I recently taught my first Plantar Fasciitis workshop. I asked for people who were currently experiencing PF or who had it in the past. Restorative Exercise gives a different spin on conditions like this because what you need to consider is not only the symptoms and the structures that pay the price for them, but the original condition of the structures of the foot, the usage and/or lack of usage of the foot and how that can be essentially a “pre-existing condition.” In other words, we don’t think there’s anything wrong with our feet until they hurt/are injured. But it could be the case (just like a disk injury) that the weakness was there all along and it just took time or that proverbial straw that broke the camel’s back (or yours!) to tip the scales to the diagnosis.
So what is Plantar Fasciitis and how is it diagnosed? The definition – “itis” being the suffix for inflammation, is supposedly an inflamed plantar fascia. This is a structure on the sole of your foot, under and next to the skin, superficial, that runs from the front edge of the heel bone to the toes at the ball of the foot. In fact, a lot of researchers believe plantar fasciitis is degeneration (known by the suffix “osis” as in plantar fasciosis), not inflammation, so taking those NSAIDS, with their associated side effects, might not be such a great idea after all.
Plantar fasciitis is usually experienced as pain in the medial (inside, or big toe side) heel. Occasionally it can spread through the whole foot and toes. It’s usually only in one foot, but in 30% of sufferers, both. If you have a diagnostic to see the inside of the foot, a markedly thickened plantar fascia is indicative of fasciitis, and a thickness greater than 4mm is considered a diagnosis (normal being 2-3mm). What (besides inflammation) could render a tissue thicker (and in the words of one study – “gritty”)? It seems that a tissue that doesn’t get used often, loaded and stretched in many ways could then become stiffer and thicker. Our shoe (and positive heeled shoes in particular) keep the soles of our feet shorter and from moving too much. Our sitting habits mean our feet are unloaded for most of the day.
The status of this tissue and its associated connected tissues and the rest of the musculature of the foot is at a small percentage of its potential and plantar fasciitis is the “gift” we have been given to let us know our feet need a lot of help! It’s not just plantar fascia you need to “fix”!
So what other structures/tissues does the plantar fascia affect? Well, surprisingly, it attaches to the skin, particularly at the heel and ball of the foot, through septa that run vertically from the plantar fascia to the skin. This provides traction at these parts of the foot, that connect to the ground. Otherwise, the tissues would slide on each other, and your foot would be on “loose skin” when it needed to grip instead. Isn’t that fascinating?
Even more fascinating is the quality of the skin of your foot. I recently had an injury which required surgery and 13 weeks of immobilization in a cast. I broke my ankle in three places. So when I got my cast off, the dead skin all sloughed off and I was left with baby skin on the sole of the foot, but thick rough skin on the top that didn’t move, rendering me unable to spread my toes. So even the skin on your foot can tell you a lot about the condition of your foot as a whole.
The plantar fascia also connects to the muscles beside it, through their associated fascia. These muscles abduct the big and baby toe respectively. So if you spend a lot of time in shoes with narrow toe boxes that don’t allow toe spread, these muscles atrophy and weaken and the big and baby toes reside too close to their neighbours, which could also affect the (lack of) tension on the plantar fascia from the sides (perhaps narrowing and thus thickening it!). In the area where the plantar fascia connects to these muscles, it is well innervated (nerves, hence pain) and also where it connects to the muscles deep to it (including muscles that flex the toes).
The plantar fascia also has mechanoreceptors present, particularly on the sides again, and for this reason the plantar fascia has a role in proprioception (it perceives the state of contraction and position of various foot muscles). If your foot has a lack of positions, experiences, sensations, surfaces, including uneven, bumpy, rocky, etc. the receptors are getting the same information all the time. No need to pay attention; nothing to see here.
The relationship of the plantar fascia with the paratenon (covering) of the achilles tendon is consistent with the idea that the calf musculature is involved in plantar fasciitis pathology. As we know from constant positive heel wearing and sitting, the calf musculature can be shortened passively and permanently.* As you may know, the exercise most commonly prescribed for plantar fasciitis is calf stretching! However, there’s calf stretching, and then there’s the Restorative Exercise Calf Stretch, which is performed in an objective manner so that everyone can safely do it and not over-do it. (It is thought that a poor response to treatment might be due to inappropriate and nonspecific stretching techniques.)
And why stop at the calves? The hamstrings cross the back of the knee as well, hence the whole posterior leg needs to be addressed as a solution for plantar fasciitis.
So you see with just this minimal amount of information about the plantar fascia, this is not a simple “stretch your calves” kind of solution. In fact, it requires a pretty much “whole body solution” (to borrow from Katy Bowman’s many book titles). Very few issues in the human body are isolated ones. For my workshop I had prepared 20 exercises and could have added more; as it was with 2.5 hours we got through 9. Perhaps instead of a workshop, this needs to be a course involving exercises, stretches, experiences and lifestyle changes to get our whole foot and our whole body to be healthier.
*unless you do something about it!
(Image above from Henkel A. Die aponeurosis plantaris.Arch Anat Anat Ab Arch Anat Physiol. 1913;113.)