(see also New Treatment for Plantar Fasciitis )
Most Illustrations by Dennis Mojo Homack, D.C.
Russ Ebbets has been in these pages before. He is on the faculty at New York Chiropractic College, Seneca Falls, N. Y., and is the author of the humorous memoir of his freshman year on the Villanova track team, Supernova. The information here is presented through the eyes of a track coach - chiropractor. Plantar fasciitis is a common foot injury in track, and this article presents Ebbets's views from his own experience in coaching, travel, and schooling.
Consult your healthcare professional before you operate on yourself.
The plantar fascia is a thick fibrous band that runs the length of the sole of the foot. The plantar fascia helps maintain the complex arch system of the foot and plays a role in one's balance and the various phases of gait. Injury to this tissue, called plantar fasciitis, is one of the most disabling running injuries and also one of the most difficult to resolve. Plantar fasciitis represents the fourth most common injury to the lower limb and represents 8 -10% of all presenting injuries to sports clinics (Ambrosius 1992, Nike 1989). Rehabilitation can be a long and frustrating process. The use of preventative exercises and early recognition of danger signals are critical in the avoidance of this injury.
ANATOMY AND FUNCTION OF THE FOOT
The foot is an architectural marvel. Together, the feet contain one fourth (52 of 208) of all the bones in the body. Structurally there are three arches (transverse, longitudinal, lateral) that provide support, stability and aid in locomotion. The three- arch system contains an elaborate support system of ligaments, tendons and muscles - the largest of which is smaller than one's thumb. Ground impact forces of running or jumping can multiply the stress on the foot 3-22 times one's body weight (Hay, 1994). Any muscular imbalance, ligamentous laxity or aberrant mechanical action (due to injury, flat feet, high arches, blisters, etc.) predisposes the foot to injury.
The largest bone in the foot is the calcaneus. The most common site of injury in the plantar fascia is at the attachment point of the plantar fascia on the medial tubercle of the calcaneus. The plantar fascia fans out over the sole of the foot ending on the plantar surface of the toes.
The calcaneus is also the attachment point of the achilles tendon/gastroc complex. The achilles attaches to the posterior superior aspect of the calcaneus and makes for a powerful lever. It is the forceful contraction of the gastroc that allows one to run and jump. Injury to or chronic shortening of the achilles/gastroc complex disrupts normal foot mechanics and predisposes the plantar fascia to injury.
The foot assumes two different roles during locomotion, that of surface adaptation and stabilization. During heel strike the foot is slightly supinated as it is during toe-off. Supination (ankle rolls out) locks in the bones of the foot making for a more rigid lever. During pronation (ankle rolls in) at mid-stance, the arch flattens, balancing the body's weight while at the same time absorbing shock.
The plantar fascia plays a key role in
both facilitating the "lock in" of the arch during supination and the
dissipation of shock during mid-stance. During the third phase of ground
contact, called toe-off, the plantar fascia is tractioned tight over the plantar
surface of the base of the toes. Due to the limited elastic qualities of the
plantar fascia, the arch is slightly raised, creating the rigid lever to better
apply the results of the forceful gastroc contraction. This is called the
windlass effect (Ambrosius 1992, Nike
During the mid-stance/pronation phase the arch flattens to absorb the shock of ground contact. Again the elastic qualities of the plantar fascia are tested. There is a limit to how much repetitive trauma this tissue can sustain before micro tears happen with pain usually presenting on the calcaneus.
Any foot problem that increases the pronation
phase can predispose the plantar fascia to injury. Many foot, knee, hip and low
back problems can be traced to an unstable subtalar joint. The subtalar joint is
made up of two bones, the superior talus and the inferior calcaneus. Injury to
or laxity of supporting ligaments of the subtalar joint can destabilize the foot
creating a situation of exaggerated or prolonged pronation during ground
Understanding the anatomy and mechanics of the foot and accepting that there are physiologic limits to the amount of stress soft tissues can sustain helps explain why the plantar fasciitis happens. Understanding the anatomy and mechanics of the foot also helps one design a successful rehabilitative program and gives clues for early identification of athletes at risk and time to initiate preventative measures.
SIGNS AND SYMPTOMS
Plantar fasciitis is usually found in one foot. While bilateral plantar fasciitis is not unheard of, this condition is more the result of a systemic arthritic condition that is extremely rare in an athletic population. There is a greater incidence of plantar fasciitis in males than females (Ambrosius 1992). While no direct cause could be found it could be argued that males are generally heavier which, when combined with the greater speeds, increased ground contact forces, and less flexibility, may explain the greater injury predisposition.
