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New Perspective: Plantar Fasciitis

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. 

Inflamed?

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

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. 

Bone spurs

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.  

Tight muscles

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, 

Deborah 

Footnotes:  

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

Longer Leg & Plantar Fasciitis

Greetings!
I’m sending this from the beautiful TCU campus where I have been teaching an intensive course this week to the dance dept. There is nothing like teaching to a group of students who are eager and avid to learn all they can to improve their technique. And an extra perk is the Texas sun and warmth – It’s going to be hard to go back to Ohio weather!

Quick reminder that registration for Lisa Howell’s Perfect Pointe Workshops ends today. Register at http://theballetblog.com/index.php?option=com_content&task=blogcategory&id=67&Itemid=152

Onto the questions of the week!

Thanks for creating such a valuable resource. I attended your session at the Dance Teacher’s Conference in New York back in August and found your information so helpful. One of my legs is a little longer than the other. This does affect my ballet dancing, particularly my turnout and jumps, etc.. I’ve also noticed that the longer leg is a little more weak than the other. Are there any exercises I can do to help? I am new to your newsletter so please forgive me if you have already addressed this issue. Thanks, Jennifer

Jennifer, if your legs are structurally at different lengths it can influence your alignment. It’s tricky to decide whether or not you should insert a small heel lift in your soft slippers. Your spine needs to be looked at to evaluate it’s curves and response to the shorter leg. Sometimes the spinal curves become less when the pelvis is balanced by putting a heel lift in – other times it might make your spinal curves worse, in which case you would not correct the leg length difference. I would suggest you see a PT or sports physician who could do an assessment of your spine and leg length.

aThere are some common patterns with uneven leg length – some of which you have referred to. When you look at the picture on the left you see the dancer has a pelvic shift right, torso shift left. The common pattern is to stand on the long leg, because to stand with more weight on the short leg would require you bend the long leg. You can see her left leg is the shorter leg.

Typically you come down heavier on the short leg side on each and every step. Sometimes dancers prefer to stand on their short leg and use their longer leg as the gesture leg – although I have seen the opposite preference also. It certainly can influence the turnout too. More often I see the long leg side having more challenges with turnout. It is easy to understand that you’d prefer to stand on your long leg and put your shorter leg in front in fifth position.

The dancer in this photo improved her alignment by putting a lift under her left heel. It evened out her shoulder line as well as equalizing the amount of weight through both legs. She put a lift in her every day shoes – as well as in her soft slipper. For modern dancers sometimes it is enough to have a lift in your shoes – keeping the musculature working evening for the majority of the time, then dancing barefoot without a lift.

There aren’t any special exercises I would offer to you to even out the two sides, rather I would encourage you to have an evaluation to see if a lift would be useful, and then do your stretches and strengtheners in such a way that you are working to balance out the 2 sides. If you find the muscles around the right hip tighter, but weaker, then do more stretching and strengthening on that side. Don’t feel you need to do your workout exactly the same on both sides. It is very common to have one iliopsoas muscle tighter than the other and I tell people if you only have time to do one side – do your right side, as many times as you can throughout the day. Then as the two sides feel more even, you can reflect by stretching more evenly as well.

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I have a student who is complaining of her arches and ball of the foot hurting when she rolls up to pointe. She has fairly flat feet and either tight calves or short Achilles tendons – she does not have a very deep demi-plie. She also tends to roll onto the outside of her pointes. Any ideas as to what can be causing her pain (plantar fasciitis?)? Courtney

heelpa2You’ve hit upon some of the reasons in your question. Having overly tight calf muscles will pull on the plantar fascia, and encourage such standing patterns such as standing slightly forward onto the ball of the foot. That decreases the pull slightly, but over time, certainly doesn’t help to get a deeper plié.

You didn’t indicate where she felt her pain when she rolls up to point. Plantar fasciitis is most often felt on the underside of the foot. The diagram to the left illustrates this.

illustration_sesamoiditisIf she is feeling pain down towards the toes, perhaps she is rolling to the outside of her feet as a way to get away from the pain. It would be useful to send to her a good sport podiatrist who may be able to evaluate her feet and make sure she doesn’t have any problems such as a sesamoiditis.

