Reducing stress within the plantar fascia to reduce plantar fasciitis pain

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Peak stress within the plantar fascia is generally regarded as occurring just after heel off .
Plantar fasciitis, aka plantar heel pain, is found at the medial aspect of where the fascia inserts into the calcaneus.
Some have speculated that plantar fasciitis is caused by an uneven distribution of load within the fascia but what causes this? In my opinion, if the met heads cannot move relative to each other during gait, then this could be a major contributing factor .

Treatment ? Stretch to give greater mobility to the met heads so that they can more easy move relative to each other during gait. It seems beyond reasonable doubt that they have evolved to move relative to each other , we know they move.

 

In the image shown the plantar fascia is represented in blue and the transverse ligament in green. The 2nd metatarsal extends distally further than the other met heads.
If the met heads are able to move relative to each other then the second met head will slide distally relative to the other met heads allowing these to more effectively bare load ,thus spreading load more evenly across the fascia reducing excessive strain on the medial aspect of the fascia.

The plantar fascia stretch, which involves manually dorsiflexing the toes, will likely have little impact on the transverse ligament.

 

What do you mean by uneven load distribution? What metatarsal motion would change the distribution of load in the plantar fascia.? What causes motion of metatarsals?

I've looked at a lot of pressure distribution maps of people walking. Those that exhibit late stance phase pronation will tend to lift the lateral metatarsals off of the ground and the foot will be pushing off the first and 2nd metatarsal heads. This will tend to put more load on the medial slip(s) of the plantar fascia.

 

When you are talking about motion of the metatarsal could you explain how the metatarsal moves relative to the other bones of the foot and in which plane is this motion occurring? Are you talking about dorsiflexion of the 2nd met when you say the met slides distally? How does the transverse ligament limit the motion you are talking about?

 

Here is a video that uses the hand as an analogy . The tips of fingers represent met heads of foot and area under elastic band represents midfoot . During push off and as the heel rises, the heads must move apart relative to each other in anteroposterior direction, and move together mediolaterally as they are tied together by transverse arch ( so distance across ball of foot narrows during push off ) .

I am sure you have Eric, but are these not predominantly people with foot pain/biomechanical problems? Also , is there not a tendency for subjects to exaggerated lateral excursion of the subject leg and foot to get it ,and not the contralateral foot ,on the pressure mat. I suppose this could be avoided by making sure the subjects COM passes directly over the center of the mat .Do you do this ?

 

I doubt your finger analogy represents reality.

A lot of the people that I looked at with the EMED pressure platform were asymptomatic podiatry students whom I also watched walk. It is quite surprising to see how many asymptomatic people have their fifth met head off the ground, visually, when walking barefoot at the end of contact phase of gait. The EMED was what made me look at the fifth met head in gait. You cannot assume that all met heads are on the ground during the entire step. Your transverse arch analogy implies that assumption. The transverse arch does not exist.

When you line the foot of interest up with the pressure mat, and not the patient's nose, there is no exaggerated lateral excursion. I had a toddler walk over the pressure mat and there was no problem with both feet hitting the map. Most people have a stride length long enough that both feet will not hit the map.

 

Sure, but it is an analogy rather than a model and as such it does its job.

I have never assumed that "all the met heads are on the ground during the entire step."

Peak stress is on the plantar fascia just as the heel lifts and so this is the point when a more even distribution of force within the plantar fascia might be of greatest important ( by "more even" I mean less biased towards the medial aspect ) . I would assume that in a healthy foot at least 4 of the met heads are on the ground as the heel starts to clear the ground.

Some time ago I watched a senior podiatrist address a professional gathering on a number of topics including measuring foot forces during gait. I think he described single step pressure mats as " better than nothing " but requiring up to 15 repetitions to capture accurate information .

I prefer "half dome that extends to the metatarsal heads." Many authors have taken distal transverse arch to mean something it doesn't. If a term misleads or causes confusion it should probably be dropped.

 

Plantar fasciitis is a symptom. Isolate the etiology of plantar fasciitis and treat it directly. That will eliminate the symptom!

Physicians treat symptoms when they are unable to identify the primary cause.

Also, in over 50 years of clinical practice, I have found stretching ligaments challenging. Now tearing ligaments, that is another story.

 

So how do you mobilize the met heads relative to each other ? Well I believe that is one of the major secrets of the exercise popularized by Dr Susan Mayes from Australian Ballet, a very successful exercise that now used to treat and maintain dancers around the world. Calf raises done barefoot on a hard surface.

Calf raises done barefoot on a hard surface would seem to be a very different beast than those done whilst wearing a soft soled training shoe.

Re the etiology of plantar fasciitis, and many other painful conditions, this might be as simple as met heads that don't move they way they evolved to, since we routinely splint feet from the moment a child can walk.

Re the "natural fallacy" criticism that I have come across when discussing shoe interference with foot mechanics , I don't think this can be levelled when considering a body part that is splinted by devices designed to change mechanics.

 

You said "body part that is splinted by devices designed to change mechanics."
I agree. Orthotics do change body mechanics. That is why I stopped prescribing them many years ago.

Plantar fasciitis can be caused by more than one etiology. As physicians, we are trained first to determine the etiology (differential diagnosis) and then initiate the appropriate intervention for that particular etiology.

You said " met heads that don't move the way they evolved to, since we routinely splint feet from the moment a child can walk."

This is possible, but unlikely. I say this with more than 50 years of experience practicing Podiatry. IMO, shoegear has been unjustly incriminated in creating havoc on the foot. Healthy feet can be reasonably shod without ensuing pathology.

Overuse syndrome can result in Plantar fasciitis (not uncommon in ballet dancers). In which case, stretching exercises would be indicated.

 

Happy to chat to you Brian for as long as you can resists using terminology you have invented yourself or conditions you have named after yourself.

The majority of your peers disagree with the majority of your views. And they have a collective experience of practicing podiatry greatly in excess of yours.

 

Hi Gerrard,

That has not been my experience. Among researchers, my work is frequently cited.

 

The exercises introduced by Mayes have been so successful that a study is presently underway to determine exactly why they work so well. The chief researcher in this PhD level study is already quite distinguished and holds a doctorate awarded for previous research. That's a good move in my book, since so much might come from this work.

I have no idea when the results will start to be published but we do know from the information gathered over 20 years that if you want your athletes to have a reduced risk of lower limb injuries then you would do well to use " the Australians".

I really hope they have include met head movement in their studies.