The most notable characteristic of plantar fasciitis is pain upon rising, particularly the first step out of bed. This morning pain can be located with pinpoint accuracy at the bony landmark on the anterior medial tubercle of the calcaneus. The pain may be severe enough to prevent the athlete from walking barefooted in a normal heel-toe gait. Other less common presentations include referred pain to the subtalar joint, the forefoot, the arch of the foot or the achilles tendon (Brantingham 1992).
After several minutes of walking the pain usually subsides only to re turn with the vigorous activity of the day's training session. The problem should be obvious to the coach as the athlete will exhibit altered gait and/ or an abnormal stride pattern, and may complain of foot pain during running/jumping activities.
Consistent with plantar fascia problems the athlete will have a shortened gastroc complex. This can be evidenced by poor dorsiflexion (lifting the forefoot off the ground) or inability to perform the "flying frog" position. In the flying frog the athlete goes into a full squat position and maintains balance and full ground contact with the sole of the foot. Elevation of the heel signifies a tight gastroc complex. This test can be done with the training shoes on.
CAUSES OF PLANTAR FASCIITIS
Plantar fasciitis is usually not the result of a single event but more commonly the result of a history of repetitive micro trauma combined with a biomechanical deficiency of the foot. Arthritic changes and metabolic factors may also playa part in this injury but are unlikely in a young athletic population. The final cause of plantar fasciitis is "training errors." In all likelihood the injury is the result of a combination of biomechanical deficiencies and training errors.
Training errors are responsible for up to 60% of all athletic injuries (Ambrosius 1992). The most frequent training error seen with plantar fasciitis is a rapid increase in volume (miles or time run) or intensity (pace and/or decreased recovery). Training on improper surfaces---a highly crowned road, excessive track work in spiked shoes, plyometrics on hard runways or steep hill running---can compromise the plantar fascia past elastic limits. A final training error seen in athletics is with a rapid return to some preconceived fitness level. Remembering what one did "last season" while forgetting the necessity of preparatory work is part of the recipe for injury.
Metabolic and arthritic changes are a less likely cause of plantar fasciitis among athletes. Bilateral foot pain may indicate a metabolic or systemic problem. The definitive diagnosis in this case is done by a professional with blood tests and possibly x-rays.
Far and away the most common cause of plantar fasciitis in an athlete is faulty biomechanics of the foot or leg. Faulty biomechanics causes the foot to sustain increased or prolonged stresses over and above those of routine ground contacts. Throughout the phase of ground contact, the foot assumes several mechanical positions to dissipate shock while at the same time placing the foot in the best position to deliver ground forces. With heel landing the foot is supinated (ankle rolled out). At mid-stance the foot is pronated (ankle rolled in). The foot is supinated again with toe-off.
The supination of the foot at heel strike and toe-off makes the foot a rigid lever. At heel strike the shock of ground contact is transferred to the powerful quads. During toe-off forward motion is created by contraction of the gastroc complex plantar flexing the rigid lever of the foot pushing the body forward.
Foot problems, specifically plantar fascia problems, arise when the foot is held in either supination or pronation too long. Although a person may have minor biomechanical problems that are of no significance during walking the increased ground contact forces of athletics (3-22 x body weight) exacerbate a bad situation.
One of the major biomechanical faults is a tight achilles tendon/gastroc complex. A tight gastroc holds the foot in a pronated position, decreasing the foot's ability to supinate on ground contact and toe-off (Ambrosius 1992). By decreasing the effectiveness of the foot as a rigid lever, the ground impact forces of heel strike and toe-off must be borne by the muscles, ligaments and tendons of the foot. Since the foot is already in an artificially pronated position, the desired pronation of midstance is prolonged, further stressing the soft tissues of the foot, especially the plantar fascia.
While a tight gastroc creates a hypomobile foot, a hyermobile foot can also cause plantar fasciitis. In a hypermobile foot (due to a history of ankle sprain, and/or ligamentous laxity of the subtalar joint) there will also be prolonged or increased pronation which results in micro trauma, inflammation and fibrotic tissue formation to the plantar fascia (Ambrosius 1992).
