Please, have a seat. Comfortable? Good. Would you like some water? No? Okay, let’s begin. I’d like you to close your eyes; now breathe deeply and allow your mind to drift off to some place warm and happy. Walmart? Um . . . sure, why not. I’m going to say two words, when I say those words I want you to stay calm and relaxed. Ready? Plantar Fasciitis. Wait, don’t get up, where are you going? Come back!
Hmm, you seem a bit sensitive. Maybe you’ve had a bad experience with the PF thing. On the other hand, it’s possible you have no clue what I’m talking about, and if that’s the case then consider yourself lucky. After all, why trouble your mind with negative stuff: ignorance is bliss, baby. That is until you’re mid-way through a build-up for your next half marathon, logging big miles, and your first steps out of bed the morning after a hard run that was maybe a little too hard feel like you’re stepping on broken glass. Then six months on, you’re still dealing with the same &%$# problem, you’re “cross-training” (oh yeah, who doesn’t love pool running???), your racing plans are a smoldering ruin, and you realize that given the option you’d have gladly stepped on broken glass so this nightmare would have ended about the same time they removed the stitches from your foot.
I’m here to offer what help I can, but be forewarned, this article will not present the cure for PF simply because it’s not a condition that favors its victims with specific causes and certain cures. I’ll merely explain what is currently known about its origins, and then offer some therapies that might give succor to the afflicted. So don’t expect a miracle; there’ll be no tossing of crutches, canes or night splints into a bonfire, no spontaneous healings. Sorry. As a yoga teacher I’m biased, naturally, toward “stretching” tissue, because I believe, and the evidence suggests, that poor flexibility has a causative role in PF. But it’s just that, a contributing factor, and not the smoking gun that sufferers are desperately seeking. Anecdotally, reports from my students suffering from PF tell me that stretching has been effective in alleviating symptoms, and some have reported their pain disappears completely. Hallelujah! Send your donations to my PayPal account, all major credit cards accepted.
What is the Plantar Fascia?
It’s a sheet of connective tissue (fascia) that runs along the sole of each foot (the plantar), from the heel to the toes. Like all fascia, the plantar fascia is made of extremely tough and resilient tissue. It is this durability that allows it to absorb and withstand the huge mechanical forces that act on it when we walk, run, or jump. But it’s that same toughness that can make it very challenging to fix when injured.
One impediment to fast healing is that the fascia, unlike muscle, has limited blood flow. The vital nutrients in blood play a critical role in the health and healing of tissue, and if there isn’t much of it, the process of repair and regeneration won’t happen as quickly.
Yet another problem is that the plantar fascia is in an awkward location. If you’re interested in moving from place to place during the course of your day and you’re not using any type of mechanical conveyance, then you need your feet. So when you stand, walk, or run, the plantar fascia is being stressed, and unless you’re off our feet it won’t get a break. But even resting the plantar fascia can be a problem because it can tighten up, especially during sleep, resulting in those painful first steps every morning.
What is Plantar Fasciitis?
Plantar fasciitis is a degenerative condition of the plantar fascia that causes pain on the bottom of the foot. The plantar fascia usually begins to hurt due to overuse or trauma, and it shows up commonly in runners because they tend to overuse things. The typical locations for PF pain are the heel, just in front of the heel, or the arch. So if you have chronic pain in those places, you probably have PF. But it could be something else, like a heel spur or flat feet.
The pain from PF can range from very debilitating and life altering, to low-grade, annoying and something that its sufferers can live with. It’s common for runners or other athletes with PF to continue with their sport, albeit in a modified fashion. But as we’ll see, this approach is self-defeating.
Plantar fasciitis has a murky provenance. A good description comes from Lemont et al. (2003): “Plantar fasciitis is widely described . . . as having a multi-factorial and widely disputed etiology.” Translation: many potential causes with little agreement on an actual cause. In an influential 1965 study, “Painful Heel”, Lapidus and Guidotti wrote that “the name ‘Painful Heel’ is used deliberately in preference to any other more precise . . . diagnosis, since the cause . . . remains unknown.” Fast-forward to 2003, Lemont and company commented on the previous quotation from the “Painful Heel” study, writing “Now, 40 years later, this statement can still be considered accurate.” So in the space of nearly four decades, little progress has been made on discovering a cause of PF. The one exception is that now it’s now considered a degenerative condition, not an inflammatory one. But this just describes the nature of the condition rather than identifying a cause.
What Causes The Pain: Inflammation Or Degeneration?
