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Fixing Foot Pain: Plantar Fasci-What?

Posted Nov 03 2009 10:30am

Over the course of their careers, almost all runners experience pain on the plantar surface of the foot, and, undoubtedly they are diagnosed (self or professionally) with “plantar fascitis.”  However, in the truest sense of the term, the vast majority of these runners are not likely experiencing plantar fascitis.  The true pathology of the injury would be better termed “plantar fasciopathy” as the injury occurs from collagen disarray without the presence of inflammatory cells.  The injury is much akin to Achiles’ tendionpathies in its cellular and histological presentation.

While plantar fasciopathy is most certainly a common source of foot pain, unfortunately we are still far too focused on treating the pain site instead of the legitimate source of pain.  Most treatment protocols for PF include stretching the muscles of the posterior lower leg, rolling frozen cans on the plantar surface of the foot, and even performing some self-massage techniques with things like tennis balls and golf balls on the foot.  While this is sometimes successful, it is rarely the complete solution.  In fact, in my experience, some of the biggest trouble making sources are higher up the chain.

There are several muscles in the lower leg that can produce pain patterns about the medial tuberosity of the calcaneus, where plantar fasciopathy pain often occurs.  Trigger points in the soleus, medial head of the gastrocnemius, and flexor digitorum longus can cause pain in and around the medial longitudinal arch that, when treated traditionally, can drive both patients and clinicians crazy.  Without first addressing the quality of the tissue, aggressive stretching protocols that are often recommended with PF can simply make the problem worse by adding stress to an already stressed tissue.  Those who appropriately addressed the issue of myofascial restrictions that refer pain to the foot are miles ahead, but are not completely out of the woods.

Of also critical importance in expeditious recovery from plantar fasciopathy is the restoration of proper movement skills.  All too often, we associate a lack of pain with health, but this is simply not the case, and a probably a strong argument for why previous injury is the best predictor of future injury.  Here, even the most savvy coach can go wrong.  If we reduce pain completely with targeted soft tissue techniques and bracing techniques and allow people to return to training without attempting to alter the movement pattern that injured the athlete initially, it is a simply matter of time before the athlete reaches his tissue tolerance threshold and begins to experience pain again.

It appears that reduced ankle dorsiflexion range of motion is the best indicator of future PF pain, and it is little surprise.  First off, one reason for a reduced dorsiflexion range is that we tend to spend far too much time in shoes, which force us into relative plantar flexion and encourage formation of trigger points and tissue shortening of the posterior leg.  Next, overpronation is correlated with incidence of PF.  Those who lack dorsiflexion will often pronate at the subtalar joint to achieve adequate dorsiflexion via the midtarsal joint at the expense of adding stress to the plantar fascia.  To fix the issue, we must hammer away at ankle range of motion using active and well-coached mobility drills.

One of my personal favorites is ankle rocking with a tibial glide to assist the osteomechanical actions of the ankle joint.

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