PLANTAR FASCIITIS – WHAT IS THE TRUE CAUSE OF PAIN?

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PLANTAR FASCIITIS WHAT IS THE TRUE CAUSE OF PAIN
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Plantar fasciitis is one of the most common
diagnoses given to those suffering from heel
pain, with almost 2 million Americans diagnosed
each year. Those with plantar heel pain are
usually between 35 and 65. They are often runners
or slightly overweight and have occupations that
require a lot of standing. But not all heel pain
is the result of Plantar fasciitis, and many of
todays popular treatments have no merit.
Physical Therapy for Plantar Fasciitis can help
by first determining the underlying cause.
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• Plantar Fasciitis is a diagnosis given to most
  who have heel pain, yet rarely the cause of pain.
• A mechanical assessment is required to properly
  diagnose the cause of heel pain instead of simply
  blaming the tissue where the symptoms are
  located. To determine the best treatment for
  Plantar Fasciitis, it is critical to first
  differentiate it from other conditions, so the
  actual problem can be treated.

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• Other possible diagnoses
• Ankle derangement
• Biomechanical strain in the ankle
• Severes in children
• calcaneal stress fracture
• fat pad atrophy in seniors
• Baxters nerve entrapment (first branch of the
  posterior tibial nerve)
• Referred from the low back

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Symptoms of Those Diagnosed with Plantar
Fasciitis

• Those diagnosed with Plantar Fasciitis have a
  consistent pain at the bottom of the heel upon
  standing or weight-bearing. The morning is always
  the worst. After a few steps, the heel pain
  improves and may even go away. But the pain
  returns when initially getting up after a period
  of inactivity and is often described as tearing
  or stepping on broken glass. The pain may also
  appear more intense on bare feet or in shoes with
  minimal support. There is tenderness to the touch
  where the plantar fascia inserts over the bottom
  of the medial heel. The worst part of plantar
  fasciitis is that it does not go away quickly,
  instead lingers for months and even up to a year
  without proper treatment.

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• The pain is the worst with the first step in the
  morning and when resuming activity after rest. It
  tends to decrease with continued motion. (This
  indicates that more weight and more use of the
  plantar fascia reduces the pain. The problem does
  not appear to stem from stress on the fascia but
  from the rest period. What happens during rest
  periods that produces pain with initial
  weight-bearing but corrects after a few steps?)
  Answering this question is important in
  determining the best treatment for Plantar
  Fasciitis.

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Risk factors

• Plantar heel pain can develop without an obvious
  cause, but factors can increase your risk of
  developing this condition and therapy for plantar
  fasciitis can help eliminate some of these risk
  factors
• 1. Foot mechanics. Excessive pronation, flat
  feet, a high arch or even an atypical pattern of
  walking because of the way weight is distributed
  when youre standing
• 2. Age. Plantar heel pain is most common in
  people between 35 and 65.
• 3. Certain types of exercise. Activities that
  place a lot of stress on your heel and the soleus
  muscle such as long-distance running, ballet
  dancing, and aerobic dance
• 4. Obesity. Excess pounds put extra stress on
  your ankle joint.
• 5. Occupations that keep you on your feet.
  Factory workers, teachers, and others who spend
  most of their work hours walking or standing on
  hard surfaces can be at increased risk.

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• Anatomy Biomechanics
• Understanding what causes Plantar Fasciitis pain
  is essential to learn how to heel Plantar
  Fasciitis / heel pain quickly. The plantar facia
  is a tough, fibrous band of tissue that runs
  along the bottom of the foot, attaching to the
  heel bone (calcaneus) and the base of the toes.
  The plantar fascia helps maintain foot structure
  by supporting the arch and absorbs shock when
  walking. Weightbearing or standing increases
  tension in the plantar fascia. This tension
  further increases when you push off on the ball
  of the foot. The role of the fascia is to taunt
  not flexible.