Over the last few decades, there’s been a significant shift in the medical-scientific community’s thinking about the nature of overuse injuries in connective tissue (in particular tendons and fascia). According to Khan et al (2000), “Advances in the understanding of tendon pathology indicate that the conditions that have been traditionally labeled as Achilles tendonitis, patellar tendonitis . . . are in fact tendinosis.” Three years later Lemont, writing about plantar fasciitis, presented findings that strongly suggest that PF “is a degenerative fasciosis without inflammation.”
Hmm, tendonitis or tendinosis; fasciosis or fasciitis: what’s the difference other than four letters tacked on to the end? As it turns out, a great deal. In essence, this discovery has shown that the pain in your plantar fascia is not due to inflammation (signified by the suffix “itis”, Latin for inflammation, stuck to the end of tendon, fascia, etc.), but instead results from degeneration of the tissue (signified by “osis”, short for “necrosis”, or tissue death). In other words the tissue that makes up your plantar fascia is not inflamed, it’s degenerating, or worse, dying.
Our continued misunderstanding of PF results from the persistence of its description as fasciitis, rather than fasciosis. The medical community, either through habit or misunderstanding, continues to refer to it as an inflammatory condition. This is important, because at a minimum the absence of inflammation and the presence of necrosis in tendon and fascia overuse injuries change the treatment protocol for the injury. In the not-too-distant past the thinking was that if you were a runner and you hurt your plantar fascia, then the pain was from inflammation. The treatment for this was familiar to many runners: rest, ice, anti-inflammatory medication, and visits to the physiotherapist, who, among other things, would do stuff to the injured area with strange machines. During my days as a hard-core runner, I ingested fistfuls of anti-inflammatories and spent countless hours icing for a variety of running-related overuse injuries.
We never questioned this approach, or should I say that most people never questioned it. That is of course until someone realized that the accepted thinking on the matter was flawed. Again, Khan et al write that “an increasing body of evidence supports the notion that these overuse tendon conditions do not involve inflammation” and “tendonitis is a rather rare condition.” What researchers have discovered is that inflammatory cells were not present in the injured tissue of tendon or fascia; what they found instead was collagen breakdown, a key indicator for necrosis. You don’t treat tissue degeneration the same way you treat inflammation. Nowadays the accepted treatment for tendinosis or fasciosis includes plenty of icing (so glad that all the time I spent icing my Achilles tendon wasn’t wasted) and the “encouragement of collagen-synthesis,” in other words building the strength of the tissue by developing collagen.
Will this shift in our understanding of connective tissue reduce the recovery time for those with PF? Well, yes and no. First, time won’t be wasted with treatment methods that have little or no effect. On the other hand, the recovery from “osis” is generally much longer than from “itis”, something those of you with PF already know.
When a girl in a bikini promises “to cure your plan-TAR fasciitis in just a few days” as she kicks and punches a heavy bag, my advice is to be a bit skeptical.
Looking For A Cure
The PF I’m currently dealing with was the result of trauma, not overuse. While taking out the trash in my slippers last summer I stepped on a sharp rock directly under my heel. For two months I barely noticed it, and was able to walk and run free of pain. Then in December it suddenly got worse, and it’s been a problem ever since. Why did it happen this way? I have no idea and my doctors offer only vague explanations. Like most runners with PF I continued to run, thinking that because my case was the result of trauma and not overuse then somehow it would be different. Ah . . . no. I’ve just completed three weeks of no running and minimal walking and my foot is feeling pretty good. I’ve been maintaining my fitness and strength with indoor cycling and I’ll start back soon with a walk/run program.
After talking with other runners who have PF, most, at least initially, don’t rest. Considering the rather obsessive nature of most runners, this shouldn’t be a surprise. Two recent conversations with students of mine provide examples. Both are avid runners who injured their plantar fasciae and continued to run despite (tolerable) pain. So they kept at it, but not in a way that was enjoyable or that would allow them to train productively. Stopping completely to rest the injury was something they weren’t prepared to do, but it was a necessary step toward resolving the issue. In fact, the refusal-to-accept-reality mindset of most runners with PF is probably the reason that it has a reputation for being persistent, and one of the main reasons it takes so long for it to heal: runners just don’t want to stop running!
Some advice: when PF is diagnosed, stop running. Trust me, it will keep hurting unless you stop, and the longer you continue to run, the longer it will take to heal. The sad fact is that tendonosis takes substantially longer to heal than tendonitis.
In his excellent, in-depth review of the literature on PF, Paul Ingraham provides a synopsis of the most viable treatments.
1) Arch support (with inserts or supportive shoes)
2) Calf stretches
3) Plantar fascia stretches
4) Night splints (devices that hold the plantar fascia in a constant stretch, or traction, as you sleep)
* Icing, popular as an anti-inflammatory, is also effective in treating tendonosis. I now ice my plantar fasciosis frequently and it definitely helps.
