Plantar Fasciitis...arch too high or too low?

Comment

Comment by Erik Dalton, Ph.D. on November 21, 2009 at 4:21pm

People presenting with a pes cavus foot and plantar fasciitis are sometimes difficult to fix. Particularly if the foot has claw toes. Thx for the tip Seth...sounds like a winner.

Comment by Seth McLaughlin on November 21, 2009 at 11:49am

In people with PF and a high arch, I've often found that the talus is anterior on the calcaneous pushing the navicular bone up and forward. To correct this, I work with tib/fib balance first. Then, I traction the calcaneous with inferior pressure, traction the rest of the foot with the other hand with ventral pressure and then dorsiflex the foot. Often, this stretch allows the talus to return to a more healthy position and takes pressure off of the arch.

Comment by Erik Dalton on August 6, 2009 at 6:55am

Hey Doug:
Thanks for the post. Can you re-post the YouTube link...didn't show up on my computer...thx...

Comment by Doug Alexander on August 6, 2009 at 6:37am

One of things mentioned above was gastrocnemius/soleus release. I recall reading a journal paper some years ago, that the more superficial fibers of the achilles tendon don't anchor on the calcaneus, but continue on into the foot and blend with the plantar fascia. This probably provides a direct fascial continuity mechanism between shortened, tense and inelastic gastro-soleus and plantar fascia strain. Every time your foot strikes and goes through dorsiflexion in gait, a tight gastro-soleus will put excessive strain into the plantar fascia. I guess this would be true even if the achilles fully anchored and stopped at the calcaneus, too. You can see a calf stretching video I recently posted at YouTube that takes into account protection of the calf with supportive shoes. It is at:

Comment by Margie Nickles LMT, BS in Educ. on July 17, 2009 at 5:37pm

I have had bi-lateral plantar fascitis for over a year and would have to agree with Eric Dalton about the lateral/anterior compartments being weak/inhibited and the gastrocs/soleus being hypertonic. I have had "total involvement" of the entire lower leg and plantar fascia. With my experience, I would say that the extreme stretching used in physical therapy sessions in general does not help much with pain reduction and probably aggravates it more so. I have been concentrating on the fast paced stim technique for the posterior and trying to strengthen the lateral/anterior; the posterior area is starting to loosen but the anterior ankle area fascia is still really tight. The inflammation to the entire area for so long is "unreal."

Comment by Erik Dalton on July 13, 2009 at 5:23pm

Yep! Gotta work all the way up through the kinetic chain to help this painful condition....and, of course, the muscles of the posterior and lateral compartments are crutial elements in a successful treatment protocol.

The most common misperception students bring into class is the idea that all the leg tissues need lengthening. The late great Vladimir Janda, MD and his research team found the gastroc/soleus complex to be typically tight and neurologically facilitated while muscles of the lateral compartment typically weak and inhibited. So, it's important to observe gait and test foot and leg function to identify muscles that need lengthening and those which need to be strengthened or tonified.

Comment by Jackie McLaughlin, LMT, MTI on July 13, 2009 at 11:40am

I have had much success in dealing with plantar fasciitis by not focusing only on the structures of the foot, but also spending quality time in the deep muscles of the lower leg - when my clients have gotten relief after a few treatments, they have stated that the only thing I did differently than other therapists and medical practitioners that they had seen was the work in the lower leg - this seemed to offer them a more complete recovery.

Comment by Erik Dalton on July 11, 2009 at 10:31am

Thanks guys for all the informative posts. Seth’s success with lengthening the gastroc/soleus complex is one well-documented method for relieving plantar fascia tension. Calf muscle shortness often develops from overuse or injury and can result in fascial bag adhesions. When fascial bags and the deep investing fascia become “glued-down”—as Ida Rolf used to say—the entire posterior compartment shortens and we’re forced to lift the heel too early. At the moment the heel of the trailing leg begins to lift off the ground, the plantar fascia endures tension that is approximately two times body weight. This moment of maximum tension sharply increases if there is lack of calf muscle flexibility. Of course, there are many other predisposing factors and treatments to be considered when dealing with the complexities of the plantar fasciitis puzzle.

