Plantar Fasciitis

Some considerations when treating Plantar Fasciitis by Art Riggs. The skill of the therapist lies in tailoring the treatment to the relevant factors.

I was quite intrigued with the recent article about plantar fasciitis and feel that their importance transcends just that condition and has general applications to all of our practices for both our efficacy in treatment and for a successful practice.  To understand my comments, it will be necessary to revisit the original articles.

As an ex-runner (knees) who treats both athletes and sedentary clients with plantar fasciitis, I feel it is almost an epidemic, and am sure that any therapist could be seeing 20 people a week for shorter sessions with a little advertising and communication with podiatrists and athletic shoe stores.  I’ve found that soft tissue techniques are extremely helpful—most clients commenting that it was the key to their recovery and more useful than a lot of the more conventional treatments offered by physicians or podiatrists.

First, the original article about the high load strength training as a treatment for plantar fasciitis.  I found the study well conducted and worthwhile, but also think that for bodyworkers, its importance is extremely important in broader perspective for growing a successful therapeutic practice.  An early teacher often quoted,  “You give a man a hammer, and the whole world becomes a nail.”  As therapists, we do our most effective work with freeing adhesions and lengthening short muscles and fascia. However, many of the problems we treat can be greatly helped by strengthening, movement work, and educating with home programs. I will go into detail in the next section, but must say that for most all conditions and injuries, adding a well-informed knowledge of other strategies will be of tremendous help for your clients and for separating yourself from the competition.  So many of my clients have commented that the suggestions for other strategies are the icing on the cake and it has been a huge referral resource.

I do concur that the high load exercises would be very helpful for many people who suffer from plantar fasciitis, especially those in which stability and lack of strength is a factor, but do feel that the condition is extremely complex and that there are many other helpful tools, particularly stretching, so putting all your eggs in the strengthening basket is not the best approach. In comparing the strengthening to the stretching in the article, I sensed an “either/or” mentality that is often seen in such studies (albeit necessary to control factors) and would hope that a multi-faceted approach would be used by anyone treating plantar fasciitis.

The author of the study also writes a full guest blog article on this  that illustrates the importance of taking the time to read the complete study rather than relying upon quick summaries.  Doing this will stimulate the critical thinking.  The original has very helpful photographs that demonstrate both the stretching used in the control group and the specific high load exercises so one could properly instruct clients.

What grabbed me in the photographs (Figure 2)  was that the exercises are not just training concentric high load muscle function, and are a perfect example of the difficulty in isolating factors, possibly leading to incorrect conclusions.   Although the protocol only speaks to “heel raises,” since the exercises require both dipping the heel far down below the forefoot with the toes supported by a towel, they also perform a significant stretch of the plantar fascia and mobilization of the transverse arch.  Possibly more important is that in lowering the heel in preparation for the concentric contraction, the patient is performing a slow, non-explosive eccentric contraction of the posterior compartment as well as a good stretch.  Many studies indicate that eccentric muscle strength is an important factor in strengthening, especially in Achilles injuries, and this may be a large factor that is ignored in the statistics claiming benefit from the high load heel raises.

Again, I think the article is very worthwhile and certainly would recommend the exercises as part of a more comprehensive treatment plan, especially including the soft tissue techniques. I am highly in favor of such studies, but think of the risks of knee-jerk acceptance that may shut off the all-important critical thinking to apply to our treatments. I want to point out a few brief points. Most important is the fact that that plantar fasciitis. is a very complex condition, and although the study is well constructed to attempt to isolate treatment factors, it is impossible to isolate the multi-faceted causes of the condition some of which are actually conflicting and would require very different treatment:

• Hypermobility: A high percentage of plantar fasciitis is a result of hypermobility  (and not just in the foot, but also knees and hips).  If this is the primary cause, then by all means, stabilization and strengthening will probably be of the most benefit.   This stabilization can be accomplished by proper shoes or orthotics, which have been shown to be quite helpful.   And strengthening as demonstrated in the article would also be very beneficial.
• Hypomobility: I actually see more clients suffering from plantar fasciitis. having a high arched rigid foot structure or from having shoes that immobilize the foot having both biomechanical effects with gait, and preventing the plantar fascia from normal stretching in activities so it becomes short and fibrosed.  A lot of new literature, including the well known “Born to Run” tout the benefits of less shoe stability so the foot can move through the range of motion that it is built for. For such people, strengthening may be less effective and techniques mentioned to increase mobility would probably be more helpful.

• Body Structure: In addition to the arches of the foot and the all important talo-tibial joint by freeing the retinaculum, one must consider a multitude of factors, including, forefoot mechanics, hip function, IT band tension causing rotational strain, valgus or varus knees, weight and general health of the client.

• Causative Activities: Any treatment should consider the activities that seem to be causative.  Is the person sedentary? Are athletic activities primarily straight ahead running or more mobile, as in sports requiring a lot of lateral mobility and quick explosive starting and stopping.

In varying degrees, these difficult to control factors may influence the outcome of studies as much as a particular technique. So the danger of any sampling is to jump to conclusions about the efficacy of treatments.  This may create an either/or myopic approach and have therapy exclude possibly benefits from other strategies or even utilize a strategy that may be counter-productive.  For example, if a large sample were to show minimal differences in results for stretching, or for strengthening, or for orthotics, one might conclude that choice of treatment really isn’t much of a factor.  In reality, the sample may include very different causes such as previously mention hyper/hypomobility, weakness, tight muscles and fascia. A result showing strengthening as more beneficial may actually be that the sample included a higher number of people with weakness or hypermobility as their causative factor, and conversely, an apparent larger benefit from stretching, might actually be a higher number of people with hypomobility as a cause. The skill of the therapist lies in tailoring the treatment to the relevant factors.

Lastly, a few comments about the importance of his treatments of specific foot muscles.  It is unrealistic to think that we can “cure” such complex issues with a treatment every week or two. Most of my clients love the work but say that the home programs I offer  (tailored to different needs as mentioned above) are equally important.

The one exception I’d offer concerns heel spurs.  So often I’ve had people with quite new plantar fasciitis. say that an x-ray showed a heel spur and that the doctor said that was the cause.  My feeling is that the heel spur has probably been there for years, and although it may be involved, until the flare up it was also there and it should not be given as the “cause.”  I have excellent results working to soften tissue around the spur along with the other areas I treat.

I also spend a great deal of time stretching and softening the posterior compartment of the lower leg, with particular attention to determining if the gastroc or soleus is more tight and working with lateral/medial balance since tightness in one of the two gastroc heads can cause torsional forces on the foot. I also agree that freeing the ankle retinaculum is extremely useful to have the foot track in a straight line. Dealing with rotational forces all the way up the leg is also helpful.  I also always check both the navicular and cuboid bones for mobility, often finding that the cuboid needs mobilizing.

I have a whole basket of golf balls I give out to clients, telling them to use several times a day, but never to the point of pain. For stubborn cases, a night splint to move the foot into dorsiflexion can be very helpful.  Interestingly, I also find that calf stretches, both with knee straight and flexed are often the key to lasting recovery, even after symptoms abate. I’m always very clear to clients that just because the pain abates, they can’t forget about keeping the area working properly with stretching and possible tune up work.

Lastly, I strongly suggest that therapists study the proper function of the foot to understand the complexity of lateral and medial arches, the transverse arch and the differences in how the foot responds to proximal forces such as knees and hips.  The old “shin bone connected to the knee bone” definitely applies.  I’m extremely impressed with James Earls’ book Born to Walk.  If you want to really understand how the foot works and the tremendous importance of how it distributes gravity through the body, affecting all the major joints through the skull, this book will change the way you approach bodywork.