Excessively high arches may also predispose the foot to plantar fasciitis. There are no definitive parameters as to what constitutes arch height. The logic of the arch height theory is that with a higher arch there is a potential greater range of motion of the longitudinal arch during mid support flattening.
A second part of the high arch theory points to the windlass effect. During the toe-off phase the toes are dorsiflexed (pointed upwards). The arch rises up into a packed position making the foot a rigid lever and the plantar fascia is tractioned tight by the dorsiflexed toes. The higher the arch the greater the potential range of motion. The increased stresses on the foot from athletic participation and/ or biomechanical deficiency may pro- duce micro tears that develop into plantar fasciitis.
Uneven leg length due to fixed pelvic rotation (a functional short leg) or congenital or acquired causes (anatomical short leg) can force the foot of the longer leg into a compensatory hyperpronation (Hammer 1992). While it might be necessary to "build up" the anatomical short leg with some type of lift, to do so with a functional short leg invites future low back, knee, hip or ankle problems. Leg length discrepancy can be evaluated by having the athlete sit on the ground with the legs extended. Check the ankle bones (malleoli) for even- ness. Any difference greater than 1/ 8" should be evaluated by a professional.
Footwear also plays an important role in plantar fasciitis. If ground contact forces are increased with running or jumping the obvious solution would be to increase the shock absorption qualities of the shoe. While the shoe companies have done an excellent job of improving the shock absorption of the shoe, they are faced with a dilemma. To significantly in- crease shock absorption with present technology necessitates substantially thickening the shoe's sole. This "solution" creates the problem of rear foot instability, in particular the subtalar joint, which has been established as one of the causes of plantar fasciitis.
A final cause, frequently overlooked or ignored, is the role myofascial trigger points play in disrupting the joint mechanics of the foot. Trigger points in the muscles of the foreleg (gastroc, soleus, peronei, anterior tibialis) can disrupt the desired biomechanics of the foot and ankle through the phases of ground contact, disrupting the supination-pronation-supination sequence.
Trigger points are due to direct muscular fatigue, direct trauma, or chilling (Travell 1992). The gastroc and soleus muscles play an important role in body posture and are therefore under stress throughout upright movements, not just athletic activities. If one pinches the pinky and the thumb together the tissue on the side of the palm below the pinkie will have a soft spongy feel while the muscle directly under the thumb will have a hard end feel. Healthy muscle should have a soft and spongy feel. Lumpy areas, areas of point tenderness or a hard feel may be trigger points.
Treatment of plantar fasciitis can be a long and
frustrating process for both the coach and athlete. If you do not have a firm
grasp of the goals of this rehabilitation program your best advice will be to
find a professional who routinely deals with athletic injuries. The "down
time" for plantar fasciitis will be at least six weeks and up to six months of
conservative care before drastic measures like surgery should be
The goal of this rehab program is to initially increase the passive flex- ion of the foot eventually leading to improvements in dynamic balance and flexibility of the foot and ankle, followed by a full return to function.
The first thing to be done is to discuss the treatment goals and rehab plans with the athlete. He/she must understand the goals and commit to achieving them. Assenting to a pro- longed period of relative inactivity is difficult for highly motivated individuals. A partial commitment can make plantar fasciitis last forever , decreasing both the quality and enjoyment of further athletic participation, if that is possible at all.
Rehab begins in bed. Have the athlete check the sheets at the foot of the bed he routinely sleeps in. Tight sheets at the foot of the bed force the foot into plantar flexion (straight out) position that promotes a short, tight gastroc complex that can over time lead to chronic shortening of these muscles, the exact opposite of one of our goals. This may seem like a small point but remember one-fourth to one-third of one's life is spent in bed.
A second point for the bed is to purchase a night splint. This idea was given to me by a colleague who re- ports great success with it (Lewandowski 1994). A night splint passively holds the ankle joint in an anatomically neutral position. This not only allows the plantar fascia to heal in this position but also insures the foot will not slip into the plantar flexed position during the night. See the references for suppliers.
The final "bed treatment" is to place a heating pad near the foot of the bed. In the morning, before rising, the athlete turns on the heating pad under the gastroc muscles for 3-5 minutes and then rises to stretch. The athlete is NOT to sleep with the heating pad on. The goal is to quickly get some extra blood flow to the area which will help loosen up the lower leg. It is generally accepted that hot, moist heat is more effective than the dry hot heat recommended here. Dry heat is chosen because of practicality. Now the athlete can rise from bed.
