Plantar “Fasciitis” – Why is it such a nagging injury & what do I do when I get it? - 3/12/13
If you are like most people that have been diagnosed with plantar fasciitis, you are probably wondering the same question; why is it such a nagging injury?
The plantar fascia is a flat band of connective tissue that starts on your heel bone (calcaneus) and runs along the medial longitudinal arch of the foot, attaching at the base of the toes. Its function is to maintain the shape of the arch through the different phases of gait. The plantar fascia acts like a cable that tightens and shortens during the propulsion stage of gait, allowing the medial longitudinal arch to maintain its height. The shortening of the plantar fascia to maintain arch shape is referred to as the “windlass mechanism.”
If there is too much motion in the joints of the foot (excessive pronation) or not enough motion in the foot (under pronation), the stresses that are absorbed by the plantar fascia during gait are increased. Different biomechanical inefficiencies in the foot throughout the gait cycle can increase the stress on the plantar fascia, resulting in heel pain. One person may over pronate, while another does not, but they still both present with symptoms of heel pain. There is not one specific abnormality that causes the pain, but rather, many possibilities. This is part of the reason why resolving the pain can be a sometimes tricky & lengthy process.
Abnormal stresses absorbed by the plantar fascia create a tensile force on its attachment on the calcaneus. These forces pulling on the bone can sometimes cause a little piece of the bone to start to grow in the direction of the forces, creating what is called a heel spur. This can potentially complicate things more, though much research suggests that the pain actually comes from the tension on the plantar fascia rather than from the spur itself.
With all of these stresses going through the foot, at roughly 3 times body weight during running; no wonder this condition is such a common complaint of runners. Over time, the tension forces on the plantar fascia cause micro-tears in the tissue, which results in inflammation. Inflammation is the body’s natural response to injury and is necessary for proper healing to occur. So in a way, inflammation is actually a good thing. The problem with plantar “fasciitis,” (inflammation of the plantar fascia) as its name suggests, is that there is not much inflammation going on at all! Once a micro-tear occurs, there is not enough time for the body to go through the full healing (inflammation) process before the next micro-tear occurs. Since most runners don’t rest at the first twinge of heel pain, there is definitely not enough healing time! The tissue gets caught in a chronic stage of degeneration, in which tears are occurring but not healing properly, which causes a buildup of scar tissue, a weakening of the plantar fascia, and a decrease in blood flow to the area. It is this combination of things that leads to the chronic, nagging nature of this injury!
You can see, since there are so many different potential causes of plantar fasciitis, that treating it & preventing it from coming back can take some time & effort!
We know that there is a buildup of scar tissue within the plantar fascia that occurs from the chronic degeneration of tissue. Scar tissue does not function like healthy tissue does. It decreases extensibility of the healthy tissue and it needs to be broken up! Breaking up scar tissue within the plantar fascia is an important step to take towards healing & preventing a problem in the first place. Self-massage through rolling the arch over different over the counter devices (Foot Rubz ball, foot wheel, etc) can be beneficial in helping to break up scar tissue. Sometimes, self- massage isn’t enough, and having a professional perform friction massage, Active Release Technique, or Graston Technique may be beneficial.
With the chronic nature of this problem, blood flow to the damaged tissue is decreased. Nutrient rich, oxygenated blood is necessary for healing. The application of moist heat to the area can help to increase the blood flow. The more blood flow to the tissue, the more receptive it is to stretching, so the massage you are doing will be more beneficial if it preceded by the application of heat. Wearing compression socks during the day or during activity will help to increase blood flow to the tissue as well. After activity, if the heel / arch is sore, the application of ice is recommended. Also, if there is ever any noticeable swelling in the area, ice is indicated and you should seek further medical evaluation.
When there is pain in the heel, the body will compensate to try to alleviate the pressure / stresses that are being absorbed by the foot and plantar fascia. Other muscles will do more than they are supposed to do and they end up getting tight. When muscles are overworked, they develop trigger points, which are localized areas of tenderness. These trigger points can cause referred pain (pain that goes somewhere else when pressure is applied to the trigger point). Often times, in the case of heel pain, trigger points develop in the muscles of the calf and can refer pain to the heel. Most people don’t even realize the trigger points are present, until they search around for them, then they are sorely surprised! Releasing the trigger points can be helpful in overcoming current heel pain & keeping the muscle tissue healthy to prevent recurrence of the problem.
Stretching the plantar fascia & the muscles of the lower leg, primarily the calf / Achilles helps to lengthen the involved tissues back to their normal state. Performing the 90/90 hamstring/calf stretch or using the ProStretch to stretch the Achilles tendon are examples of beneficial stretches. The use of the Strassburg Sock or other dorsiflexion night time splint will put the involved tissue on a low level, prolonged stretch; which is the most efficient way to elongate tissue.
Strengthening the intrinsic muscles of the foot & lower leg, especially the tibialis posterior muscle is important in preventing the pain from coming back. Barefoot exercises like towel curls with your toes, picking up marbles with your toes, single leg balance, and theraband exercises for the ankle are all examples of good strengthening exercises for heel pain.
One of the most important things in preventing plantar fasciitis from coming back again is addressing the faulty biomechanics that caused it in the first place. Making sure that you are in a proper shoe for your running gait is important. Different inserts can also be used to decrease the strain on the plantar fascia. Even if you are in the best shoe, it is always important to remember to stretch, strengthen, and practice good running mechanics (not overstriding).
There are a variety of approaches to treating heel pain and sometimes more than one type of intervention is necessary for full recovery. With so many over the counter treatment options available, don’t forget about the importance of a proper diagnosis. If you are trying to get rid of one condition when you really have something else going on, you are not only wasting time, but could be making yourself worse! If you don’t notice improvements relatively quickly after starting your own interventions, be sure to check in with your doctor!