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• During standing, 10-15 degrees of dorsiflexion is
  required as the lower leg glides over the foot.
  Joint mobility is necessary for proper loading
  and unloading of impact forces and in
  transferring the associated potential energy. If
  you do not have ankle mobility to allow the knee
  over the toes, the body will compensate by
  turning your foot out (walking like a duck),
  lifting your foot up early (bouncy gait), or
  pronating, making up the required motion by
  dropping your foot arch. Pronation causes the
  navicular bone to drop down and in. A slight
  amount of pronation is normal as pronation helps
  to absorb the initial shock of weight-bearing.
  But excessive pronation pulls on the plantar
  facia, leading to stress and possible micro-tears
  and progressive abnormalities, including the
  formation of heel spurs.

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Tightness in your calf muscles will cause a loss
of dorsiflexion. The calf is made up of two
muscles, gastrocnemius and soleus muscles which
taper and merge forming the Achilles tendon. The
gastrocnemius is the larger with two heads
forming the bulge that we normally associate with
our calf. It is a powerful muscle enabling heel
raises and jumping. The soleus is a smaller, flat
muscle that lies underneath the gastroch. The
soleus functions in prolonged running and is also
a major postural muscle designed to stop the body
from falling forwards at the ankle during stance.
Risk factors for developing plantar heel pain
include long distance running and occupations
that require prolonged standing, both of which
over use the soleus muscle.
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Another cause of loss of dorsiflexion is a bony
block due to the talus bone being shifted
slightly anterior. The talus is fascinating
because it is like a floating bone in that it has
no muscle or tendon attachments. Because of this,
it is also prone to shifting with trauma and
sustained pressure. The talus can shift
anteriorly due to its shape. When the talus
shifts anteriorly, it blocks dorsiflexion. It
feels like a hard stop at the end range of
motion with tightness and sometimes pain at the
anterior ankle. Physical therapy for Plantar
Fasciitis will address loss of dorsiflexion.
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What causes Plantar Fasciitis / plantar heel
pain? Todays common perception is that tension
and stress on the fascia cause small tears until,
eventually, the fascia becomes inflamed, causing
heel pain with weight-bearing. But research has
found that plantar fascia tears are NOT
associated with plantar heel pain. Instead, heel
pain was associated with thickened and abnormal
plantar fascia and thickened plantar fat pad when
loaded. Continued stress on the plantar fascia as
it attaches to the heel may cause a spur to
develop.
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It is believed that heel spurs is what causes
Plantar Fasciitis pain, but contrary to what you
may think the bigger the bone spur, the less
pain! The body responds to stress by laying down
calcium, and spurs result from excessive stress
on a tissue. But to find the best treatment for
Plantar Fasciitis, you need to determine first
what is causing the stress on the plantar facia?
Heel pain is a symptom located at the insertion
of the plantar facia to the calcaneal bone.
Instead of assuming the plantar facia is the
cause of pain, we need to uncover and address the
actual problem!
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Proper treatment requires uncovering the root
cause of pain What Causes plantar fasciitis
pain? 1 Risk Factor for developing Plantar
Fasciitis is reduced ankle dorsiflexion. Ten
degrees of dorsiflexion is required to walk and
at least fifteen degrees is required to run (5
deg in subtaylor neutral). Without adequate
dorsiflexion, the body will compensate so that
the knee can translate over the foot from stance
to swing. When the calf and ankle lack adequate
mobility to allow this translation, the body must
make up motion in other ways, leading to pain and
overuse injuries. Common compensations include
excessive foot pronation and knee valgus (knocked
knee). (Limited ankle dorsiflexion is also
associated with Achilles and patellar
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• Pronation is the most common compensation for
  lack of ankle dorsiflexion.
• If your foot pronates too much, the ankle rolls
  too far downward and inward with each step. Over
  time, compensating with pronation can cause the
  arch to collapse and muscles and supporting
  tissues to over-stretch and lengthen. The thick
  fibrous band of the plantar fascia is pulled with
  each compensating step of excessive pronation,
  causing strain and eventual abnormal changes. In
  response, the bone may also develop a bony growth
  (heel spur) right in the center of the heel.

