce the pain. One thing the patient almost always needs is rehabilitation aimed at the muscles that are weak and are allowing for the ‘dropping’ of the arch and resultant damage to the PF.
Although many think that Plantar Fasciitis is a hard condition to treat, it isn’t if it is caught early enough and if the proper structures responsible for the PF pain are identified. I, for one, really enjoy treating foot and leg injuries as they tend to have a high resolution rate.
Do you have a source for your hypothesis about the extrinsic sling muscles being weak in patients with PF or is this just a logical “guess”? How do you test the door extrinsics to confirm they are weak?
Thanks
Ben,
I did a total literature search on PF a little over a year ago. There is such a lack of good information on how to resolve the problem…I was amazed. The only reproducible information I found was on taping to support the arch. This made total sense to me. We know the PF is not contractile tissue. It is only a support structure. We know the extrinsic muscles form the actual sling for the ‘arch.’. When we tape to support an arch, the tape is doing the work of the PF but it’s not correcting what is causing the PF problem. The PF doesn’t get injured on its own. We have to figure that something is causing the PF to ‘stretch’ or ‘tear.’ It’s the other structures that are causing the problem. This can occur with pes cavus or planus.
Muscle test the associated muscles and see what you find. Do not discount facilitation/inhibition patterns normally found but muscles should not be testing weak regardless. You will be quite surprised with what you find and when you approach the PF problem this way, the resolution rate is quite high. Don’t forget to assess for calcaneal stress reaction/fracture as all too often PF is misdiagnosed and you have a bone issue to contend with.
Let me know what you find.
Dr. M