We’re going to do a deep dive into plantar fasciitis over the next 2 newsletters. I want to share some new perspectives which might help guide those with who have a chronic problem with their plantar fascia.
In its simplest definition, plantar fasciitis means inflammation of the thick sheath of fascia that is on the bottom of the foot. ‘Itis’ means inflammation – and here is my first perspective shift gained from my research. With the exception of perhaps the initial phase of symptoms, rarely is the plantar fascia inflamed in the normal way that we think of inflammation.
Instead, the plantar fascia goes through a process of collagen degeneration and disorganization. (1) This is not to say that initially rolling your foot on a frozen water bottle might not help. It may, especially in the early stages and for pain relief, which is one of the positive benefits of cold treatments.
This collagen degeneration can be thought of as tissue fatigue in the arch due to excessive strain. After all, we are on our feet all the time, and dancers, like runners, are constantly asking this fascia to act like a spring, keeping us light on our feet.
Common causes you always hear about
There are commonly held beliefs about the causes of plantar fasciitis. Pronation, bone spurs and tight calf muscles. Let’s look more closely at these common challenges to the dancer.
Pronation as we know is when the foot rolls inward, collapsing the arch. Flat-footedness may stretch the plantar fascia, making it hard to have the desired springiness, but pronation is not the same as being flat footed. (pet bugaboo of mine … dancers who have a low arch, trying to ‘lift’ their arches higher creating a whole host of alignment challenges)
We know pronation is an aspect of many chronic injuries, knee and ankle pain, poor use of the rotator muscles at the hip, and, yes, plantar fasciitis. If pronation was a root cause one would think all dancers who pronate would get plantar fasciitis and that certainly is not true. Supination which is the opposite of pronating also influences the plantar fascia – as well as having a high arch. Hmm… perhaps plantar fasciitis can have many factors to it… and isn’t quite as straight forward as we thought.
What about bone spurs? When my sister was diagnosed with plantar fasciitis (she wasn’t a dancer, but a slightly overweight business woman who was on her feet a lot) the podiatrist took an X-ray and showed her the bone spur and said ‘This is why you have plantar fasciitis!’.
I found out that about 10-20% of the population has extra bone (spur) in front of the heel bone. (2,3) And many people have painless spurs and don’t even know it until they have an X-ray for something else. The spur isn’t creating the pain, the pain is coming from the fascia and other soft tissue structures. (4) Certainly, we should opt to first work with conditioning the fascia over having surgery to correct a bone spur. Many a bone spur will return if the mechanical stresses that created it in the first place aren’t taken care of.
What about calf tightness? I told my sister that because she wore heels all the time, it was her tight calf muscles that were influencing her plantar fascia and if she just focused on stretching her calf muscles her fasciitis would improve. Stretching helped her stand flat footed without pain as her gastrocnemius and soleus muscles were so tight that she had to wear a heel insert in the beginning and slowly work herself into tennis shoes and being able to walk barefoot without pain. Stretching was an important part of her rehabilitation – but was tightness the cause of her plantar fasciitis? Or was it the heel spur the doctor found? Or the fact that she had a high arch? (which I was jealous of since she was the non-dancer and I had average height to my instep)
We haven’t even talked about alignment influences.. being bowlegged, knock-kneed, uneven leg lengths, etc. All of which influences how the weight goes through your legs and feet and into the floor.
My new perspective on plantar fasciitis is less about decreasing inflammation and more about taking a multi-pronged approach to how I work with someone with this condition. It’s clear to me that there isn’t an easy answer as to why one person is beset by this problem and another one not.
Next newsletter we’ll talk about strategies to approach this challenging situation.
To your success,
1. Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc. 2003;93(3):234–7.
2. Barrett SL, Day SV, Pignetti TT, Egly BR. Endoscopic heel anatomy: analysis of 200 fresh frozen specimens. J Foot Ankle Surg. 1995 Jan-Feb;34(1):51–6
3. Moroney PJ, O’Neill BJ, Khan-Bhambro K, O’Flanagan SJ, Keogh P, Kenny PJ. The Conundrum of Calcaneal Spurs: Do They Matter? Foot Ankle Spec. 2014 Apr;7(2):95–101
4. Tountas AA, Fornasier VL. Operative treatment of subcalcaneal pain. Clin Orthop Relat Res. 1996 Nov:170–8