This is a guest post by Dr. Jarred Boyd
Plantar fasciitis is one of most nagging and limiting orthopedic pathologies in the foot. It’s estimated that nearly 2 million Americans experience plantar fasciitis each year and is the most common condition of the foot for runners. Plantar fasciitis can be defined as inflammation of the plantar fascia+perifascial tissues due to repetitive microtrauma from excessive traction and/or loading forces. How do you know whether you MAY have plantar fasciitis?
– Plantar medial heel pain: most noted with initial steps in the AM or after a period of inactivity as well as prolonged weight bearing.
– Symptoms may appear after an increase in weight bearing activity (running, walking).
– Bone Spur on the heel (due to excessive tension from the plantar fascia causing periosteal lifting of the bone).
There are many risk factors that are attributed to developing plantar fasciitis including: stiffness in the gastroc-soleus complex, high BMI, poor ankle joint dorsiflexion, running and an inefficient WINDLASS MECHANISM. In addition, there is a misconception that only people who OVERPRONATE are at risk for plantar fasciitis, however people who UNDERPRONATE can also develop fasciitis. It is the duration of how long you remain in pronation, rather than pronation itself, that is problematic.
OVERPRONATION: Flattens the medial longtidunal arch (MLA) causing the plantar fascia to elongate and have increased tensile forces causing microtears. This type of foot has too much mobility.
UNDERPRONATION: Limits shock absorption and unable to dissipate forces so the fascia takes the brunt of the load. This type of foot has too much rigidity.
The Windlass Mechanism
In Part 1/5 in our plantar fasciitis series, @jfitboyd sheds light on the importance of the windlass mechanism – especially for those that overpronate. In this exercises, it is KEY that you DO NOT COMPENSATE. Only the arch should be raising, keep pressure on the ball, or the exercise will be accomplishing absolutely nothing!
The orientation of the plantar fascia helps maintain the arch of the foot when walking and to maintain the appropriate timing of pronation and supination. Originating from the calcaneus (heel) to the phalanges (toes), the plantar fascia helps to maintain the medial longitudinal arch via the WINDLASS MECHANISM. The windlass mechanism occurs with dorsiflexion of the big toe (toe pointed upwards) and plantarflexion of the metatarsal, allowing for a RIGID FOOT needed for EFFICIENT PROPULSION AND PUSH OFF during the gait cycle. If this mechanism is altered there may be over FLATTENING of the arch causing excessive tensile stress to the fascia. If you are an overpronator, you will benefit greatly by improving your windlass mechanism, minimizing tissue stress and thus pain.
Here is a great exercise that works on developing intrinsic muscle strength as well as re-creation of the medial longitudinal arch to create a stable foot for propulsion.
Step 1: Sit in a chair with both feet placed flat on the floor
Step 2: Raise the arch of your foot by sliding your big toe toward your heel WITHOUT curling your toes or lifting your heel. Do NOT COMPENSATE.
Step 3: Hold the position for 2seconds then relax
Once you feel comfortable performing the short foot movement you can gradually progress to performing the exercise while standing and then eventually from a single-leg standing position similar to Episode 133.
Heel Cord Stiffness
A lack of dorsiflexion range of motion is one of the biggest risk factors for developing plantar fasciitis and also a MODIFIABLE risk factor. What’s that mean? It means you can incorporate this technique demonstrated by @jfitboyd into your routine NOW to [P]Rehab your movement system!
Heel cord (or gastoc-soleus) stiffness can limit the amount of DORSIFLEXION at the ankle joint. Dorsiflexion (ankle pointing upwards) is essential in the gait cycle to allow the body to move and progress over the foot. Both, individuals with over and under pronation can benefit from improving extensibility of the GSC (Gastroc-soleus complex).
OVERPRONATION: A stiff GSC will encourage a person with a very mobile (planus) foot to unlock the midfoot and pronate excessively as a compensation, placing stress on the fascia.
UNDERPRONATION: A stiff GSC in a person with a stiff (cavus) foot will also apply more tension to the fascia due to inability to absorb shock and dissipate forces.
Traditionally the calves are stretched from the standing position by leaning against a supportive wall. However, while leaning forward, the calf muscle is performing a lengthening contraction to stabilize both joints and is not fully relaxed. The best stretching position for a relaxed calf is performed in a sitting position.
ACTIVE ISOLATED STRETCHING uses gentle repetitive motion to improve the circulation of blood and nutrients, supporting the healthy repair of tissues. It not only improves tissue length but also strength in the newly acquired range.
Sit with both legs straight out in front of you. Loop the rope around the foot of your exercising leg (still straight). From your heel, move your foot back toward your ankle, using the rope for a gentle assist at the end of the movement. Placing a ball behind the leg is an added bonus to improve the tissue quality of the calf musculature. A bent knee will allow you to more specifically stretch the soleus.
