Plantar fasciitis: A functional perspective

Plantar fasciitis is a common condition experienced by a wide variety of patients, and it can stem from numerous causes.

By definition, plantar fasciitis is the inflammation of the plantar fascia or aponeurosis. It can be caused by trauma, such as from a jumping or running activity, or it can have a more chronic nature from the longstanding stretching of excessively pronated feet.

The pain of plantar fasciitis is commonly at its worst when a patient is rising from bed in the morning. The first steps of the day cause a painful stretching of the tissue after hours of being in a shortened position. As a person sleeps, the feet naturally go into a position of plantar flexion, shortening the gastrocnemius, soleus and anterior compartment muscles including the tibialis anterior muscle.

The abrupt lengthening of the plantar fascia and lower extremity musculature caused by moving to a standing position can initiate a sharp pain. Mild relief is common after the patient has been up and moving about for a while.

Treatment considerations

Conservative treatments for plantar fasciitis have included reduced activity, cryotherapy, ultrasound, taping, massage and orthotic support. While these treatments all have their merits, there are a couple of other aspects to consider.

You’ll want to look beyond the site of the symptom to see if there are some “silent partners” contributing to this dysfunction, but consider the most obvious first: the foot.

If the patient is capable of walking without an antalgic gait, look to see if there is a significant amount of foot flare during the gait cycle. Here is the rule of thumb regarding foot flare: Both feet should be pointing in the general direction the patient is walking toward.

Any significant deviation from a line directly in front of the patient involving one foot more than the other is a red flag for a biomechanical dysfunction in the kinetic chain and may be a contributing factor in the plantar fasciitis syndrome.

Foot flare is a compensation mechanism to help balance an unlevel pelvis, and there is a strong likelihood that a low medial arch is contributing to this mechanism.

If this is detected, remove the shoe and sock and observe the medial arch. In more than 80 percent of your patients, you will see some degree of excessive pronation that is most often bilateral but occasionally you may see an asymmetrical presentation.

Research has shown that measuring the navicular drop from a non-weightbearing seated position to a weightbearing standing position is a predictable indicator of excessive pronation.^1,2 This test is a reliable method to document this aspect of your patient’s foot function and has a direct correlation to the Q angle of the knee.³

Gentle care is essential

Direct palpation of the plantar fascia may reveal painful fibrotic thickenings, especially along the medial longitudinal arch where it inserts into the antero-medial calcaneus. These fibrotic thickenings are result of the repetitive “tear and repair” process. With the foot relaxed, grasp the toes and gently pull them up into passive dorsiflexion.

The “gentle” part is essential; as this motion stretches the irritated plantar aponeurosis, it is frequently quite painful, and is an obvious positive objective sign.

A patient with plantar fasciitis will commonly also present with fixations or subluxations of the bones of the feet. The collapse of any of the three arches of the foot sets the stage for joint fixation and biomechanical compensation mechanisms.

It’s easy to place all the focus on the pain aspect of this syndrome, but remember the neurological implications. Any time there is joint fixation, whether it’s in the spine or foot, it’s inhibiting Type 1, 2, and 3 proprioceptive fibers and stimulating Type 4 nociceptive fibers, which will either create pain or stimulate the sympathetic nervous system.

Mobility and function

Mobility is life to a joint, so don’t overlook the benefit of adjusting the subluxations or fixations of the lower extremity. Check for joint fixation of the calcaneus, cuboid, talus and metatarsal heads and adjust as necessary. Once the acute phase of plantar fasciitis is under control, you can address the factors that contributed to the condition.

Most often, these patients will have a compromised arch structure that needs to be supported in an optimally functioning position. Flexible, custom-made stabilizing orthotics that support all three arches of the foot are indicated and provide the necessary support to reduce the tension on the plantar fascia by blocking the excessive pronation that stretches the plantar aponeurosis.

You should also address the muscular function of the lower extremity. If plantar fasciitis is present, there is often myofascial dysfunction in the gastrocnemius, soleus and tibialis anterior, as well as in the iliotibial band and quadriceps muscles. Latent trigger points in these muscle groups are asymptomatic but are easily triggered by palpation.

Proceed with caution

It is necessary to improve muscle function of the entire kinetic chain by massage or other forms of muscle management to improve muscle compliance, which is the ability of the muscle to contract and relax. Chronic muscle tension creates chronic joint dysfunction and is one of the contributing factors that can lead to the inflammatory process in the plantar fascia.

A massaging or mechanical compression down the length of the plantar fascia will usually restore some degree of flexibility to that tissue, but this should be approached cautiously. Having the patient roll the foot over a golf ball or similar device for the purpose of restoring fascia flexibility can have profound effects on foot pain and function.

Patient tolerance is the key to any technique used, so be gradual when increasing the pressure and the length of any intervention. The idea that if a little is good, then a lot is better can result in a painful aggravation of the condition and a very unhappy patient.

Be clear in your instructions and you will be successful in guiding your patient out of the inflammatory stages of plantar fasciitis toward a better-functioning foot.

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References

1. Brody D. Techniques in the evaluation and treatment of the injured runner. Orthop Clin North Am. 1982;13:541-558.
2. Hyland JK. Navicular position testing. Pract Res Studies. 2001;11(4):1-4.
3. Kuhn DR, Bennett N, Carpenter J, Eldridge A, Nosco DL. The validity of Brody’s navicular drop test. J Chiro Ed. 2004;18(1):66-67.