This blog was found on Athletes Training Athletes and written by Leigh. We highly recommend you check out this website!!
We’re going to kick off our new “Injury of the Week” series with Plantar Fasciitis for a few reasons. The first is that this one gets all of us in some shape or form at some point. The second is that now is a popular time of year for it to start. Shiny new shoes, high motivation levels for the upcoming season, and aggressive training schedules can all contribute. The good news is that the earlier you catch this and address it, the easier it is to get rid of. If you wait months because it “really isn’t that bad” or “it goes away as the day goes” or “it’s not stopping me from training”, then you’re heading for some potential trouble.
So what is Plantar Fasciitis exactly?
The plantar fascia starts on the heel bone (calcaneous) and then moves up to the ball of the foot and toes (also known as the heads of the metatarsals, one for each toe). It is a thick connective tissue that supports the arch of the foot to provide support to all of the little muscles and tendons on the bottom of the foot. It is NOT a muscle. That means it does not contract and it’s so strong fiber wise that it barely even stretches (less than 2% under full body weight). It gradually takes on the weight of the body and uses that tension to help get the foot ready for push off.
So what does that mean exactly? It means that the plantar fascia is a structure that gets injured because something else is getting stuck during the gait cycle. It either is unable to lengthen fully and loses what little elasticity it has or it gets strained making up for restrictions elsewhere. Remember, the PF works in support of the muscles on the bottom of the foot. In particular, it works with the Flexor Hallicus Brevis (FHB) and Abductor Digiti Minimi (ADM), as well as, the longer tendons of the Flexor Digitorum Longus (FDL) and Flexor Hallicus Longus (FHL). The key take away when looking at the muscles is this. Some of the muscles are strictly in the foot, start to finish. Some are not and only exist in the foot as skinny tendons to our toes. These tendons are from muscles up in the calf. Hint hint. You’ve gotta take care of your calves! They may not hurt, but if you’re feet do, they are involved.
So what can cause plantar fasciitis?
#1 Abnormal rotation of the foot. Meaning that the foot is twisted too much or too little during the weight bearing process (i.e. overpronation or under-pronation). Sound weird? Here’s an easy visual. Think of the foot like a rubik’s cube.
The only way to beat the cube is to get all of the little colors lined up. In the picture above, the red is the toes, the yellow is the metatarsals, green is the five midfoot bones, blue is the talus which sits right under the lower leg bones, and orange is the heel/calcaneus. Each of these sections can rotate and cause problems. When things are straight and the cube is lined up, all of the force travels from the heel to the big toe to push off for propulsion. When things are not lined up, the body needs to compensate somewhere.
Looking down, this is a right foot with the cube idea. All boxes are lined up nicely throughout the foot. As the weight travels from the heel towards the toes, those boxes and colors all line up, allowing all of the small muscles on the bottom of the foot to maintain a good arch and rigid foot that is strong as the foot pushes off the big toe. When those boxes/colors do not line up, the muscles have to work harder than normal. Over time they will break down if this is not corrected and the next structure down the chain is the plantar fascia. Remember, it’s not a muscle so when this happens it can be overstretched and even torn.
Those are just two common examples. There are a dozen different variations of how the different parts of the foot can rotate and even more variations for how the body tries to compensate for them. This is why shoe selection is a huge culprit. If you are in a shoe that exacerbates these bad rotations or limits the normal rotation we need to weight bear efficiently, you’re setting yourself up for problems. Bottom line: not sure about your shoes and have foot problems?? See a pro. Not the high school kid selling shoes at your local sporting good/running store. These rotations occur during movement, not while standing still with wet feet to look at what your foot print looks like. Arch height is not a factor in who gets plantar fasciitis and who does not. It’s the amount of rotation and strain on the bottom of the foot.
Okay, so now that I’ve rambled about rotation evils, let’s move onto the other possible causes.
#2 Bunion/loss of big toe extension. In the event that motion becomes restricted in the this area, the foot will become unable to fully load the big toe in preparation for push off. Over time this will lead to compensation and rotation of the lower leg and ankle to allow the foot to fully flatten to the ground during full weight bearing. Typically this is seen as the foot pointing out and push off coming off the side of the big toe. The problem here is that as the rotation occurs, the big calf muscles become less efficient and the smaller muscles of the lower leg must assist with forward propulsion. The foot isn’t designed like that and the “cube” and all of the bones/joints/muscles in it can get all twisted up.
#3 Ankle restrictions. In particular, not enough dorsiflexion of the ankle (being able to pull your foot up towards your shin). When this is limited, you’re stride is shortened and your push off decreased. The larger muscles will be unable to fully help and the workload will shift from the big toe to the mid-foot and arch. Sprain your ankle often or break it as a kid? This is where old sprain/strain injuries and fractures can sneak back up on you.
#4 Restrictions up stream. Just like the ankle can be a huge factor, so can the knee and hip. I know we’ve all heard “it’s all connected”, and probably rolled our eyes, but it is very true. For example, the gastroc (large calf muscle) and hamstrings criss cross behind the knee. Restrictions in one, will affect the other. Period.
The bottom of my foot hurts? NOW WHAT?
1) The first step is determining if it is truly a plantar fascia injury or something else. Other possible injuries include bone spurs off the calcaneus (aka heel spurs) or a stress fracture of the calcaneus. Remember, the goal of this series is not to keep you away from your doctor so that you can self treat everything. It’s to teach you how to catch the early symptoms and take care of them before it becomes a full blown injury. That being said, Plantar Fasciitis starts as pain and stiffness in the arch of your foot. These symptoms are worse with activity/motion, better with rest. When the symptoms are close to the heel or hurt along the bone itself, then you should be thinking doctor. This would mean that actually standing on your heel hurts. A true fasciitis feels better standing back on your heel versus forward on your toes because it’s that loading phase that hurts versus just the contact of the heel to the ground. The reason I say doctor for heel pain is that you’re in spur territory. If the symptoms are sharp and not improving, it’s time for an x-rays. Calming down the inflammation around a spur is the only way to keep it from growing bigger.
