Sunday, 28 June 2015

Plantar Fasciitis

Sports Massage Therapy Exeter by Liam Clarke
A condition I come across on a frequent basis, here's some important information regarding the condition, which if not treated by a therapist with a great understanding of the 3 fascia bands of connective tissue, can leave you with pain and dysfunction for many months, even years. Don t suffer Sports Massage Therapy Exeter can use a vast variety of techniques to from ultra-sound to manual/physical therapy, complementing kinesiology tape to lift the pain receptors that compress on the connective tissue which causes the inflammation.
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What is plantar fasciitis?
Plantar fasciitis is an overuse injury, like carpal tunnel syndrome or tennis elbow in your foot, a kind of tendinitis: an inflammation and/or thickening3and/or degeneration of the plantar fascia. It’s especially common in runners, and in menopausal women. “Many people are afraid of running because between 30 to 70 percent (depending on how you measure it) of runners get injured every year.”4 And roughly 10% of those are PF cases.5
I’ve just used the familiar terms “tendinitis” and “inflammation” to introduce plantar fasciitis in the most familiar and conventional way. However, these are misleading terms and the truth is more complicated. The plantar fascia is not really a tendon: it’s a sheet of connective tissue (“fascia”), more like a ligament than a tendon. It stretches from the heel to toes, spanning the arch of the foot, from bones at the back to bones at the front (whereas tendons connect muscles to bones).
The “itis” suffixes in tendinitis and fasciitis mean “inflammation,” Many people are afraid of running because between 30 to 70 percent of runners get injured every year.but the tissue is rarely inflamed the way we usually understand it (maybe at first, not for long). Instead, the plantar fascia shows signs of collagen degeneration and disorganization. In 2003, Lemont et allooked at 50 cases and found so little inflammation that they declared that plantar fasciitis “is a degenerative fasciosis without inflammation, not a fasciitis.”6 So it would be better to use a more generic suffix — like opathy(diseased) or osis (condition).
In fact, this is true of all so-called “tendinitis” — inflamed tendons are not so very inflamed. “Recent basic science research suggests little or no inflammation is present in these conditions.”7 And Khan et al wrote that “numerous investigators worldwide have shown that the pathology underlying these conditions is tendonosis or collagen degeneration. This applies equally in the Achilles, patellar, medial and lateral elbow, and rotator cuff tendons.”8
And in the plantar fascia, where the degeneration is “similar to the chronic necrosis of tendonosis.”9 Necrosis is bad. It’s Latin for “tissue death.” In plantar “fasciitis,” the plantar fascia is not just hurting, it’s dying — eroding like a rotten plank.10 And this isn’t just to make you squeamish: inflammation and “necrosis” are not the same medical situation, and understanding the difference is essential for effective treatment.
[Diagram of the foot and plantar fascia to demonstrate the anatomy of plantar fasciitis]
Foot arch-ery
The arch of the foot functions like a bow (as in a bow and arrow), and the plantar fascia is like the string of the bow. The tension in the “bow string” holds the shape of the arch. But every time you step, the “bow string” stretches… and when stretched too hard and too often, it gets irritated, and then it’s like a bow shooting you in the foot!
So why does it happen? Plantar fasciitis is basically caused by chronic irritation of the arch of the foot due to excessive strain.
If the arch of your foot is like a bow, think of the plantar fascia as the bow’s string. The plantar fascia, along with several muscles both in the foot and in the leg, supports the arch and makes it springy.11 Too springy, and the foot flattens out, overstretching the plantar fascia. Not springy enough, and the plantar fascia absorbs too much weight too suddenly.
Either way, it starts to burn with the strain.
Other than the fact that it’s on the bottom of your foot and you step on it a lot, why is the plantar fascia vulnerable to strain? Why exactly? What happens?

Getting to the root of plantar fasciitis: could it be bone spurs?

Clever-sounding biomechanical explanations for plantar fasciitis are as common as plantar fasciitis itself. Many therapists and articles on the internet will insist that you must treat the “root cause” of plantar fasciitis. It would certainly be a good idea — there’s no disputing that. Now, if only it were possible to identify the root cause!
There are three particularly common biomechanical “explanations” for plantar fasciitis, which I will cover over the next three sections. None of them is completely useless, but none even remotely qualifies for “root cause” status:
  • bone spurs
  • flat feet and/or pronation
  • tight calves
Unfortunately, there are so many possible causes of plantar fasciitis — probably several of them happening at the same time — that it is effectively impossible (or just extremely impractical) for therapists to make any confident biomechanical diagnosis. It’s simply too complicated an equation, and the scientific literature is riddled with contradictions. Let’s start breaking this down with bone spurs…

Surely hard bony growths in the arch are painful?!