Have sesamoiditis once myself I know how easy it is to simply rise a little bit more towards the little toe side to get away from the irritation and inflammation of the area underneath the big toe.

There are other reasons she might feel some discomfort only in relévé, but we won’t go into those now. My advise would be to have her get checked out and make sure there isn’t anything structural going on.

As far as deepening her demi plié, I would encourage her to do a lot of soleus stretching. Spend 1-3 minutes in the following stretch.

soleus stretchUntil next time!

Warm regards,

Deborah

“Education is the key to injury prevention”

Sore Arches

Quick announcement: I’ll be in NYC for the Dance Teachers Summer Conference sponsored by Dance Teacher Magazine and MacFadden Performing Arts Media. I hope to see many of my loyal readers! The subject of my two classes will be, Conditioning the Body for Jumps and 10 Tips Towards Keeping Teachers in Top Shape. Hope to see you August 9-11!

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Recently I’ve been doing a lot of tendus and the like daily to increase the strength and stop my toes “crunching” while pointing. Over the past few days the tendon/muscle going from the top of my toe over the arch has become incredibly sore and “crunches’ when I flex and pointe. After some very brief research on the net, I found that this could be tendonitis. More research also points to a small bone fracture or something to do with the tissue. I was just wondering what you think this is and how to treat it?
Regards,
Jane

My recommendation would be to use the pinkie ball to see if releasing tension from the anterior tibialis muscle will release the discomfort on the top of your arch. That muscle contracts when you flex your foot and needs to stretch and lengthen when you are pointing.

You’ll want to gently kneel on the pinkie ball to massage the front, outside portion of your calf where the anterior Tibialis muscle is. After doing the front of the calf, take some time to massage the bottom of your foot by standing and rolling your foot over the ball. If you are practicing your tendus and lengthening the toes you are strengthening the intrinsic muscles of the foot – always a good idea! That, along with lengthening the front of the ankle is what creates a beautiful tendu.

If releasing the pull from the muscles around the ankle helps – super! If the top of your foot continues to feel sore, and you are hearing crunching or cracking noises – I would encourage you to go to the doctors and get some x-rays in order to rule out a stress fracture or other boney problem.

The doctor should also look carefully at your standing alignment to make sure your foot is not pronating, which so strongly affects the muscle balance around the foot.

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I am suffering from Plantar fasciitis…I am doing everything (ice, taking time off, walk with heels, massage, exercises for the feet and legs, hamstring and calf lengthening and ease) and there is no change. What do you recommend?

I was diagnosed by a foot doctor.
Lori

Lori, you are following the traditional protocols for plantar fasciitis, and since it is not getting better I would look at other potential factors. Is one foot or both bothering you? Did it start all of a sudden, or come on more gradually? Were there any precipitating events?

It appears that you are going to need to put on your detective’s cap to figure this one out. I would check for any imbalances between the two legs. Could there be a leg length driving this problem? Does one foot have a tendency to pronate more than the other? Do you have a difference in your turnout between the two legs? Are you able to walk more comfortably when your arch is taped up for pronation? Often, that will help ease the pull and strain to the plantar fascia, which will help it heal.

As far as immediately trying to release the strain – I would encourage you to find a practitioner who has been certified by Tom Meyers, who wrote Anatomy Trains, the best book on understanding the myofascial relationships in the body, in my humble opinion. Here is the link to his practitioner list. http://www.anatomytrains.com/kmi/practitioners

There are massage therapists who have studied other myofascial techniques that could also be useful. My focus would be on releasing the entire line of fascia that runs from the bottom of your foot all the way up the back of your leg, spine, neck, and finally ending on your head. It could be that other areas are feeding this posterior line of fascia and once they are released the weight and pull on the plantar fascia will be released.

Plantar fasciitis can be a very tenacious problem – I wish you the very best for a speedy recovery!

Warm regards,
Deborah

“Education is the key to injury prevention”