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Maybe or Maybe Not!
By Scott Greenapple, DC, CCSP, FIAMA
One of the more common problems that come into the office especially with runners is the complaint of arch or heel pain. Through a variety of “experts” including the internet, other runner’s, other doctors, therapists etc. the athlete has been given the diagnosis of plantar fasciitis. They have heard a variety of treatments that have cured at least one of their friends. Active Release Technique, cross friction massage, acupuncture, laser, dry needling, Graston, taping, soaking raisins in rum, (yes I am certified in all the above, except raisin soaking), are just some of the multitude of options out there. They have also heard the statistics of the possibility of stopping them from running for months to even years. Cortisone shots, stretching, Epsom salt baths, orthotics, golf ball massage, you name it and there is person preaching it. So why is this so hard to treat, and why are the results all over the board? Most of the time, the diagnosis and treatment were limited to the plantar fascia, which is rarely the only issue at hand.
Due to the limited space for this article I will try and keep this as simple as possible and not go into great detail about form and running analysis. We will take the assumption that most of the arch and heel pain that comes in is due to excessive pronation (arch collapse) which is the most common foot that has this, but certainly not the only one. I see many cases with the opposite type of foot, a high rigid arch that supinates.
Anatomy and proper knowledge of what muscles and bones do as levers is the key to sports medicine and proper diagnosis and treatment. First of all when we speak of pronation or calcaneal (heel) eversion I want you to know that this is a normal part of the gait. Pronation has gotten a bad rap from the shoe industry, but it is very important in the gait cycle. The foot must pronate to absorb shock and then lock back into supination for its rigid lever to toe off. The foot should pronate about 8 degrees in mid stance. However we must look at the foot in motion not in a static view. We need the foot as a loose lever in midstance (pronation) to absorb shock and then a rigid lever in toe off using the calf muscles, gastroc, soleus and Achilles to push off. The problem starts when the athlete stays in midstance too long with pronation. Now, the tibia rotated internally along with the femur which causes the ilium to have an anterior tilt and the sacro iliac joint and low back to lock up. Did I lose you? OK, the leg goes in and the pelvis locks and so does the low back. All of this happens because your arch hurts? Or does your arch hurt because all the above started first?
When the active muscles of pronation and supination get inhibited they can’t support the soft tissues and the plantar fascia gets inflamed. You can treat the plantar all you want but it will never get better until you fix, and strengthen what is wrong. There are several muscles that can be involved in the arch of the foot. Short toe flexors, (flexor hallicus brevis), Flexor hallicus longus, Posterior Tibialis, and peroneus longus (fibularis), Tibialis anterior just to name a few, (see the picture zone of confusion). Most of those muscles go up the leg and can be affected or inhibited there. They then can affect the entire movement or kinetic chain of the entire gait cycle. Those are just the common muscles of the foot, what about the bones?
There are 24 bones in the foot. The most common ones affected in the diagnosis of plantar fasciitis are only six. The calcaneus, talus, navicular, medial cuneiform, first metatarsal and lateral cuneiform. So the question is how do we treat the common junk diagnosis of plantar fasciitis?
First off, proper diagnosis as always is key! Look at all the biomechanics involved. After that, I treat the bones and muscles of the foot first. Meaning through neuromechanical impulses and adjustments of both the bones and the muscles we can stimulate nerves that control balance, ligaments and fascia. This helps the firing pattern to help with timing of pronation and supination. Then go up the leg, tibialis posterior, tibialis anterior and then to the hip, sacro iliac joint and low back. Sound complex, you bet. The body is complex and so are most injuries. This is why a simple condition like plantar fasciitis can be so frustrating. After treatment, rehab to all of those areas is crucial. I will leave you with two simple exercise that you should do right away. Yes these are for rehab and prehab as no runner wants to get plantar fasciitis. Remember the foot is an important part of the body and needs to be strengthened! Due to the limitation of this article, feel free to email for more exercises, stretches and any questions. Now go run!