Understanding the Root Cause of Plantar fasciitis

Plantar fasciitis is something we see in the clinic fairly often and is something I have personal experience of! It’s extremely painful and can be very persistent. So I thought today I would look at a functional approach to the causes and treatment of plantar fasciitis.

The plantar fascia is a thick band of connective tissue that runs along the sole of the foot between the calcaneus and the metatarsal heads. Plantar fasciitis is inflammation of the plantar fascia, though more long standing cases that show degenerative changes would more accurately be could plantarfasciosis (or opathy) as they are not related to an active inflammatory process. I have a fairly simple brain and like to think in simple terms before adding the complexity.

In simple terms the tissue will become inflamed or degenerate as a result of persistent over-load, which is likely to be over a long period of time. It’s only my opinion, but the root cause is likely to have been present for a long period of time prior to symptoms appearing. Like with anything else I am always trying to balance out the time spent on symptom relief and time spent eliminating the root cause.

Understanding the Causes

If you are looking for the root causes of plantar fasciitis then in my opinion you are looking for something that is causing excessive force to be felt by the plantar fascia. If you have read the Foot and Ankle Series you will know my thoughts around the function of the foot and ankle. Of particular interest for plantar fasciitis is the post on the Mid-Tarsal Joint (MTJ). The reason for this is that the ‘locking’ mechanism at the mid tarsal joint. This mechanism allows the foot to be more flexible when the foot hits the floor because the MTJ is relatively ‘unlocked’, whereas, as a back foot the MTJ ‘locks’ and becomes more rigid. If this mechanism is not working, then the plantar fascia will be feeling increased force to compensate for the lack of support from the MTJ.

This is a brilliant mechanism and the first thing I look for when assessing plantar fasciitis is can the MTJ lock and unlock off weight bearing. If it’s not happening off weight bearing, then it is highly unlikely it is happening in function, so in this case you might be looking for some external help to relieve the dysfunction…an orthotic most likely.

If the locking mechanism is in tact off weight bearing the assessment moves to on weight bearing and I am trying to see if there is a functional reason why the MTJ is not locking. The reasons are far to many to cover them all, but I’ll try and cover the main ones here:

– Excessive pronation at the sub-talar joint
– Lack of talo-crural dorsiflexion
– Lack of hip internal rotation (same side)
– Lack of hip extension (same side)
– I better stop there or I’ll be writing forever!!!!!

Excessive STJ Pronation

This one on its own is massive, there can be a million different reasons for excessive STJ pronation. So I’ll leave the big list for you, but the reason this causes a problem for the plantar fascia is more important. If the STJ over pronates then it is very difficult for it to supinate in time for the push-off phase of gait. This means that the calcaneus will not be inverted and the MTJ will remain unlocked…decreasing the bony stability and increasing the force felt by the soft tissues, including the plantar fascia.

Lack of TCJ Dorsiflexion

Lack of dorsiflexion is a common finding in patients with plantar fasciitis and again the reasons for this can be numerous, but it’s involvement in plantarfasciits is more straight foreword. As you progress through gait you need more dorsiflexion, if you haven’t got enough dorsiflexion to complete the cycle your body will compensate. The most common way it does this is by pronating the sub-talar joint late in the gait cycle in order to access the dorsiflexion component of pronation. If the sub-talar joint pronates, the MTJ unlocks and decreases the bony stability, increasing the forces felt by the plantar fascia.

Lack of Hip Internal Rotation

I’m sticking to the same side suspects because of word count constraints, but don’t forget the opposite side lower limb and the thoracic spine.
If there is not enough hip internal rotation to complete the gait cycle then the body will again compensate to complete the cycle. In this case the foot will be forced to laterally rotate and spin out…as a result the STJ will pronate, unlocking the MTJ and increasing the force on the plantar fascia.

Lack of Hip Extension

This is similar to the hip internal rotation explanation, but the body uses the spinning out of the foot to delay the push off to the appropriate time, however, the result is the same…the foot is laterally rotated at push off, the STJ over pronates late in the gait cycle, unlocking the MTJ and increasing the force on the MTJ.

Summary

I think I will leave it there as these are my main suspects and would begin treatment on one of those to begin removing the root cause. I also think you will be seeing a pattern to what is causing increase force on the plantar fascia, therefore you can start seeing your own reasons for why that patient isn’t able to get good bony support in the later phases of gait. Most of my time would be spent eliminating these root causes, though I may spend a short time on symptom relief, I mainly use kinesiotape for that initially as it is very effective and can stay on for up to 5 days. During this time they will have a home exercise programme aimed at reducing the impact of the root cause.
I will return to this topic in the next few weeks to look at specific assessment and treatment strategies.