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Large heel spurs and plantar fascia tears are not
associated with heel pain. If the plantar fascia
and heel spurs are not the cause of heel pain,
what is? Faulty biomechanics appears to be the
trigger that causes damage to the plantar fascia.
The plantar fascia may cause some pain but is not
the primary source. Could faulty biomechanics
also cause stress elsewhere, triggering pain? It
appears so.
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Those with plantar heel pain note that their
symptoms are always worse with the first steps in
the morning. While sleeping at night, the foot
rests downward. This plantarflexed position
allows the Achilles tendon to tighten and also
opens space for an anterior derangement. (A
derangment is a disruption within the joint due
to a particle or the talus bone moved
anteriorly.) Night splints are one of the best
treatments for Plantar Fasciitis because the
splint keeps the ankle in a neutral position
preventing the Achilles from tightening, and also
avoids an anterior joint derangement. Night
splints work because they address the Achilles
tendon and the talus bone, not the plantar
fascia. A lack of ankle mobility is usually
secondary to tight Achilles OR a joint
derangement in which there is a bony block to
normal joint mobility.
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• Best TREATMENT for Plantar Fasciitis
• Most common therapy for Plantar Fasciitis include
  anti-inflammatories and plantar fascia
  stretching. But do they address the problem of
  plantar heel pain?
• Anti-inflammatories Heel pain comes and goes,
  so it cannot be caused by inflammation because
  pain from inflammation is constant and
  short-lived, similar to a toothache. Instead,
  plantar heel pain is worse with initial steps but
  relieved with continued walking.
• 2. Plantar fascia stretching The role of the
  plantar fascia is to be tight and stable to hold
  and support the foot arch. Stretching goes
  against the basic role of this dense tissue. The
  plantar fascia functions like a ligament its
  role is to be taut to maintain the stability of
  our arch. Massaging the tissue, on the other
  hand, may help to break up abnormalities found
  with chronic plantar heel pain.

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The most common therapy for plantar fasciitis are
not the most beneficial because they do not
address the root cause of symptoms. Plantar heel
pain is usually diagnosed based simply on the
location of pain rather than performing an
in-depth assessment to determine the true
problem. Treating the area where the symptoms are
located, rather than the true culprit increases
the risk of chronic symptoms.
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Key Focus Reduced ankle dorsiflexion is the 1
risk factor for developing plantar heel pain or
what causes plantar fasciitis pain. This is then
a key focus. When there is a loss of
dorsiflexion, the required motion must be made up
by altering mechanics and the most common is
excessive pronation. The plantar fascia will then
be stretched too much due to excessive pronation
pulling on it to compensate for the loss of
motion in the ankle. A mechanical assessment
investigates any loss of motion and altered
biomechanics and determines why.
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• Varying research has demonstrated improved
  plantar heel pain to static Achilles stretching
  for the best treatment for Plantar Fasciitis. In
  contrast, another has shown more benefit to quick
  high load Achilles strengthening, but recent
  research has suggested slightly better outcomes
  with progressive loading. These variations on
  which is best treatment for Plantar Fasciitis
  boils down to the specific cause of pain. Is the
  heel pain secondary to a tight Achilles tendon or
  a stiff ankle joint secondary to the talus bone
  shifted anteriorly? Static Achilles stretching
  would aid Achilles flexibility, while dynamic
  strengthening and progressive loading would be
  more effective in reducing an anterior derangment.

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• Achilles stretching with the knee bent is much
  more effective therapy for Plantar Fasciitis than
  plantar fascia stretching.
• This indicates that the soleus muscle is more
  involved than the gastrocnemius or an anterior
  talus benefits from more pressure over the
  midfoot. The soleus muscle plays a major role in
  distance running, as well as, the major postural
  muscle designed to stop the body from falling
  forwards at the ankle during stance.
• What Causes Plantar Fasciitis pain is closely
  linked to abnormal tightness in the soleus muscle.

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• Validated Treatments
• 1.Depending on the patients specific limitation,
  dorsiflexion stretching targeted at either the
  soleus muscle or the ankle joint.
• 2.Posterior shift mobilization of talus with a
  band (if talus anterior needs to be screened
  by PT)
• 3.Night splint
• 4.Proper shoewear with arch support
• 5.Biomechanical assessment of running to assure
  proper form supination and heel out during
  swing.
• 6.Modification of activity and progressive plan
  to return to sports/ function.
• Schedule an appointment with one of our
  specialists to get relief now!

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