Get a Leg Up on Foot Pain!

Foot or heel pain can be debilitating because we spend much of our lives on our feet. Plantar fasciitis or plantar fasciiosis is the most common cause of heel pain and involves irritation to the thick band of tissue at the bottom of the foot called the plantar fascia. The plantar fascia runs from the heel bone to the toes, and it is composed of a thick, fibrous connective tissue that is able to stretch slightly. Its primary functions are to create tension to maintain the arch of the foot and to facilitate movement of the foot by stretching out when the foot impacts the ground.

When the tension on the plantar fascia becomes too great, it can create small tears within the fascia at a microscopic level. This cycle of repetitive stretching and tearing can cause the plantar fascia to become irritated or even inflamed. The body attempts to heal the area by laying down scar tissue in an aberrant fashion that causes improper movement of and support from the plantar fascia, hence leaving the foot more vulnerable to injury. When this occurs, it can cause pain on the heel, especially the inside of the heel, when stepping out of bed in the morning. The pain can decrease as the day progresses but will often return when standing on the feet for long periods or wearing non-supportive shoes. The pain associated with plantar fasciitis usually develops gradually and gets worse over time. In fact, most patients enter my office after having the pain for several months, hoping that it would go away on its own. Or they have visited another practitioner or several other practitioners without lasting results. We will discuss this in further detail later in this article.

Those most commonly affected by plantar fasciitis are populations between the age of 40 and 60, women, runners, dancers, and people with occupations that require standing on the feet for long periods of time, such as teachers and healthcare workers. Obesity is a common risk factor because the increased weight puts more stress on the plantar fascia, and there is often significant weakness in the musculature of the foot/ankle, hip, and core. Improper foot-wear can also cause plantar fasciitis, especially shoes with high heels. The reality is that almost anyone can be affected by this condition, and we have seen many young, healthy people, as well as the elderly, suffer until they have received the proper treatment.

In the past, heel spurs have been attributed to causing plantar fasciitis and were removed surgically. Surgical removal is not currently the treatment of choice because many people who have heel spurs have no heel pain. Therefore, structural abnormalities and bony degenerative change that is seen on imaging, such as X-ray or MRI, do not correlate with the patient’s pain. This has led to the current understanding that plantar fasciitis is more of a functional problem, not one that is structural. Medical management includes non-steroidal anti-inflammatory medication, such as ibuprofen and naproxen, as well as corticosteroid injections. Multiple injections are not recommended because they can weaken the plantar fascia and lead to more tearing or even rupturing. There is an appropriate time for treatments such as injection to the plantar fascial tissue to reduce significant inflammation. If a patient is so acutely inflamed and any activity or treatment is causing worsening pain, then injection will usually be of substantial benefit.

With that being said, we see all too often that patients are being given the wrong treatment at the wrong time. So why is it that we have such great success with this condition? Most people would not think that chiropractors would be treating conditions such as plantar fasciitis and getting better results than most podiatrists and other therapists. Well, my background is in sports chiropractic, manual therapy, and rehabilitation. Most chiropractors who are trained as chiropractic sports physicians have an incredible understanding of the human body and its biomechanics. Biomechanics is the study of how structure relates to the function and movement of the human body. The reality is that most podiatrists and therapists do not have a great understanding of the function of the body. That includes most of my chiropractic colleagues.

When we see a patient who comes to me looking for help with this condition, many times, they have already had failed treatment or short-term results with a podiatrist, another chiropractor, or other manual therapists. Many have already had an injection to the area with little or no relief, generally because their problem was not an inflammatory issue. Many have tried “rolling out” their calves or stretched themselves into even more pain. For your information, stretching is largely ineffective, will provide only short-term relief, and can actually cause worse damage in the long run. Unfortunately, at this point in time, injections, stretching, icing, and orthotics are all common treatments that are deployed by many healthcare practitioners with little long-term success.

What is the proper evaluation and treatment approach for patients suffering from plantar fasciitis?

A functional assessment must be performed in order to achieve good, long-term results. You must determine where the patient has significant weaknesses in order to correct the problem. Instability and weakness in the intrinsic foot and ankle muscles are commonly seen. Also, weakness in the hip/gluteal muscles, as well as the low back and core, are just as common in this population. Imagine you built a house that had no foundation or support beams. What would happen? The walls would begin to crack, and eventually, everything would fall apart. This is exactly what happens with a patient who develops plantar fasciitis. The muscle structures that are designed to support the joints and tissues involved are basically not doing their job to the best of their ability. I like to think of it as load versus capacity. You can only put so much burden and tension on a particular tissue before it reaches its capacity. Once it reaches its capacity, it will begin to fail. With that being said, if that tissue has support from other tissues around it to make it stronger, it is less likely to fail. So, if the muscles of the back, hip, ankle, and foot are strong and able to support your activity, then it is less likely that your plantar fascia will reach its capacity and fail. The practitioner must also assess for scar tissue formation within the plantar fascia as well as tissue extensibility problems within the calf, hamstrings, and inner thigh muscles.

What does a typical treatment plan look like to resolve plantar fasciitis?

First, we begin by releasing tight musculature in the calves and thigh with manual techniques such as ART (Active Release Techniques). This is a very effective form of sports massage. Second, we must release and reduce the scar tissue that has formed in the plantar fascia. I have found that the most effective way to minimize scar tissue is using a form of instrument-assisted soft tissue manipulation called Graston Technique. This involves using a set of stainless steel instruments to manually scrape the scar tissue out of the affected areas of the plantar fascia itself. In the initial stages of care, it may be helpful to support the plantar fascia and heel with taping techniques that will alleviate pressure on the affected area and help reduce inflammation. And most importantly, we must create resilience to the entire kinetic chain by strengthening the intrinsic muscles of the foot and ankle, the hip/gluteal complex, and the core. It always amazes us to see how weak patients with plantar fascia usually are. It is also amazing to see that with some active rehabilitative care and the proper strengthening techniques how well they respond, especially if patients have failed with other types of care. You can expect to see excellent results in 6-8 weeks; however, some patients with more severe, chronic pain may need to be treated in this fashion for up to 4-6 months.

If you have this condition or have failed with other methods, we urge you to take a different approach. The only way to truly solve this issue is with the proper manual therapy and prolonged exercise that creates stability and resilience. If you have any further questions or concerns, please feel free to reach out to our office by phone or by filling out the form below and schedule an appointment. We look forward to working with you to achieve your goals!

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