by Alex Quintana

If you have ever suffered from plantar fasciitis, you know that it’s not to be taken lightly. The pain can be severe, and life-changing. In some patients that I see, it is an ongoing, chronic condition that has been in their lives for months — if not years — before they manage to get help.

Plantar fasciitis impairs the gait, which can lead to a plethora of unhealthy postural compensation patterns, musculoskeletal pain and bone spurs. The psychological effects of not being able to move freely can be quite severe as well. 

Starting the day with  a sharp pain in your foot or, in some cases, both feet, is stressful, and it can become very depressing over time. My clients often mention that the impact on their mood and self-confidence is considerable. It is heart-breaking to see how people who used to love being active, exercised a lot and were genuinely happy going to the gym, running, playing tennis, and so on, had to alter their lifestyle completely to adjust to this new reality of living with plantar fasciitis. 

Unfortunately, with the NHS being so overwhelmed at the moment, it can be really difficult to get the kind of hands-on physiotherapy treatment that also lasts for long enough to really make a difference. To boot, there is no medication that can get this sorted quickly and effectively.  Despite the surfeit of advice and ‘remedies’ out in the wilds of the Internet, I often see people who have been trying to get help for a very long time, with no results. 

One can think of plantar fasciitis as a condition that is simply running out of time to heal. The healing process starts when you stop moving, stop putting weight on your feet. Unfortunately, the time required to heal is longer than a few hours sitting at the desk or the 6-8 hours that we spend in bed. It’s a vicious cycle of re-injury and endless pain, because we simply need to start walking at some point.

So, is there anything you can do to help it? 

Yes! I am writing this blog post precisely for this reason. There is a lot we can do at our clinic, and there are some simple things you can do yourself to stop thwarting that healing process that we are talking about. But let’s start from the beginning.

WHAT IS PLANTAR FASCIITIS?

You mean, besides being one of the most difficult medical conditions to pronounce? :-) 

Yes, there is that. But what is it?

As it is usually the case in modern medicine, the name of the condition has to do with the anatomical structure involved. The plantar fascia is a layer of very strong and thick connective tissue covering the bony structures of the plantar surface, or underside, of the foot. It plays an important role in the normal biomechanics of the foot by providing the tension that maintains the shape of the arches of the foot (yes, there is more than one of those). The suffix -itis comes from the Greek and means “inflammation”, so plantar fasciitis is the inflammation of the plantar fascia. (This doesn’t quite explain what is going on, though… read on, this will get very interesting later).

So what does this thing do besides hurt, anyway?

The plantar fascia is a a flat broad sheet of dense connective tissue, of which there are a few in the body. We variously call them fasciae, aponeuroses, or flat ligaments. The purpose of these structures is always the same - to prevent some movement that it would be very bad for your health and happiness if it happened. 

As an example, think of the lumbar fascia, which covers the lower part of your back. The lumbar fascia is there to reinforce the structure and stability of the lower back. The vertebrae in this part of your spine don’t have any other bony structures around to buttress them when you move about (this is good — otherwise you wouldn’t be able to walk, run, dance, etc.), but it does put them in a difficult position (pun intended). Enter the lumbar fascia: when you turn, twist or arch your back, this flat sheet of tissue is flexible enough to allow some movement, whilst at the same time preventing you from going too far (unless of course you manage to bend forward and twist your torso in this position, which is a ‘tried and tested’ way of hurting your back — but that’s another conversation). 

Anyway, back to the foot. Some people tend to think of the plantar fascia as just the bottom layer, the ‘flat’ of the foot, i.e., the layer of tissue that is under the skin and happens to be in a shape of the foot. However, there is more depth (sorry for the pun) to it. The plantar fascia is actually four layers of tissue, stacked on top of each other, each one shorter than the last. Like the strings of a bow, their job is to maintain the shape of the arches of the foot, acting like a spring and a shock absorber every time we take a step.  

So, why do you say the name is misleading?

