Monday, March 2, 2009

Plantar Fasciitis

I see people with this diagnosis fairly frequently and it is a common source of frustration. It can be quite disabling at times and is notoriously stubborn to going away. Also, like many painful conditions, there is a lot of bad information running around about it and how to treat it. So, in this post I’ll try to provide some information regarding the condition, research, misconceptions, treatment, and return to activity.

What is it?

Plantar fasciitis is a diagnosis literally meaning “inflammation of the plantar fascia.” The plantar fascia is a tissue structure in your foot that runs from the front of the heel bone (calcaneous) to the end of the pre-toe bones (Metatarsal heads). It provides some (but not much) of the passive support of the arch of the foot. It is similar to a ligament (which runs from bone to bone) but is also continuous with some of the muscles/tendons of the extensor mechanism of the foot which includes the calf muscles, Achilles tendon, and the toe flexors.

How does one know if they have Plantar Fasciitis?

Plantar fasciitis is diagnosed through what are called clinical testing (as opposed to a laboratory test in which a sample is taken and tested. Ouch!) and by symptom description. Plantar Fasciitis is typically diagnosed by a few key findings:


1) Pain that is worst with the first steps in the morning or after prolonged periods of being off the feet. The pain typically improves after taking a few steps
2) Pain which worsens with activation of the extensor mechanism (through stretching back the big toe or bending back the ankle, for example)
3) Pain to pressure over the plantar fascia, especially where it attaches to the heel bone (calcaneous).

How is Plantar Fasciitis usually treated?

The following are treatments which are in the typical regimen for a patient with plantar fasciitis that have some research support behind them:

Manual therapy, progressions of stretching, use of over the counter or custom shoe orthotics, steroid injections, night splints (if the problem is chronic), taping (in the first couple of weeks only), iontophoresis (in the first couple of weeks only)

Common misconceptions:

First, this is a fairly non-specific problem with a very specific name. In other words, there are many instances (if not a majority) of foot and heel pain that have this same or very similar presentations which have nothing to do with the plantar fascia other than being in the same part of the body. Commonly any pain in the arch gets called “Plantar Fasciitis.”

A common misconception is that pain means that inflammation is present. This is not true. Signs of inflammation (red appearance, hot to touch, visible swelling) are often absent making the diagnosis of fasciitis (inflamed fascia) problematic in such cases. The physiology of tissue repair is such that when the process is continually restarted, inflammation (which is the first stage of the healing process) eventually stops initiating and the soft tissues become degenerative (a state of breaking down) and become infiltrated with new growth of blood vessels (called neovascularization) and nerve endings. This is exactly what has been found in several research studies looking at the state of tissues that had been diagnosed as inflamed. The current thinking is that many presentations that have typically been called Plantar Fasciitis are actually Plantar Fasciosis (degenerative tissue).

What to do about degenerative tissue?

First off, the most important thing to know is that degeneration does not hurt. This is heresy, I know, but it is what the research/science supports. You have to consider the nervous system whenever pain is involved. So, if you have pain and a degenerative state tissue you’ll have to handle the nervous system too, but I’ll get to that in a minute. Changing the environment of the tissue to one of building instead of breaking down is what is required. There are multiple ways to accomplish this and one specific form of exercise called eccentric loading has research to support it.

More misconceptions:

What is an often overlooked component to foot pain, especially when the pain won’t seem to go away or stay away, is the nervous system. The plantar nerves reside in the same area and are a more logical culprit for these symptoms much of the time. Nervous system can become sensitive in absence of inflammation. Think about a time when you’ve been outside in the cold without gloves and then went directly to take a hot shower. The water feels 10 times as hot on your hands as it does on the rest of your body. This is an example of nervous system sensitivity of the temperature sensing nerves. You wouldn’t think that your hands are inflamed when this happens, would you? This same phenomenon happens in the nerves that sense movement through stretch or pressure.

Nervous system gets sensitive for an almost infinite number of reasons and is a very complex process. The easiest way to think of it is like a moody friend (click on the first link when the page opens).

So, what do you do for nervous system sensitivity?

The good news is that when the problem is sensitive nervous system there is nothing “wrong” with your foot. Sensitivity is a normal function of your nervous system and all testing and imaging would come back negative. But, if you treat the foot as if it is inflamed, (rest, ice, compression, and elevation) you’ll be treating a problem that isn’t there and often times the pain returns as soon as you resume your normal activities. You treat a nervous system that is sensitive to movement…..with movement. Only not just any old movement will do. You’ll want to move in a way that does not cause the moody friend to show its teeth. Then you’ll gradually want to move more and more, exposing the nervous system to ever increasing movement and activity. My friend and colleague, Jason Silvernail, wrote an excellent essay called “watering the grass” (click on the 2nd link on the page that opens) that helps clarify this concept.