Bone spurs on the heel (aka heel spurs and calcaneal spurs) seem like they must be a smoking gun — a simple and obvious cause of plantar fasciitis. They are common — about 10–20% of the population12 has an extra bit of bone growing on the front of the heel. They often get the blame for plantar fasciitis because it seems so obvious that having a bony outcropping on your heel would indeed cause heel pain, for much the same reason that you wouldn’t want a rock in your shoe. Even more damning: they are indeed found more in people with plantar fasciitis than without.
Not as bad as it looks. Having a bone spur is more like stepping on a cracker than a nail. A very thin cracker.
Seems straightforward, right? Wrong.
Unfortunately for common sense, bone spurs aren’t very bone-y: they’re merely a modest calcification of the plantar fascia. The spur is brittle and thin. It’s not much more like bone than tinfoil is like a sheet of steel. It makes the plantar fascia a bit crispy and crunchy.13 So bone spurs aren’t as much of a painful mechanical problem as they sound: more like stepping on a cracker than a nail. A very thin cracker.
So perhaps it isn’t too surprising that lots of people have painless spurs. And there is good evidence that, when there is pain, it’s not the spur that hurts but the plantar fascia itself or other soft-tissue structures.1415 And surgically removing a bone spur does not necessarily relieve pain, which makes it a lot less likely that it was causing it in the first place.1617 Spurs also tend to just grow back. No wonder a 2007 study concluded, “Overall, the presence of a calcaneal spur [was] not correlated with patient satisfaction and recurrences.”18 And it’s why there is a broad consensus that they are not the culprit. In a 2014 review in the journal Foot & Ankle SpecialistMoroney et alwrote:
Though once synonymous with plantar fasciitis, calcaneal spurs have, for several decades, largely been regarded in the orthopaedic literature as incidental findings. 
But they probably aren’t completely irrelevant. They also wrote:
However, it may be premature to completely dismiss the significance of plantar calcaneal spurs.
It’s clear that spurs are probably more painful and problematic when other tissue X factors are present, but those factors can and do also cause plantar fasciitis symptoms whether you have a heel spur or not — and heel spurs may be completely painless without those factors!
Of all the possible “root causes” of plantar fasciitis, bone spurs superficially seem like the simplest and most obvious — and yet it’s neither. As tempting as it is, it turns out that you just can’t count on a nice straightforward connection between heel spurs and plantar fasciitis.
Other alleged root causes are even less satisfying.

Maybe it’s my pronation? Or flat feet?

“My therapist said I’m a pronator.” I hear this a lot. It’s not clear that it matters.
Pronating is rolling the foot inward. It is almost synonymous with having flat feet, because the arch tends to collapse as you roll the foot inward. They don’t necessarily go together, but they often do, and they are both routinely claimed as root causes of plantar fasciitis. Personally, I think therapists just like to accuse their patients of “pronating” because it makes us sound like we know what we’re talking about. Sound a little harsh? Some experts believe the idea of pronation is so useless — and yet so common! — that they have called for it to be abolished:19
[Overpronation] contributes nothing to our understanding — it is not definable, not reliable or valid, not diagnostic, its relationship to injury is not fully understood, and it does not dictate what the most appropriate management plan may be. It should not be replaced, it should be removed.
It’s just as likely that under-pronation and high arches are a problem. While flat feet are a more popular cause, one professional will blame high arches, and the next will say it’s flat feet … sometimes about the same patient. Surprisingly, professionals often seem to have trouble deciding whether a given foot has a flat arch or a high arch!20
So why are experts contradicting each other? Probably because both flat and high arches are likely causes of plantar fasciitis.212223
For years, I incorrectly told plantar fasciitis clients with high arches that they were exceptional, because I knew only the conventional wisdom: namely, that plantar fasciitis afflicts the flat-footed. Now that I know better, it seems obvious that the plantar fascia can also be irritated by an excessively tall arch. If the arch is high, it means the arch-support system may be too rigid and not springy enough, so it absorbs too much force too quickly.
This is a Goldilocks case: the arches need to flex and give just the right amount — not too little, and not too much.
Pronation is one side of a Goldilocks equation too. The truth is that excessive supinating — rolling outwards — is probably just as much of a problem24 — but that gets almost completely ignored. You never hear about supinating — there’s little research about it.
As much as the body likes things to be just right, it’s also remarkably adaptable. Many flat-footed pronators and high-arched supinators in fact do not have plantar fasciitis. And many people who do have plantar fasciitis have completely normal arches, and neither pronate nor supinate excessively. 
Arch height and pronation are almost certainly risk factors … but not root causes.
If you walk in a shoe store and their sole basis for choosing a shoe for you is how much your pronate and what your arch looks like, turn around and walk out the door. The science simply does not support this protocol.

Probably my calves are too tight!

Could be. Tight calves are another classic plantar fasciitis scapegoat, and the gastrocnemius and soleus muscles (the big calf muscles) certainly can put a strain on the plantar fascia.25 This situation is typical for people with a leaning-forward “ski jumper” postural pattern. And of course it is the predictable side-effect of wearing high-heeled shoes for many years.26
For interesting contrast, the Twa people of Africa grow up climbing trees, which earns them amazingly limber calves that allow their ankles to bend halfway (45˚) to the shin27 — two to four times greater than the average urban person! Look at them go:

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