Physioblogger

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6 Responses to Understanding the Root Cause of Plantar fasciitis

  1. Keith Graham December 19, 2011 at 9:26 pm #

    Me again. I think the biggest cause of PF is heel-strike on landing. It practically forces the heel and therefore by consequence the hindfoot and MT joints into excessive pronation – with all the sequelae felt more proximally.

    I think it’s odd that we (lumping physios together here) talk about the importance of the kinetic chain, yet don’t mind the thought of landing on the heel ( ie NOT at the end of the kinetic chain). It’s pretty much accepted wisdom that landing forefoot or whole foot reduces impact which to my mind then reduces the force available to evert the calcaneus. Add to that the tensioning effect of the soft tissues of the forefoot thro the PF brought about by gradual dissipation of landing forces and can you see how you wind up, or tension the rearfoot so it is less likely to every/pronate?

    Interested in your thoughts here. To me the whole heel-toe concept is back to front.
    Cheers

    • physioblogger December 20, 2011 at 5:06 pm #

      Hi Keith,

      Thank you for you kind words and your thoughts. I find gait facinating and have studied it for a fair while now. I’ve never really had anything against heel strike though. For me I want the force to evert and pronate the foot as that is what loads the system. However, the problems arise when the foot pronates/loads, but is unable to supinate/unload. I want the body to have good motion that they it is able to control…load and unload.

      What do you think?

      Neil

  2. Graham Theobald January 4, 2012 at 2:16 pm #

    Am interested in Keith’s suggestion………….. ‘It’s pretty much accepted wisdom that landing forefoot or whole foot reduces impact which to my mind then reduces the force available to evert the calcaneus.’………the research does not suggest this at all. I’m not saying that heel strike is right but that statement is not backed up by the literature in any way. I suspect that this is leading to minimal footwear………..? I too work on the whole kinetic chain but considering the anatomical structure of the ST joint its not an open and shut case. Excessive pronation needs controlling but this can be done in many ways. All interesting stuff though.

  3. MrPhysio+ Mark Quittner January 7, 2012 at 4:57 am #

    Hello Everyone,
    Plantarfasciitis is one of my special interests. Over 20 years of treatment experimentation I have formed a few views as to the cause of and correct treatment for plantar fasciitis. I have moved away from my previous view that supportive shoes and orthotics are necessary in the majority of cases.

    Minimalist footwear makes more sense and it seems, provide improved outcomes – with some strong proviso’s. If someone is using high support shoe structures they should be weaned off these shoes gradually to allow the foot structures to accomodate the new increasing tissue flexibility. Sudden changes will cause problems. Intermediate support shoes / orthotics can be dispensed with more quickly.
    It is very true that the plantar fascia is likely to have been undergoing changes for a long period prior to symptom presentation. The inflammatory as against ‘opathy’ argument may be related to duration of causation with one, the other or both figuring in the aetiology.

    It is my view that over supportive arch supports / orthotics in shoes results in decreased movement of the foot structures resulting in a shortening of the fibrous tissues. It is often the case that rigid orthotics are seen to eventually cause dropped metatarsal heads due to the fascia length reduction.

    The most successful treatments I provide involve very deep friction massage along the fascia from calcaneus to the metatarsal heads. Three stripping movements are given along the high, middle and low part of the longitudinal arch of the affected foot or feet.

    The patient is then instructed to use a frozen plastic bottle (300 to 600 ml size with the traditional coke bottle shape of chest and waist taper to best fit the foot arch) under the arch of the foot (transversally) in standing with around one third body weight force twice daily for up to two minutes at home for three to seven days. The bottle is rolled back and forth with weight applied from the back to front of the foot. The cold acts as an anaesthetic, reduces treatment swelling and the movement mobilises tight structures.

    Be aware that the in rooms treatment is VERY painful if done correctly. Warn the patient. Usually the pain goes within a few minutes and if successful the patient reports improved spring in their step before they leave the treatment room.

    If a patient has used rigid orthotics then it is wise to graduate them through flexible orthotics prior to eliminating arch support completely.
    If the above technique is used, most if not all the previously reported ‘locking’ of joints will disappear and foot function will normalise. Do not be concerned with ‘flat’ feet unless other problems are present.

    MrPhysio+ Mark Quittner

    • physioblogger January 8, 2012 at 9:36 pm #

      Hi Mark, thanks for taking the time to share your experience, really appreciated.

      Neil

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