To be precise (and we love being precise with our anatomy here at the Healing Space) plantar fasciitis isn’t really inflammation. There is a lot of research pointing to the fact that the reason why plantar fasciitis is so difficult to treat is precisely the opposite - there is not enough inflammation for the healing to take place. Inflammation is the natural response of the body to injury, and the first step of the process to getting it healed. Tendons and ligaments don’t have a rich blood supply, nor is the tissue pliable enough to take a lot of swelling. Therefore, it would be more appropriate to refer to the condition as plantar fascial stenosis. 

What does that mean, anyway?

Stenosis is another of those Greek words, and it means ‘narrowing’. I’m using it somewhat liberally here, to mean that the layers of the plantar fascia have actually become constricted and tight, so they’re not properly hydrated and they lose whatever pliability and elasticity they are supposed to have to do their job correctly. See, tendons ands ligaments don’t have a rich blood supply, and this is by design. However, they have a lot of nerves, because the body gathers a lot of information about where the body is in space from these structures. So the pain is caused because the tissue has become tight, dehydrated and spastic, none of which are synonymous with inflammation.

Hm, ok. So why does this plantar fascia-whatever happen? 

The are several causes for plantar fasciitis:

• Repetitive movement of the foot which is not optimal, i.e., if there is a tension somewhere in your body, your foot might end up compensating for it and not moving the way it should.

• Prolonged foot movement on hard surfaces - i.e., running on concrete as opposed to a dirt track, or whatever other surface you’re using to escape the oncoming tiger.

• Impaired circulation in the lower legs and feet, which can happen for many reasons. Athletes and the elderly (two of the groups that most frequently present with plantar fascia pain) have over the years accumulated a build-up of repetitive and micro-traumas in the area, that can lead to tension and pain.

• Inappropriate footwear, i.e., shoes that squeeze your foot, or prevent it from moving freely and naturally, splaying out when it’s flat on the ground and bouncing back into its natural shape when it moves off the ground. This is unfortunately the case for most shoes these days (those high heels have a lot to answer for)… Shout-out here to barefoot shoe lovers and barefoot walkers over there!

In essence, bad postural habits combined with wearing shoes all the time amount to an ongoing effort to damage the plantar fascia. Again, limited blood supply means that this tissue needs to move, stretch, and spring back into shape in order to stay supple and hydrated. If it lacks that for long enough, it goes into spasm, and when such richly-innervated tissue goes into spasm, we experience pain. If it is tight and dehydrated enough, it might even start pulling the bone out of shape, creating bone spurs. 

That all sounds awful… and very complex. Can you explain what plantar fasciitis is in simple terms?

Sure. The problem of plantar fasciitis is NOT that there is an inflammation. The problem is that the fascial structures of the foot cannot do what they’re supposed to do, because you’ve prevented them from doing it for too long, and now the tissue is dry, out of shape, and ‘screaming’ at you.  

Yikes. So, how does it feel?

What most of my patients mention, and what I can clearly remember from my own plantar fasciitis experience, from way before I became a therapist, is pain after a period of rest.

The pain is usually located around the heel and the middle part of the arch of the foot. It can be experienced as a sharp, shocking sensation when first putting weight on the foot in the morning, or when standing suddenly after sitting for a while. Once the person starts warming up and moving around, the pain usually wears off a little, but not for long. It usually comes back again, just when one has managed to forget about it. It can also appear out of nowhere for seemingly no reason, during a usual activity, which is one of the most disconcerting aspects of this condition.

What do you do to this get better?

Aha! Glad you asked. When treating plantar fasciitis with myofascial techniques, one of the fist things one must endeavour to do is discern which of the four layers is/are not moving properly. Just pushing on the affected foot or lower leg won’t help, and likely it will hurt like the blazes. Like all fascial treatments, the purpose is to open up the tissues, separate the hydrophilic from hydrophobic fibres in the fascia so that there is space for more water and the tissue can recover some of its pliability and plasticity. 

You mean, hydrating the tissues? How do you do that?