The athlete's first foot contact with the floor should be non-weight bearing. From a seated position a quick scan of the musculature of the foreleg is made looking for trigger points. Healthy muscle tissue should have the soft pliable consistency of the pinkie side of the thumb-pinkie pinch mentioned above. If any areas have a hard end feel like the thumb side it is a sign that the muscle is overly taut and needs muscle work. Gentle kneading over a period of days should restore the soft feel to the muscles. If the tight areas persist the professional help of a chiropractor or massage therapist will be necessary.
The self-massage should continue down the foreleg to the foot. If the point tenderness at the medial tubercle of the calcaneus is particularly bad, avoid this area. Next, take a minute to bend the toes up and down (plantar flex and dorsiflex).
At this point one can extend the legs and wrap a towel around the forefoot to offer resistance for plan- tar flexion (foot out straight) and increase the stretch of dorsiflexion (foot drawn towards the body). Variations can include doing circles or writing the alphabet with the foot.
After a minute of the towel work the athlete can bring the feet under the butt and sit back on the heels. In the acute phase this stretch is not recommended. Pressure should be gradually increased so that a gentle stretch is felt along the soles of the foot. This stretch should not be done ballistically (quick bounces). Three times 7 -8 seconds will be plenty. At this point the athlete can rise to his/ her feet.
The next phase of care involves management of plantar fasciitis in conjunction with the activities of daily living. Depending on one's philosophical bent, one might consider medical steroidal anti-inflammatory injections into the plantar fascia to reduce pain (Ambrosius 1992). Effectiveness of the steroids depends on the accuracy of the injection and the athlete's compliance with this period of reduced activity. It should be noted that 10 of 11 cases of spontaneous rupture of the plantar fascia followed steroidal injections and an aggressive return to activities. (Ambrosius 1992)
A second consideration is to tape or strap the foot. The Low-Dye method of taping has been recommended (Brantingham 1992). This taping technique can also be used on healthy athletes racing in spiked shoes.
Inspection of the footwear is
critical. The athlete should make every effort possible to wear shoes that are
comfortable and do not foster poor foot postures. If arch supports sold over the
counter are not satisfactory one must consider either a podiatrist or
Debate has raged for decades as to whether or not orthotics are necessary or simply a crutch (Keating 1992). The Russians have no translation for foot orthotics and subsequently do not use orthotics. When asked about the severity of their athlete's foot problems I was told, "We have no foot problems. We strengthen the foot." This is also one of our goals.
Although the pros and cons of orthotics are not within the scope of this article, understanding of the different types of orthotics available makes one a wiser consumer .
The theory behind orthotics is simple. Feet that pronate (arches roll in) have a prolonged mid-stance phase of ground contact and may cause excessive internal rotation of the tibia. As has been established, the excessive pronation can compromise the plantar fascia while the excessive rotation may injure the knee. These faults can lead to hip and low back pain because they allow the affected leg to drop unevenly, stressing the supporting muscles and ligaments of the hips and low back.
Orthotics, by forming a solid foundation for the foot, can prevent excessive pronation and therefore check excessive or aberrant movement further up the kinetic chain of the leg. Physicians who routinely use orthotics (podiatrists and chiropractors) can cast two different types of orthotics - biomechanical/functional or accommodative orthotics.
The biomechanical/functional orthotic "is capable of controlling functional pathology of the foot and legs by maintaining the foot in its neutral subtalar position or close to it." (Hammer 1992) The criticism of the functional orthotic is that over time it will cause the muscle of the foot to weaken and atrophy and serves more as a crutch than a curative measure (Keating 1992). Biomechanical orthotics are usually cast in a non- weight bearing position with the foot held in a "subtalar neutral" position which is the anatomically correct position of the foot.
The accommodative orthotic is made of a softer, more pliable material. This type of orthotic is usually casted weight bearing, with the main goal and function to supply "accommodative support and act as a shock absorber." (Hammer 1992) The drawback of accommodative orthotics is that due to the tremendous forces the foot must sustain these orthotics can lose their shape and subsequent effectiveness over time.
The decision of functional versus accommodative orthotics is not within the realm of the coach or athlete. With one of the goals of rehabilitation of the plantar fascia being to strengthen the foot, less emphasis can be placed on the orthotic as foot strength improves. We have had tremendous success with the foot drills described below.