Note that of Ingraham’s seven recommendations, three involve stretching tissue, either the plantar fascia itself or the calf (really all the muscles on the back of the lower leg). Also, #3 and #4 are essentially the same: while #4 uses a device to hold the foot dorsi-flexed for a prolonged time, usually overnight, #3 would be short duration yoga-type stretching.
In my yoga classes and workshops, I teach specific postures that create a deep stretch on the front and back of the lower leg, and the top and bottom of the foot. While in Virasana (see photo), students plantar-flex (point toes and feet) and dorsi-flex (curl toes under) their feet. The structures most affected by this routine are the calf, soleus, Achilles tendon, and posterior tibialis on the back of the lower leg; the anterior tibialis on the front of the lower leg; the plantar fascia on the bottom of the foot; and the peroneals on the lateral side of the lower leg.
To those of you suffering from PF, I can only say good luck and don’t give up hope. Investigate your options, do the work, and be optimistic. The vast majority of those afflicted are completely cured or a have a substantial reduction in their symptoms. If you are proactive, diligent, and patient, you’ll be part of that majority.
When examining the architecture of the foot we see that it is, in fact, a tripod. The three “feet” that make up the tripod are the heel bone (calcaneus), the head of the first metatarsal (the big toe mound), and the head of the fifth metatarsal (the little toe mound). Connecting each of the three feet are three myofascial slings, or arches. These are the medial longitudinal arch that runs along the medial side of the foot; the lateral longitudinal arch that runs along the lateral side of the foot; and the transverse arch that spans the foot from the head of the first metatarsal to the head of the fifth metatarsal. When the three feet of the tripod bear weight equally, then the foot is in a stable position. If one of the feet is not bearing load our nervous system will sense instability and turn off or inhibit some of the muscles responsible for whichever action we’re trying to produce.
Plantar sensory feedback, primarily from the proprioceptors, plays a central role in safe and effective locomotion and in stabilizing the stationary body. When we are upright and supported by our feet the nervous system measures the fluctuation of pressure from receptors on the sole of the foot. From that proprioceptive feedback, we unconsciously put our body in the right place, balanced over that foot. When the body responds properly to feedback from the feet, the positive response feedback turns on, and in turn it switches on the anti-gravity muscles of the leg.
The problem is that many runners have lost connection with their feet. Most runners have either non-responsive, floppy feet, or they have functionally rigid feet, which is the complete opposite of the listening foot. This is a foot that hangs on like grim death by grabbing the floor, trying to maintain some semblance of equilibrium or balance so the body doesn’t topple. Suddenly, all of the athlete’s control and tension is from the knee down. This is a common sight in yoga classes: when stability is tested, as with a balancing posture for example, the student’s toes curl under and grip the floor, the foot shrinks, and the muscles of the lower leg twitch and quiver in an attempt to stabilize the body. So if the practitioner lacks balance, stability, or control, peripheral tension is created and the listening foot is doing anything but listening. Now it’s not able to relay high quality proprioceptive information, which is essential to the body’s ability to orientate itself in space and maintain equilibrium.
What we want is for the information from our feet to flow freely and orient our body with perfect alignment, balance, and control. So if the emotional, neuromuscular, and cognitive connection with our feet is dysfunctional, this will be reflected in the quality of the sensory information flowing through the body, with predictable consequences. Yoga is a method of integration that requires the practitioner to bring awareness to all regions of the body, without regard to how challenging that process may be.
Whenever I think of ankles, I think of Misery. It was 1990, and the movie based on Stephen King’s novel Misery had just been released. It starred James Caan as an acclaimed novelist and Kathy Bates as a nurse who cares for him after he is seriously injured in a car crash near her isolated, snowbound house.
As the bedridden Caan recuperates in her house, he (along with the audience) begins to realize that Bates is kind of . . . um . . . off. Well, not just kind of off, very off. Despite the fact that Bates’s nurse character is a huge fan of Caan’s writer character, she takes issue with the plot line in his new novel, and, well, at that point things pretty much go south for Caan. Sensing that something is amiss with Bates, he uses her absence from the house to leave his sick bed and roam the house in a wheelchair, plotting an escape. Oops, bad move. Bates returns, cottons on to his unauthorized wandering, and decides a preventative measure is warranted to ensure this behavior is not repeated. So she does what any demented caregiver would do: with Caan now tied to the bed, she grabs a sledgehammer and breaks his ankles. Yes, both ankles . . . with a sledgehammer. Need I emphasize that these are not light taps she administers, but a full wind-up? I think you get the picture.
