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

Many of us tend to blame plantar fasciitis on pronated or pes planus feet but what about clients with a high rigid arch, i.e., supinated or pes cavus foot? Although prolonged duration of pronation is thought to be the most common mechanical cause of structural strain resulting in plantar fasciitis, I’ve found that a pes cavus foot places as much or more strain on the plantar aponeuroses and peroneals and can be much harder to fix. Loss of flexibility in the stirrup spring system causes the foot to absorb too much force too quickly. How do you treat plantar fasciitis in your practice?

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Comment by Holger Hubbs on July 9, 2009 at 12:16pm: Howard, we are both on the same page.

Comment by Howard Weingarten on July 9, 2009 at 10:44am: Holger,

Actually, a balance between theoretical concepts and hands-on skill is a fortuitous one for the massage therapist. Having a working knowledge of "body parts and conditions" gives the therapist a basis for performing good effective manual therapies.

Comment by Holger Hubbs on July 9, 2009 at 9:08am: Thank you Seth for your post! Simplicity may intimidate an expert. Naming body parts and conditions has its place in the mental realm.

Comment by Howard Weingarten on July 9, 2009 at 8:15am: Erik,

Pes cavus can cause probs with the plantar fascia via the "spanish windlass" mechanism of the fascia rolling over the metatarsal heads and tightening excessively, thus creating a pulling force on the anterior calcaneus. In addition to attempting to alleviate hypertonicity in the triceps surae, attention must also be given to tib posterior. As it is in the best position to limit overpronation, it is often hypertonic as well. This is often overlooked as a contributing problem, and one can spend lots of time stretching gastrocs/soleus without ever addressing what may be an important other component. Tib Post. is one of the unusual muscles in the body that has the fascial ability to stretch more than we can actually stretch it, therefore it tends to be a big player in faulty foot mechanics.

Comment by Seth Delaney on July 8, 2009 at 8:07pm: I don't know or remember all these anatomical terms yet have had very good results in myself and several clients over the years in relieving pain diagnosed as plantar fasciitis. Invariably I have found chronic tension in the calf muscles. If I recall my charts it is in the gastroc particularly. I don't have charts here and am not an anatomy scholar so I can't remember the entire correct term. At any rate, when I work out the tightness in that area the foot pain tends to be relieved. In my own case this strategy has kept me pain free for over 20 years. Sometime in the 80s I was diagnosed with Plantar fasciitis and got custom orthotics which I hated. A while later I discovered the extreme tightness in the back of my calves and developed techniques for releasing it. The foot pain disappeared. If the calf tension came back so did the pain. After a few sessions I managed to eliminate the chronic tightness and the plantar pain has only returned in rare circumstances when I"ve done something to overstress the calf muscles. Every time it was relieved by releasing them. After storing the expensive custom orthotics for a few years, I threw them away.
In the ensuing years when I have encountered clients with a diagnoses of Plantar fasciitis I have checked and virtually always have found a gastroc muscle more like a rock. When I worked on them they got noticeable relief right away. I have taught several clients how to work their own calves and they have been able to gradually eliminate the need for orthotics. I certainly don't claim to be a Podiatrist or diagnose or treat any disease, but if I remember my anatomy charts correctly, the tendon from the plantar fascia connects directly to the gastroc muscle in the calf yet everyone seems to be looking for the problem in the foot.
As I said,I'm not a scholar, just a hands-on massage therapist, but it seems to me that it may be less complex, in many cases, than the experts would have us believe.

Comment by Erik Dalton on July 8, 2009 at 6:55pm: Hey Bert:
I'm happy to see you include joint mobilization routines when dealing with foot disorders. Loss of joint play in any of the foot's many articulations will inhibit the muscle or tendon crossing that joint.

It is well documented that the most common asymmetry found in the lower extremity is foot pronation which typically results from a valgus subtalar joint (STJ) accompanied by a dropped navicular bone. In foot supination, the STJ is usually fixated in a varus position accompanied by a collapsed cuboid.

Most structurally-oriented manual therapists have witnessed how a rigid cavus foot creates strain in all myoskeletal structures (foot to lumbar spine) leading to disorders such as peroneus tendinosis, stress fractures, trochanteric bursitis, tibiofibular fixations and plantar fasciitis. Leg length asymmetry caused by a supinated or pronated foot can initiate a painful ascending syndrome pattern that travels up the kinetic chain damaging knee, hip, pelvic and low back structures.

Comment by Bert Davich on July 8, 2009 at 3:10pm: I have found that complaints of 'plantar fasciitis' often involve fascia other than the plantae, plantae fascia and the medial arch. To that end, my approach is generally to first find the areas of tension or constriction by manipulating the foot into plantar flexion, dorsi flexion, inversion & eversion with one hand while palpating for restrictions with the other hand. I also check for restriction of movement in the Tarsals, Metatarsals, and Phalanges, particularly in the anterior-superior direction. Twisting the joints in the foot (mindfully) while flexing and extending can also reveal restrictions not otherwise observable and provides some treatment at the same time. As restrictions are revealed I integrate myofascial lengthening techniques, acupressure and trigger point therapy appropriate to the client and condition. Particular attention should be paid to the retinaculum with any kind of myofascial foot pain as a probable contributor in restricting muscles & tendons that pass under it. Releasing a restricted retinaculum can be a key factor to foot pain relief. I refrained from recommending specific treatment such as "lengthening the quadratus plantae" because the goal is to achieve balance which may require more, less, or no lengthening of any given component.