The ability to maintain general physical fitness and specific cardio-vascular fitness is an important goal throughout the rehabilitation period. There are several proven methods that can maintain fitness levels while at the same time not placing stress on the plantar fascia that would delay recovery or possibly reinjure the healing tissue.
An overall weight training pro- gram can be instituted as soon as possible. Event specific routines can be developed. All calf work, toe raises, etc., should be avoided.
Two other commonly used rehab modalities that might be considered are bicycle riding and water training. Bicycle riding, either stationary or street, may excessively stress the plantar fascia and probably should be avoided until there is no pain for several weeks. Water training, on the other hand, can begin immediately. There are several flotation devices on the market that can be used. Workouts can be designed that simulate distance runs or interval workouts. The water should be deep enough so that there is no ground contact. The goal of this type of work is to maintain some cardiovascular fitness, with the secondary benefits being improvement in running technique and strength of the hip flexors.
Once foot pain has subsided and there are no problems that arise from walking, one can begin the foot drills. By themselves the foot drills will not create any significant overnight change. Used on a daily basis the foot drills accomplish several goals. They improve range of motion, proprioception, flexibility and strength of the foot. They take all of three minutes to complete and are the most important preventative measure one can take. Done by a healthy athlete, they will prevent shin splints, achilles problems and greatly reduce foot and leg problems.
The six foot drills are done once daily (or before each workout) in stocking feet. The athlete walks 25 meters 1) on the outside of the foot, 2) the inside, 3&4) with the toes pointed in/out, 5) up on the toes, and then 6) with the shoes on, 25 meters walking on the heels. These drills are very simple, there should be no pain or problem. The positive effects of these drills are cumulative.
Before starting to run get a pair of HARD plastic heel cups. This is the solid plastic cup, such as invented by Bill Falk of M-F Athletic Company. You do not want anything that props up the heel making the foot more un- stable. Trimming off the back of the heel cup prevents blister formation.
Heel cups should be worn all the time in training and racing shoes. There are two theories as to why heel cups help. The heel cup cradles the bottom of the heel bone and does not allow the protective fat pad at the base of the heel to spread out on ground contact, thereby increasing the shock absorption capacity of the foot. The second theory is that during the push-off phase the heel cup loses contact with the foot, creating an air gap. Upon ground contact this slight "air cushion" helps decrease ground contact forces.
Use of an "eight board" or wobble board will increase the range of motion of the ankle, increase proprioception and strengthen the small intrinsic muscles of the foot. The eight board is easy to construct and should be used daily. Incline boards are also useful for stretch of the gastroc complex. Once pain in the plantar fascia has subsided this stretch can be used both mornings and evenings.
A return to running should be considered only after there is a three to four week period of no pain. The return is done gradually, on a level surface, and initial workouts are short. Going to a track (smooth, flat surface) and running a series of 100m runs (one should not run too fast or too far and there are no turns) slowly will introduce running to the injured foot. Initially this can be done for 15 - 20 minutes, eventually extending the workout for 30 minutes, all without pain. Supplemental training will include the aforementioned water training and some light calf work.
After two to three weeks of pain- free training on the flat smooth track one can consider going to the roads. Begin with shorter 20-30-minute workouts. If no pain or problems arise, slowly increase the distances run to the point where one is training normally after about a month. Even in the pain-free state the morning exercises and preventative exercises should continue to be done.
The foot must sustain tremendous
forces during athletic competition. Any and all measures taken to improve the
shock absorptive qualities, intrinsic strength and proprioceptive balance of the
foot will only enhance athletic
Injury to the plantar fascia can be difficult to resolve and will require a prolonged recovery period. Halfhearted or sporadic attention to rehabilitation of this injury will produce minimal results. Far and away the most common cause of plantar fasciitis is a series of biomechanical factors (high arch, poor stability, tight gastroc complex, uneven leg length, myofascial trigger points) that combine to produce cumulative micro traumas by stressing the plantar fascia past its elastic limits.
Rehabilitative goals must include passive stretching of the gastroc complex, increasing the range of motion, dynamic proprioception and strength of the foot. The use of heel cups and orthotic supports for the foot should be considered.
Personal experience has taught that daily use of the eight board, in- cline board, heel cups, morning stretches and foot drills will drastically reduce the incidence not only of plantar fasciitis but also achilles tendinitis, shin splints and knee problems in any athletic population. An ounce of prevention is still worth a pound of cure.
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