2) If after reading number one, you fall into the fasciitis camp, then the good news is that there is a lot you can do to calm this down on your own. Be smart though. If you aren’t getting better, get some help. I can’t tell you how many patients I get who wait months and even years before coming in for treatment. The longer you wait, the harder it is to get rid of. Here are some tips for finding the right health care professional:
- Find someone certified in soft tissue mobilization, whether it’s instrument assisted like Graston Technique or hands on like Active Release (ART). This is where you need to do your homework to see who’s near you. Follow the links to those sites to search their provider lists and read up on what each is all about. Plantar Fasciitis requires some hands on/massage work. Exercise alone won’t cut it most of the time.
- Not every PT and chiropractor are created equally. Some do very little soft tissue work and rely mostly on exercise and manipulations, others do not. We all specialize in our own little areas. Frustrating right? Not really. Most of us have websites to tell you what we are certified in. If we don’t? Pick up the phone and call us. There’s nothing worse than wasting 8 insurance visits not getting better only to switch places and have them fix it in two.
How to treat it.
** Click here to download PDF Treatment Session Sheet with all of the links/directions you need all in one convenient sheet***
Don’t skimp on phase one. This is your chance to heal everything up so that it doesn’t get mostly better and sneak back to bite you later. Let’s break it down.
Aim for at least twice a day for 5-10 minutes while still having pain. Not enough or you have to be on your feet for work? Bump up the frequency. Pack a ziploc bag of ice for the break room. Ice before and after work. If at home, shoot for 3x/day. If you go with the frozen water bottle, start off easy and use while sitting. Progress up to standing to apply more pressure. Wear a sock and avoid direct ice on skin. This part shouldn’t hurt if standing. Pain = back off.
#2 Soft tissue mobilizations.
During phase one, this is going to be the meat and potatoes of your game plan. The goal is to loosen up the muscles on the bottom of the foot and up into the calf. Let’s start from the ground up. These are the links to our self muscle massage posts. In each you will find detailed guidance for how to use a foam roller and tennis ball.
Time goal- 2 minutes with the roller on each muscle group. Go after the problem areas with the tennis ball as demonstrated in the video’s.
If you can’t seem to loosen anything up, try ten reps of these using the tennis ball. All the directions you need are in the video’s.
- tennis ball mobilization for the foot and plantar fascia. Click here.
- tennis ball mobilization for the posterior tibialis. Click here.
#3 Joint mobilizations.
Sometimes, the muscles have been tight for so long that they’ve caused the joints they move to stiffen up as well. In this case, we’re talking about the big toe and the ankle joint.
This is how you maintain the mobility you just got back with the foam roller/tennis ball. For an injury like plantar fasciitis, you want to stretch out the entire leg to loosen up the entire chain. The goal here is to loosen up the entire leg chain to find any “upstream” problems. Pay attention. If one stretch seems more difficult then the others or there’s a marked difference between your good and bad legs, put the roller to it and see if that helps even them out.
- These are my five go to stretches for leg injuries. Click here.
- Goal is 20 second holds, 3 reps of each.
- Follow the guidelines in the videos! This stuff should NEVER hurt.
#5 Kinesiology taping.
By now you’ve probably seen athletes covered in all kinds of colored tape. Some of you have probably even tried it out. Here’s my go to application for plantar fasciitis.
- PF taping. Click here.
Like I said before, the above is the meat and potatoes of healing this kind of injury. Soft tissue work and stretches should be done DAILY. No exceptions.
We’ve broken the exercises down into three levels based on pain levels. This stuff should NOT hurt. If it does, go back a level or ease up on the resistance. Only progress as pain free.
What you’ll need: 1) resistance band/tubing. This is easy to find in any sporting good store these days. You can probably even get it in walmart or target.
Optional equipment: a balance disc. Always good to add difficulty to your strength exercises. Affordable too at $20.
Video’s for each level are here. Please note, in the PDF download below you will find details for reps and difficulty progression, as well as, benchmarks you should meet before progressing to the next level. The number one thing to remember is that these exercises should be pain free. If you’re getting discomfort, go back a level. You can’t force this injury to heal, but you certainly can make it worse if you over do it.
To help put it all together, I’ve also created a PDF you can download to walk you through what a “treatment session” would look like. In it you will find everything you need including links to the videos and posts. Click here.
Hope that helps, and fire away with any questions in the comments.
This blog was found on Athletes Training Athletes and written by Leigh. We highly recommend you check out this website!!
1) Capobianco, Dr. Steven and van den Dries, Greg. (2009). Power Taping, 2nd Edition, Rock Tape Inc, Los Gatos, CA.
2) Hammer, Warren. (2007). Functional Soft-Tissue Examination and Treatment by Manual Methods, 3rd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.
3) Hyde, Thomas and Gengenbach, Marianne. (2007). Conservative Management of Sports Injuries, 2nd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.
4) Kase, Kenzo, Wallis, Jim, and Kase, Tsuyoshi. (2003). Clinical Therapeutic Applications of the Kinesio Taping Method.
5) Michaud, Thomas C. (2011). Human Locomotion. Newton Biomechanics, Newton, MA.
6) Muscolino, Joseph. (2009). The Muscle and Bone Palpation Manual. Mosby, Inc, St. Louis, MO.