Plantar Fasciitis a unique case study
An interesting case of plantar fasciitis presented last week that is quite different to what I normally see in clinical practice. Plantar Fasciitis is an extremely common condition, we see multiple cases every week and generally speaking the underlying issue is usually one of four common causes, but this particular case didn’t follow the normal pattern.
To first get a true grasp of why the plantar fascia can become so painful in so many people, it is important to understand the anatomy. The plantar fascia is a fibrous band that extends from the heel to the toes, running under the foot. It is like a very large ligament. It supports the integrity of the arch of the foot and protects the sole from injury. The origin of the plantar fascia is on the medical tubercle of the calcaneus (heel bone), which is why so many people have pin point pain under the heel that is slightly closer to the arch side of their foot, than being directly in the middle. Keep in mind everybody’s anatomy is slightly different, so pain on the heel directly in the middle can also be how plantar fasciitis presents although it is more uncommon. The insertion of the plantar fascia is at the toe end, it spreads out over all 5 toes, which is why some people with plantar fasciitis can experience pain under the ball of their foot, rather than the heel, this is a lot less common.
Now that we understand where the plantar fascia resides and where it attaches, lets talk about why it can become tight and inflamed and result in so much pain. Basically, there are four main causes:
- Anything that changes the biomechanics of the foot;
- Anything that changes weight bearing, which will always affect the foot;
- Any kind of muscular imbalance that affects the heel and/or toes; and/or
- Flat feet (excessive pronation)
Let’s elaborate on the causes of plantar fasciitis:
Changes to the biomechanics of the foot can come from the ankle and foot itself, or the knee, hip or pelvis, or a combination of the above. When the biomechanics, the actual function of the joint, doesn’t work properly the extra tension on the plantar fascia is greatly increased. These joint dysfunctions, especially when the pelvis is involved, causes a dramatic change in weight bearing, which also filters down to the feet, putting further pressure and stretch on the plantar fascia. The plantar fascia can only deal with so much extra tension before it begins to become damaged. Micro tears in the plantar fascia can be the beginning of the development of plantar fasciitis. These biomechanical and weight bearing issues, if left untreated, can continue to damage the plantar fascia and result in further physical damage, which is why simply adjusting these subluxations (as we Chiro’s call them), is not necessarily going to bring about instant relief of the pain caused by plantar fasciitis. The resultant soft tissue damage to the plantar fascia needs to be addressed as well for complete and long lasting results from this condition.
We also mentioned muscular imbalance and this is also a very common contributing factor too. In fact any imbalance that results in the calcaneus bone being pulled away from the toes, or vice-versa will put stretch tension on the plantar fascia. As we mentioned above, the plantar fascia is like a ligament, which means it doesn’t have a lot of stretch ability, meaning that constant tension on it will result in damage. The most common muscle imbalance arises from tension in the calf. When the calf is tight it pulls upwards and backwards on the calcaneus, pulling it away from the toes and putting tension on the plantar fascia. There are a number of other muscles under the sole of the foot that attach to the heel as well which can contribute to these imbalances.
The final thing to consider is flat feet. When the muscles surrounding the leg and feet are not doing their role of supporting the arch properly, the feet can become flat, otherwise known as excessive pronation, resulting in excess pressure being put on the plantar fascia yet again. Flat feet are nearly always the result of an incompetent muscle falling behind on its job of creating and maintaining the arch.
Quite simply in Chiropractic terms, we adjust all of these joints that are not functioning properly, which allows normalisation of the weight bearing issues, removing undue pressure on the plantar fascia. We then work on the soft tissue structures to bring about normal balance in the area, including the calves and all of the muscles under the feet. I choose to use therapeutic massage, dry needling and cupping to bring about this necessary balance. We also look at the arch and prescribe exercises to strengthen the muscles and orthotics when absolutely necessary.
Let’s get back to my interesting case, as although it fits into the category of muscular imbalance, it wasn’t caused by the more common muscles, like the calf muscles and a pull on the Achilles tendon. It was coming from a completely different area. It was a the result of tightness in the toe extensors that was causing the issue. What became noticeable on physical assessment was that this patients toes were pulled up even when her foot was in a relaxed position. This is a really good test that you can do on yourself to check if you have this same issue. Take your shoes and socks off, straighten your legs out on your bed or couch and completely relax your feet. Do your toes just remain relaxed or do they seem to curl back towards you slightly? Look at the tendons in the top of your foot, are they tight and noticeable?
Take a look at this obvious example, you can see that the toes on this persons right foot are relaxed and nicely balanced, whereas the toes on their left foot are being pulled back by tight muscles at the front. You can clearly see the tendons on the left foot pulling the toes backwards. Remember the anatomy, this excess pull on the toes will result in the plantar fascia being elongated once again. This time it is from the toes end, not the heel end! In this very unique case, dry needling was required in the toe extensor muscles to relieve this tension, this allowed the toes to settle back into their normal position and to allow the normal tension to return to the plantar fascia. This along with some work on the ankle and foot subluxations that these over tight muscles had caused, as well as some ultrasound therapy with KiroFix Injury Relief Lotion to reduce the inflammatory response that had developed from the plantar fascia muscle pulling so tightly on the origin and insertion points under the foot. Case closed!!!
So in a nut shell, there are a lot of different causes to plantar fasciitis, but the goal remains the same, to relieve tension on this fascia and heal the damage that has been done over time. Unfortunately, if left untreated the excess pull on the heel can result in a heel spur developing. This is the body’s attempt to bring the heel and toes closer together to take pressure off the plantar fascia. More on heel spurs in another blog.