Anatomical variances that can strain the fascia include leg length discrepancy, flat feet, high arches, and lax ligaments. Biomechanical theorists have focused on lack of control of the hindfoot as the culprit. As stated earlier, over-pronation during the midstance phase of gait is one of the leading causes of plantar fasciitis. Over-pronation typically results from postural asymmetry, obesity, decreased strength of the intrinsic foot muscles, or inhibition of the muscles of the stirrup spring system, i.e., tibialis anterior/posterior and peroneus longus. Deep tissue lengthening or stretching of these muscles is counterproductive...they require restoration of contractibility…not extensibility. I find fast-paced ‘muscle-stim’ techniques beneficial in bringing tone to these overstretched, neurologically inhibited tissues.

The proximal and distal tib/fib joints are frequently neglected in the plantar fasciitis pain puzzle because their function is not well understood or documented. I find these joints to be “key lesions” in many lower extremity disorders. When working properly, the tib/fib articulations should perform as magnificent shock absorbers with their actions enhanced by properly toned ‘stirrup’ muscles and kept in sync by a resilient but tough interosseous membrane.
Each time we take a step, all our body weight rests on the heel of one foot. As the foot flattens and the tibia internally rotates, a great deal of pressure is placed on the plantar fascia. If the foot overpronates, the arch falls excessively causing an abnormal stretch of this relatively inflexible structure. Most heel pain arises from partial tearing or avulsion of the plantar fascia at the medial calcaneal tuberosity. Some studies show a lack of inflammation in many plantar fasciitis cases. As the highly innervated periosteum is pulled away from its attachment, loss of blood circulation allows calcium to leach out from the injured periosteum causing a bony spur. Lemont (2003) defined it a ‘fasciosis’ very similar to what has been termed Achilles tendinosis (rather then tendinitis).
Assessment and treatment for any painful disorder should incorporate a wholistic approach aimed at re-establishing proper function and structural balance to the entire musculoskeletal system. Visit “Foot Posture and Low Back Pain” e-newsletter @ www.erikdalton.com/NewslettersOnline/May_09_Newsletter.htm for additional examples of the relationship of foot posture and other kinetic chain structures. Thanks again for your input…

Comment by Seth Delaney on July 10, 2009 at 4:49pm

I absolutely agree that knowledge and full understanding of any physical problem is helpful. I am not against any of that. If my post appeared to dis theoretical knowledge that was unintended. I only intended to state what I have seen and learned in the massage room re plantar fasciitis and to bring a little balance to what appeared to me to be a bit heady.

Comment by Nickie Scott on July 9, 2009 at 2:13pm

I worked with New York City Ballet for many years and plantar fasciitis was common amongst dancers. One of the main recommendations that the orthopedic doctor for the company gave the dancers was to make sure that when they first got out of bed in the morning that they immediately put on arch supported shoes until the connective tissue matrix heated up enough to allow the arch to stretch without damaging the tissue. Stretching of the plantar surface of the foot can be counterproductive and can cause more inflammation. A thirty minute foot bath followed by a thirty second to no more then three minute ice cold foot bath should be done before stretching or massage to help relief this condition. The person should also roll their foot over a tennis ball gently at first and then more firmly within the pain threshold to help stretch the connective tissue. Certainly any myofascial release on the leg and trigger point work there also helps to reduce the splinting effect. Muscle stripping in both the crural and sural regions would help give some relief. We would also need to look at shoe wear patterns, foot size anomalies, excessive loading, familial connective tissue pathological history, work loading etc. etc.. Bartenders, waitresses, construction workers, dancers, pregnant women and anyone who is on their feet for long periods of time should be given self help techniques to help address the problem. Some people say that magnet pads for the shoes work for them although I haven't seen enough evidence of this. As to the question of whether the arch is to high or to low, either can be the case. Excessive stretching of the longitudinal arch in flat footed people can cause the entire fascial network be overloaded but if this were the only criteria then most people with flat arches would have plantar fasciitis and the same would be true of high arched people. Hypertonicity with excessive loading would seem to be the main problem. Since excessive loading seems to be the main cause reducing the loading would be the best cure for the problem.

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