Plantar Fasciitis – “What if”

As I write these words, I am aware of the very strong opinions and views “out there” from people who have dealt with this diagnosis and from people who treat this diagnosis. So, I take no offense if there is disagreement with my “proposition” as to the cause of this foot aliment.

The foot and ankle are mechanically, a lever. The plantar fascia makes up the bulk of the “material” of the lower part of this lever. The muscles of the foot attach and blend with this fascia to both move the foot and toes and to move the lever up and down as when walking and running. Up to this point there is likely little disagreement with what I have stated.

The cause of this malady though seems to be somewhat of a mystery and so is the best way to treat it. Here are some common explanations.

1. Your foot does not have enough support. You need orthotics.

2. You’re an overpronator(arch is too low; related to the explanation above)

3. Your shoes are not supportive enough or not proper for you.

4. You are an over supinator (arch is too high)

5. Your Achilles tendon is too tight.

6. You are too active, slow down and let the body “heal”

Well, which is correct? Answer: None or maybe some of the above are contributing factors, but not really the cause(?).

Now you have the sharp, stabbing pain (worse in the morning) which comes and goes. It may be so bad at times that you are truly incapacitated. Professionals might tell you to alter your activity. Runners must stop running. Walkers must stop walking. Anything which may “hurt,” you must now stop or restrict. The experts may tell you that you must go through expensive programs of therapy, injections, acupuncture, chiropractic, orthotics, and the endless search of the “perfect” shoe.

Prior to this enigmatic aliment you needed none of this and what is worse you are beginning to question whether the “experts” are managing symptoms as opposed to resolving your problem. When I learned of the diagnosis and how to “treat it” in PT school, it was from a dispassionate point of view. I had never experienced it. I was a good student, learned that it was a difficult diagnosis to manage and went along with the conventional wisdom.

Until that is, one fine morning I woke up, stepped out of bed, and nearly fell over from the pain. Wow! That really hurt! The pain was so severe that I could not tolerate

Figure 1: The painful foot – plantar fasciitis

my weight on my left foot. I had to call in to work sick. I knew what was in store for me. Doctor visits, PT sessions, acupuncture, chiropractic, orthotists and orthotics, specialist, injections. I would be told to stop running. The search for the shoes. On and on. Depression and misery. Maybe I would luck out and respond more quickly to the myriad of treatment offerings. This was going to “stink”.

The definition of plantar fasciitis is defined as inflammation of the plantar fascia where it originates at the front of the heel bone. Now I had all the time in the world to think about my dilemma. Why the left foot and not the right? Why now? Was there some other cause. After a little acceptance of the situation. It was time for a little ole fashion observation, hitting the books (anatomy and biomechanics) and most importantly, “think”.

Observation: I had seen by that time some pretty sad examples of feet that were pain free and conversely, excellent examples of what appeared to be strong and healthy feet that were a painful mess.

I started to just really watch my feet. I first noticed I could not spread my toes at all on my left foot and could with effort spread them partially on my right foot. I initially thought, “so what!” I moved on. My calf muscle (the top part of the foot-ankle lever) was tight. But I

Figure 2: The region of pain and swelling of the plantar fascia (red)

noticed the sides were equal and the tightness was not severe, actually it was minimal. Could the fact that I was “flat footed” be the cause? I have been that way all my life. I was in good shape and 30 years old. I was strong and relatively flexible. Was it age? Going over it all from the anatomy to the mechanics, I could not make sense of it. Why was the plantar fascia, this very tough and resilient tissue inflamed? Maybe it was just a “flip of the switch”, 30 years old and my first “age related problem”

The answer to my question “appeared” while waking from the next night’s sleep. I had to call in sick again. I could not walk well enough and ice packs - aspirin just made the pain bearable. I had pinned a photo of the foot’s muscles on my wall and a head of a screw was poking through it. As I was waking up, I found myself staring at the screw while scanning the photo marveling at the massive size of the muscles that are responsible for spreading the toes. I thought to myself, why do people need all that muscle mass just to move the toes in a “spread” or abduction? Seemed to be a “waste”. The body though does not waste space. Then all at once I saw the lever, the muscles that power the lever and the “screw” or torque of the planter fascia. “That’s it!”

I hobbled out of bed. First, I had to get the inflammation under control. So, the ice packs were replaced with ice immersion baths and later contrast baths. Then I passively moved and stretched my toes spreading them out with my fingers. I then started actively spreading my toes and assisting with my fingers. I then would try, until fatigued set in, to spread my toes without assistance. Rested an hour or so and continued this all day.

By evening my foot was tired and numb. Went to bed. Day 3 was to start with an 80% reduction of pain upon standing! I was ecstatic. Continued over the next week. Day 4 went back to work. Within 2 weeks 98% of the pain was resolved and by 3 weeks, 100% of the pain was gone. By the 4th week, I could strongly spread my toes.

What was the revelation? The “what if?”

It occurred to me that the muscle spreading the toes which attach to the plantar fascia were profoundly weak. The muscles were unable to in reverse action to prevent the plantar fascia from twisting excessively while engaged in standing

Figure 3: Stretch and spreading activity exercise

activity creating the inflammatory response. By targeting these muscles for strengthening and anti-inflammatory measures the precipitating cause was resolved.

This of course was reasoned speculation and at best empirical and anecdotal. “One person, So what!” So naturally I had to determine if this was something or not. Fortunately, I was a PT who worked in an orthopedic setting in a large hospital. I had patients to assess and treat. Every patient with this diagnosis had weak toe spread muscles. I started with the regimen I described for myself and gradually modified it. I even wrote it out at the request of one of my patients to send to his mother in Florida. She was scheduled to have surgery to address the severe and long standing plantar fasciitis. Two weeks after starting this “program”, the surgery was cancelled, and she was 70% better. Six weeks later, no pain .

After approximately 3 months of this, the foot specialist from the hospital called me to ask what I was doing. I explained in fairly anatomical and biomechanical terms what I was doing. I expected praise. I received instead a message that he would no longer refer patients to me as he was losing income on the loss of office visits, shots, orthotics, night splints, etc. I remember sitting at my desk, stunned.

I do not expect people with strongly held beliefs, opinions, or assured convictions to accept this or believe it. To the open minded, I only ask you to ponder, “what if”.

Dr Michael J. Malawey, PT