Eccentric Posterior Tibialis Control
In part III of our plantar fasciitis series by @jfitboyd, we demonstrate a highly effective FUNCTIONAL exercise for developing eccentric posterior tibialis strength. Traditional strengthening with a theraband, into plantar flexion and inversion, is still a great exercise. But once adequate motor control/strength has developed, incorporation of functional strengthening is recommended.
As stated in previous posts, one cause of plantar fasciitis is prolonged pronation. This is often due to posterior tibialis—known commonly as the post tib—weakness. The post tib is a primary arch stabilizer as it ECCENTRICALLY controls pronation. Therefore, developing strength of the post tib is critical in helping reduce over-lengthening of the fascia, which can result in microtears and periosteal lifting (bone spurs). A traditional way to strengthen the post tib is with a Theraband around the foot while sitting in a chair or lying down.
However, a more functional approach is to perform a lateral step down. This will not only train the post tib, but also intrinsic musculature of the foot as well as the glute medius muscle as an added bonus. When you descend into the squat, your foot will naturally pronate. This pronation must be eccentrically controlled by your post tib.
HOW TO: Start with both feet on top of a step. Next, slowly lower the unaffected leg down off the side of the step to lightly touch the heel to the floor. Then return to the original position with both feet on the step. If you do not have a step, a box works just as well for this exercise.
Remember! Maintain proper knee alignment: Knee in line with the 2nd toe and not passing in front of the toes.
Proximal Stability – GLUTES!
Proximal stability promotes distal mobility and is an adage that we have used time and time again as it holds true for plantar fasciitis as well. Strengthening the hips, as@jfitboyd demonstrates here, is vital.
Regional Interdependence is defined as a SEEMINGLY unrelated impairment in a remote anatomical region contributing to the primary complaints. This concept is especially important when attempting to resolve the POOR BIOMECHANICS that contribute to plantar fasciitis.
Proximal muscle weakness from the gluteus medius, gluteus minimus and quadriceps may contribute to dysfunction at the foot, causing fascia irritation. How?
These proximal muscles assist with the loading response of gait—when the heel first hits the floor—which is necessary for shock absorption. If these muscles are weak, there may be excessive transmission of shock to the structures of the feet rather than dissipation throughout the entire limb.
Furthermore, weakness of the glutes causes an increase in hip internal rotation, as opposed to external rotation. External rotation is necessary for foot supination as it creates a rigid lever needed for propulsion. Poor supination due to prolonged pronation from GLUTE WEAKNESS may cause overstress to the plantar fascia.
This video depicts a great exercise to develop quadriceps and glute strength in a functional manner. Place a theraband above the knees and get into a mini squat position. With one leg forward in a slightly bent position, step back with the opposite leg and then step forward again. The goal is the maintain stability on the stance leg and KEEP TENSION on the outside of the band at all times to sufficiently activate the glutes.
Developing High Load Strength
This specific treatment strategy—known as “high-load strength training”—may stimulate an increase in collagen synthesis, encouraging normal tendon structure in addition to fascia to tolerate load. Additionally, this exercise facilitates an increase in dorsiflexion and intrinsic foot strength. The concept of Davis’s law states that soft tissue heals according to the imposed demands by which it is mechanically stressed.
In order to perform this exercise, fold a towel under the toes so there is greater toe extension and thus greater tension through the plantar fascia at the top of the motion. The towel underneath the heel specifically targets the windlass mechanism, discussed in part one of this series. At the bottom of the calf raise, the calves are stretched if you go down far enough, which helps correct the tight calf muscles often associated with the condition as discussed in part 2 of the series.
Every calf raise consists of a three second concentric phase (going up) and a three second eccentric phase (coming down) with a 2 second isometric phase (pause at the top of the exercise). Do not rush this exercise – far too often people neglect the eccentric portion of this exercise – and eccentric strength is vital for proper foot mechanics.
Citation: Bolgla et al. Plantar Fasciitis and the Windlass Mechanism: A Biomechanical Link to Clinical Practice JOAT 2004 and Martin et al. Heel Pain-Plantar Fasciitis: Revision 2014
About The Author
Jarred holds a Masters in Athletic Training and Doctorate in Physical Therapy from Shenandoah University in Winchester, Virginia. His passion lies in inspiring others to achieve what they deem impossible when it comes to health, fitness and rehabilitation. He is eager to provide integrative services that promote a healthier you. If you are ready to start the journey to an exciting healthier life then Jarred is here to equip you with the dedication and diligence necessary for a successful achievement of your health and fitness goals.