There’s little doubt that in the annals of movie sadism Bates’s “hobbling” of Caan ranks near the top of any list of non-gratuitous, ghastly acts. As to the audience’s reaction, 23 years has done little to diminish the freshness of my memory of that moment. The collective gasp, muffled screams, and “oh my Gods” still ring clearly today.
But as macabre a story as Misery was, I like to think of Nurse Bates less as a destroying angel and more as a symbol of what awaits runners if they lose the range of motion (ROM) in their ankles. The demon image of Bates looming over us haunts our sleep like a perpetual nightmare. There she stands, smiling grotesquely, sledgehammer slung over her shoulder, preparing to dispense her own brand of therapy as you lie tied to your bed, mouth open but unable to scream.
When we consider the ankle joint, we see that an important requirement for its proper functioning is a high degree of mobility in the sagittal (forward and back) plane. This mobility is demonstrated by the ability to dorsi-flex (bring the top of the foot, or dorsum, closer to the shin bone, or tibia) and plantar-flex (point the foot and toes) the foot. With the bare foot flat on the floor and the heel grounded, we should be able to move the knee forward over the toes, reducing the 90-degree angle between the tibia and foot by at least 20 degrees. But runners with poor ankle mobility can barely dorsi-flex their foot/ankle, almost as if the shinbone and top of the foot are frozen into a right angle.
Unless it’s the ankle itself that’s been injured, it’s usually starved for attention. Unlike the knee, with its diva-like needs and neuroses, and the depressive foot, with its fallen arches and calloused skin, the ankle tends to linger in obscurity, unloved and easily overlooked as we rush our attention back and forth between the knee and the foot. Part of the problem is that most runners are clueless as to the true source of their pain and dysfunction. This is because pain can be a terrible liar, and has a way of manifesting where the real problem isn’t. The compensatory tricks the body employs to move around the ankle’s limited mobility are devilishly effective, but the results of that compensation are pernicious.
This is because the body plays a kind of zero-sum game, and at some point the ankle will reclaim its lost range of motion from elsewhere in the body. When we walk or run with tight ankles the body searches for the lost mobility by initiating a series of compensatory actions, and this is where the problems really begin. What’s so perplexing is that runners won’t necessarily feel this limited mobility. Instead, they’ll experience the effects of the compensations: collapsed arches, bunions or hyper-pronation in the feet, anterior knee pain, various problems in the hips, or low back pain.
There are several ways mobility in the ankle joint can be compromised. The first is as a result of injury. If the ankle has been sprained or broken, scar tissue or impingements can impair its ability to move freely, reducing range of motion.
Ankle mobility can also be reduced if the tissue in the back of the lower leg is tight. The structures that can become very short and tight, thereby reducing mobility, include the Achilles tendon, gastrocnemius (calf), soleus, and posterior tibialis.
Finally, choice of footwear can affect the ankle’s ROM. Our favorite sport (or sports) may require footwear that allows the ankle little or no movement. Downhill ski boots, hockey skates, and high-top basketball sneakers are examples of footwear that can limit ankle mobility. Also, habitually wearing shoes with high or stacked heels will shorten the tissue in the back of the lower leg, limiting dorsi-flexion.
That I stress the importance of ankle mobility in my runner’s yoga classes and workshops shouldn’t be a surprise. In class, people with tight ankles are easy to spot. As they sit in any posture that requires substantial plantar flexion of the foot (Virasana, for example: see photo), they’re the ones who have difficulty keeping their ankles and feet straight. One of the body’s tricks is that it will try to move around areas of stiffness, so if the ankles are tight they will crescent outwards to avoid the restriction and find room to move. When I see “bowed” ankles, I reposition them to be sure they’re straight. This way they’re moving into the stiffness and not around it.
Weird looking dude in Supported Virasana (Hero) pose, with feet and ankles plantar-flexed
Outside of yoga class, another tight ankle “tell” is a bouncy stride. As we run, the main direction of movement should be forward, with slight up and down motion. But the runner with ankle mobility issues avoids the restriction by lifting their heel of the ground prematurely at the end of the stance phase. This action sends them “up” instead of forward, wasting substantial energy and shifting the mobility emphasis from the ankle to the forefoot. The calves and other posterior structures of the lower leg are now being used to push them through the gait cycle. Runners with this type of gait pattern are referred to as “quad dominant”, because rather than using the powerful gluteus maximus (buttock) muscles, they extend through the quads and calves.
If there’s any lesson to be learned from Misery, it’s to keep your ankles mobile and avoid the problems that poor ROM creates. For added incentive, rent the movie. Think of it as Nurse Bates making a house call.
If you laughed yourself sick when you read this, then you’ll get sick again if you miss my intensives in Halifax and Vancouver. Check the schedule and sign up soon!