Fascial manipulation separates the layers of fascia so that water can get into them. After a treatment, it is usually suggested that clients move, like going for a walk of doing some light exercise and/or stretching, to keep the layers gliding and sliding on each other. It is also recommended to drink water during the first two hours after your treatment, so that there is water for your body to absorb and put into those tissues whilst they’re nice and open.

Ok, but what do you actually do? Do you just manipulate the foot?

Another key aspect of this treatment is, fascia is everywhere in the body. A treatment for the plantar fascia wouldn’t focus solely on the foot. There is a big probability that the problem started somewhere else (remember those compensations we were talking about?) and the plantar fascia is the victim rather than the culprit in this scenario. My most recent patient had some considerable post-surgical scarring in the abdomen. The surgery happened a few years ago and the symptoms in the foot followed not long after that. During the treatment, I evaluated the circulation from the common iliac artery through palpation and realised that the scarring from the surgery was impairing the circulation of the lower body. 

So the scars in the abdomen were causing the pain in the foot? Are you taking a mickey? 

I’m not saying that in itself caused the plantar fasciitis, but it definitely put a damper on the body’s ability to recover from the tension that accumulated in the legs and feet. These kind of partial impairments to the circulation diminish our body’s ability to get nutrients and oxygen to the tissues downstream from them, and also removal of wastes, which makes recovery difficult. In the case of this patient, releasing the scar tissue had a profound and pretty immediate effect on the feet. I also found tension in the deep calf muscle - the soleus - which happens to play a little-known-but-hugely-important role in the venous return from the legs to the general circulation. Working with this muscle, along with the scar tissue in the abdomen, allowed for the cascade of releases that were so needed by the body. 

Each body is truly unique. I am often blown away by the particular ways in which what a person is doing with their bodies results in plantar fasciitis. The most humbling part is, it is often easy to see that this was the least-worst way that the person’s body managed to sort itself out to keep going for this long. 

That is interesting but you also said that there is stuff I can do on my own?

Indeed! You as a patient can help the healing process. The goal is to avoid shocking your body with sudden movements, especially in the morning whilst it’s still working on the healing. We also want to re-introduce some flexibility to the tissues, by learning some fun new movements for the foot. 

5-MINUTE MORNING ROUTINE

Bring a belt to your bedroom and place it on your bedside table (soft dressing gown belt or yoga belt will do the trick).

Set your alarm to give yourself at least 5 minutes to do this. These 5 minutes, along with professional treatment, can be a game-changer in your healing process and recovery.


1. Massage the sole of your foot for 1 minute 

Whilst still in bed, sit up and position your thumbs in the middle of the foot near the toes. Massage towards the sides of the foot. Work gradually towards the heel. It might be sensitive around the middle of the foot. If it is too sensitive to massage, work the tissues around it.

2. Curl and uncurl your toes

Whilst still in bed, hold on to your toes and bring them towards the front of your body. Hold for 30 seconds. Repeat on the other side.

This will mobilise the fascia between the heel and the toes where the troubled area is located. You will feel this movement in your calf muscles and this is absolutely fine.

3. Soleus stretch

Sit on your bed and reach out for the belt. This is all about stretching the deepest layer of the calf - the soleus muscle. We can access it when the leg is bent, so bear that in mind.

Bend your leg, catching the foot with a belt just below the toes. Pull the belt towards you to stretch the calf muscles for 30 seconds. Repeat on the other side.

4. Hamstring stretch

You can also lie down and put one leg up, still holding it as close to you as possible with the belt. It will stretch the calves and the hamstrings. Hold for 30 seconds.

Repeat on the other side even if only one foot is painful.

DURING THE DAY - ALPHABET FOOT DRAWING 

During the day, if you sit at your desk (or at a very boring meeting), lift your foot off the ground and then draw the letters of alphabet in the air, as if your big toe was your pen. 

Do it at least once a day with both feet. 

If you you get bored, switch to capital letters! It’s so much fun for your feet and the brain.