Foot pain can be a stubborn problem, but...
For some people, pain in the bottom of the foot can be just an annoyance during the first few steps out of bed in the morning. But for others, it can be a debilitating problem that can sideline even the most determined athlete. In my practice, patients often come in saying they have Plantar Fasciitis. Sometimes they do and sometimes they don’t. “Plantar Fasciitis” is one of the most common misdiagnoses that I encounter. This is understandable considering that there are many other causes of pain in the bottom of the foot. Here we will break down the most common causes of foot pain, what true Plantar Fasciitis really is, and how to treat it.
The worst thing you can do for Plantar Fasciitis!
First, what is Plantar Fasciitis? Even the name Plantar Fasciitis is misleading. First of all the anatomical structure that causes Plantar Fasciitis isn’t really fascia at all, it’s actually a type of aponeurosis, a thickened connection between the fascia and the bone. This is important because this tissue doesn’t get much blood supply and doesn’t really become swollen, as is implied by the “itis” name. So, when you understand this you know why a common treatment for Plantar Fasciitis is the absolute wrong thing to do! Since the problem isn’t inflammation, taking an anti-inflammatory won’t help. But worse than that, ibuprofen, a common anti-inflammatory recommended for Plantar Fasciitis probably contributes to stress fractures in the foot! This makes Ibuprofen the worst thing you can do for Plantar Fasciitis, yet it’s the most common recommendation!
The second worst thing you can do? Steroid injections. While this might be able to temporarily relieve plantar fascia pain, it will not cure the problem. Worse, steroid injections can cause the fat pad on the bottom of the heel to shrink, causing more pain and injury, plus they may cause the plantar fascia to rupture. Not what you want at all!
What is it?
In true Plantar Fasciitis, there is injury or damage to the connection between the Plantar Aponeurosis and the heel bone, or calcaneus. The cause seems to be entirely biomechanical in nature. And since my practice is based on solving the true cause of musculoskeletal problems, that’s where we’ll focus. It’s becoming clear through research that the number one cause of Plantar Fasciitis is reduced dorsiflexion of the ankle. That’s when the ankle does not flex (think of standing and bending your ankle so your knee moves forward) as much as it should.
How Do You Treat Plantar Fasciitis?
Many treatments can help the tissue heal faster, including Active Release Technique, dry needling, or extracorporeal shockwave therapy, even gently rolling the foot over a golf ball or frozen water bottle can help some people. However, the most important factor is changing the ability of the ankle to dorsiflex. A very careful examination of biomechanics, especially of the lower extremity is required and there are usually multiple causes of reduced dorsiflexion.
Some of the more common causes are tight or rigid calf muscles like the gastrocnemius and the soleus, poor function of the flexor hallucis longus (big toe) muscle, ankle joint capsule function, and ankle ligament function. All of these can usually be treated with manual therapy and exercise, but in most treatment protocols, they are ignored because they aren’t usually painful. Occasionally there is a more global problem. Weak or ineffective gluteus major muscles and poor core stability can both contribute to poor ankle function.
One of the greatest errors of all manual therapy treatments is the propensity to focus solely on the painful tissue. By taking a more “whole-body” approach we are often able to resolve even the most stubborn problems when many treatments have already failed.
When treatment of Plantar Fasciitis fails, it is often because the problem isn’t really Plantar Fasciitis at all. Pain on the bottom of the foot may be caused by other tissues. And each of these must be approached differently than Plantar Fasciitis. Some common causes of foot pain that are mistaken for Plantar Fasciitis are often overlooked.
Pain in the adductor hallicus muscle can resemble Plantar Fasciitis. Often this muscle of the big toe will be overworking when the gluteus maximus muscle is under-working. Another common cause of foot pain is a nerve entrapment on the bottom of the foot. Sometimes, a heel spur is the cause, although usually heel spurs that show up on X-rays are asymptomatic and not the cause of pain.
In order to resolve Plantar Fasciitis or any pain on the bottom of the foot, the first step must be a careful diagnosis. Understand, that there are many causes of foot pain and continually addressing the wrong tissue or ignoring the mechanical dysfunction that causes the irritation will undoubtedly lead to months or even years of frustration.