19 Jan The Truth About Plantar Fasciitis (and Arch Pain)
Does the bottom of your foot hurt?
Then you may have plantar fasciosis. (Notice I didn’t say plantar fasciitis.)
Why It’s Not “Plantar Fasciitis“
The “-itis” ending for tendonitis or fasciitis implies “inflammation.”
Plantar fasciitis is usually diagnosed under two conditions:
- Location – plantar foot (usually at the calcaneus attachment point).
- Symptom – pain that is worse with activity.
Inflammation is the natural bodily process of attempting to heal. It is normal and healthy in musculoskeletal conditions such as a bruise on the arm or a torn hamstring. When the immune system is busy trying to clean up your mess and you try to use the damaged tissue, your nervous system will let you know it’s angry at you with your subjective experience of “pain”.
Inflammation isn’t normal when the body is in a hyper-inflammatory (“hyper”= too much), usually through a diet consisting of grains, processed or low-fat dairy, and sugar, but that’s for another time.
The hallmark signs of inflammation are:
- rubor – redness
- tumor – swelling
- calor – heat
- dolor – pain
In most diagnoses of “plantar fasciitis”, the only hallmark sign of inflammation that is present is pain. There is no redness, swelling, or heat present. With one out of four signs of inflammation present, it makes one wonder “If it’s not fasciitis, what is going on?”
Plantar fasciosis, different from plantar fasciitis, is diagnosed under two conditions:
- Location – plantar foot (usually at the calcaneus attachment point), in the same location that plantar fasciitis would occur.
- Symptom – pain that in the early phases of degeneration, would get better with activity.
Notice the very clear difference concerning when the pathology is provoked. In fasciitis, activity makes the symptoms worse. In fasciosis, activity makes the symptoms better (as long as the degeneration is in the early stages). In the later stages of fasciosis, symptoms will be provoked with activity and will resemble fasciitis.
The difference between diagnoses cannot be overstated for symptom resolution.
What is fasciosis?
Fasciitis is an acute overload of the fascia.
Fasciosis (or degeneration) is the chronic overload of the fascia.
Chronic overload is due to:
- overload of healthy tissue (too much work) in the short-term … or …
- overload of underloaded tissue (not enough work in long-term that causes tissue to weaken then degenerate with too much work) over time.
When researchers open up the fascia in anatomical studies, they don’t find inflammatory cells in the face of this chronic overload.
What do they find?
This is how the fibers are oriented in a normal, healthy tendon. One that can handle the load you put on it.
Now take the box of spaghetti and cook it or worse, throw it on the ground (and waste it). After either event, the spaghetti will no longer be parallel, but going in every direction.
This is how the fibers are oriented in a degenerated tendon. One that can’t handle the load you put on it (and lets you know that the fire alarm is going off with “pain”).
Conventional Management of Plantar Fasciitis (and Arch Pain)
As mentioned above, degeneration in the plantar fascia occurs by doing too much or too little work.
It can develop in a runner who does fifty miles a day or in a tv-watcher who watches fifty tv shows a day.
With a diagnosis, Wikipedia’s list of treatments for plantar fasciitis (and arch pain) includes:
- massage therapy
- weight loss
- night splints
- motion control running shoes
- physical therapy
- Cold therapy
- anti-inflammatory medications
- injection of corticosteroids
Two data points(location and symptom provocation) are often correct to diagnose plantar fasciosis. The issue with this list of treatments is that it does not address the cause of the problem, only a plethora of random solutions that have potentially worked with the whole spectrum of plantar diagnoses, not your individual body.
Let’s look at the list again and discuss the dysfunction blocks that the solution points to.
- rest – implies “acute inflammation” of plantar fascia, and is only helpful when the tissue was healthy before the incident.
- massage therapy – implies a “soft tissue problem”, but is largely ineffective at removing scar tissue.
- stretching – implies “tightness”, which is often very true with restricted ankle dorsiflexion and plantar flexion (see below – Measure your ankle dorsiflexion through the directions here). Tissues can be tight for various reasons that warrant further detail to resolve (ie. muscle tightness from disuse, “protective tightness” from the nervous system due to local pathology, “increased tone” from the nervous system due to systemic pathology, etc.). The gross ineffectiveness of this solution is observed with the duration, in months to years, that individuals try stretching without actual feeling more flexible.
- weight loss – implies “increased load from standing or walking” is a problem. It can be, but it isn’t first priority.
- night splints – see the rationale for “stretching” from above.
- motion control running shoes – this intervention assumes pronation or supination need to be controlled. This is a valid point and a priority, just not priority one.
- physical therapy – implies that “weakness” is a problem. Weakness is often involved, especially when symptoms are bilateral. If this were priority one, physical therapists would be hitting home runs every time with this problem. They aren’t.
- Cold therapy – implies “inflammation” is a problem. But we’ve already clarified how plantar fasciitis is not caused by inflammation, it is plantar fasciosis caused by degeneration.
- orthotics – implies “faulty bone structure and alignment”. Definitely a priority that needs to be addressed. Unfortunately, most orthotics are garbage. We use Sole Supports (as does my mentor and the community of chiropractors he continues to teach) and get great results with them.
- anti-inflammatory medications – implies “inflammation” is a problem. See intervention cold therapy from above.
- injection of corticosteroids – implies “acute inflammation.” See rest from above.
- surgery – implies “something needs to be cut out or removed.” Whoa, what are you cutting Mr. Ortho?!
The Successful, Unconventional Treatment of Plantar Fasciosis
If the interventions above worked, patients wouldn’t go from podiatrist to podiatrist, year after year, looking for answers as many of our patients do.
The NUMBER 1 problem in plantar fasciosis is the scar tissue that develops in the calf (tibialis posterior, flexor hallucis longus, flexor digitorum longus, flexor hallucis brevis) and the degeneration that occurs in the plantar fascia as the fibers are oriented in a haphazard fashion. You can learn if you have scar tissue in these structures by self-assessing your ankle dorsiflexion range of motion.
Legitimate secondary problems are non-optimal bone alignment, high-load activities of daily living, excessive mental and emotional stress, and systemic inflammation through diet or environmental toxins.
Knowing what all of these problems are, a sweet spot solution needs to be delivered for each individual problem.
- The NUMBER 1 solution for plantar fasciosis: a myofascial treatment that reduces the amount of adhesion in 1-5 visits, as observed in a Test-Treat-Retest Metholodgy of Treatment. My personal opinion is that an Integrative Diagnosis provider offering Manual Adhesion Release is the best choice for quick and permanent results. The plantar foot is also one place where instruments such as Graston work very well, but it can only be used on superficial tissue. Graston would not work well on the deep calf structures.
- Orthotics – to correct bone aligment between the second metatarsal and the tibia. As much as I used to believe that everyone should be walking around barefoot, faulty bone structure proves this belief wrong. I learned this the hard way through destroying my own ankle with barefoot running.
- Modification of Activities of Daily Living –the body needs to be loaded just the right amount to be healthy. Overload (running too much without sufficient time for recovery) or underload (sitting for eight hours a day) won’t keep the spaghetti lined up nicely in the box. Only in introducing movements such as squats and lunges into an exercise program, taking breaks from sitting, managing the amount of running one days we can prevent this problem from developing in the future.
Here’s the big picture: if you have plantar fasciosis and you’re not getting the scar tissue addressed through manual therapy, you’re not addressing the main problem. Your symptoms may go away with Wikipedia’s interventions, but I’m confident in saying they will return.