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Sunday, September 9, 2012

Can You Strengthen The Plantar Fascia??

I began looking for more effective treatments and permanent results for plantar fasciitis (PF) over for the past several years.  It's never set well with me the passive and palliative type of treatment that has been mainstream for so many years.  These treatments in my opinion are drawn out far too long and are only partially effective.  The cause of PF is usually not a concern of the treating healthcare provider.   The typical scenario when going in to a physical therapy clinic is to strengthen the muscles in the foot.  But has anything been determined that there is something actually wrong in the muscles of the foot?  From what I have been able to discern, there has not been any earnest effort into a more effective and permanent resolution of PF.  Given that the plantar fascia is such a tremendously strong piece of tissue, why the heck would you want to sit around and scrunch up a pillowcase or sheet with your toes and massage the bottom of your foot with a frozen water bottle?  Why would you want to enable further demise of the plantar fascia using rigid orthotics for indefinite periods of time and potentially cause a greater imbalance and increased dysfunction upstream in your legs, thighs, hips, or back?  And why do physical therapists, doctors, podiatrists, and other healthcare providers not look for the cause of PF?  There seems to be a common opinion about feet of which I strongly disagree with.  This opinion is that from the day you were born, your feet are going to fail you!  Your feet will need special shoes and orthotics if they are to last throughout your lifespan.  This is the marketing angle and propaganda that many people become persuaded by and then believes that their feet are doomed!  As you’ll read later, the plantar fascia is usually the last tissue to become dysfunctional if in fact it even does become dysfunctional.  The plantar fascia is your last line of defense in maintaining proper structure and mechanics in your foot.  There are multiple factors that lead up to PF that have nothing to do with how your feet are designed.  We as people and healthcare providers have a tremendous amount of evidence based information to treat and heal specific tissues in our bodies including the plantar fascia. 

This is precisely what this specific blog entry is about.  With this blog you will be better able to identify the most likely cause of PF.  You will be educated on what type of tissue the plantar fascia is, and finally, you will be taken through the most logical steps of treating the PF.  The gross resultant outcome is one of which you now have complete control over your own feet.  No more over priced orthotics, no more injections, no more night splints, no more being drawn in to advertising propaganda that plays on your gullibility.  And most of all, you will experience a remarkable amount of decreased down time from the activities that you most enjoy participating in! 

So, my first question is why do most persons treat the plantar fascia with such pampering and passive treatment when it is such an extremely strong and durable structure?  

The answer to this is people don't want to feel pain!  No one likes pain.  However, sometimes pain is part of the healing process.  Just ask anyone who's had rotator cuff repair, a knee replacement, or a hip replacement.  Even a simple arthroscopic menisectomy can cause unexpected pain during the recovery and rehab process.  Many people believe that if any pain is felt while treating the plantar fascia, then this is just causing more damage or inflammation.  It's easier to put a band-aid on an injury, treat the pain, and leave it at that.  But this doesn't resolve the underlying cause of the injury.  Since pain is present in the process of acquiring and then especially healing PF, it comes down to a persons constitution.  A person needs to understand the healing process, that it's normal to feel pain for a short duration of time when treating PF, and that certain pains indicate a positive healing response by the body and tissue.

The next logical step is to identify what type of tissue is the plantar fascia and what are it's characteristics.  Each tissue in our body has differences and responds to differently to specific treatments. 

With this basic piece of information, the next logical step is to put in place a specific treatment plan for the type of tissue that we know the plantar fascia to be.  

Finally and of most importance, what anatomical dysfunction has occurred above the foot that precipitated PF?  

What Type of Tissue is the Plantar Fascia?

What you will read next may present as somewhat technical information and you may have to read some of this more than once.  No worries though, I didn’t use disappearing ink!  If you’re already a gym rat or in to endurance sports, strength training, running, basketball, soccer, etc. you’ll already most likely be using some of these workout and exercise techniques.  But what you may not know is the technical names of the exercises you’re already doing.  So, here we go.

During my literature review and research, the plantar fascia is referred to as a ligament in the medical field.  Since the plantar fascia is a ligament, a treatment protocol has to be aimed at improving the integrity of the ligament.  Now, with that being said it's important to understand the properties of a ligament and whether or not a ligament can become inflamed and even a bigger question:

Can you really strengthen a ligament?  And the answer to this is...You'll have to read on further!!

The following may or may not be a lot of extraneous information for you but it's the foundation in which healing and PF are based on.  Now, with the above being asked, and with some extensive reading of peer-reviewed literature such as medical journals, university research, and speaking with experts in the field of foot mechanics and anatomy, etc. the plantar fascia is referred to as a ligament as previously stated.  So, if we're going to treat a ligament, we need to know the properties of it, what it responds to, and how to treat it.  So, the main properties and characteristics of a ligament are the following:
  • ·       A ligament can thicken depending on the workload demanded on them.  Often, a ligament can interfere with the function of a joint, i.e. carpal tunnel syndrome, crowding of the spinal cord when the longitudinal ligaments become thickened due to instability of the spine.
  • ·       A ligament is a passive stabilizer.  Meaning, a ligament has no voluntary contractile properties.  It's like a cable that's attached to a power pole and is stabilizing it.  A ligament can be stretched.  But if this is done, then the integrity of the ligament has just been compromised.  If stretched too far, then instability in that joint can occur.  If instability occurs then it's up to the muscles surrounding the ligament to take up the stabilizing properties of the ligament.  So...if the muscles are weak as well, then there's nothing to stabilize the joint resulting in further break down of that particular part of the body.  There are degrees in which joint or ligament instability is referred to.  They are simply referred to as a grade I, II, III, and so on instability depending on what part of the body or specific joint that is being referred to.  Grades I through III often respond well to conservative treatment.  Grade IV and up typically require surgical intervention.
  • ·       A ligament attaches bone to bone.
  • ·       A ligament receives its nutrients not at the ends where it attaches to bone, but more in the middle via the synovial fluid.
  • ·       A ligament has no blood supply at least none to speak of anyway.  Therefore, with out blood supply, nervous tissue is absent as well! 

This last point is extremely important!  When neither blood nor nerves are present, then there's no way for the ligament to call out to the body for its’ repair.  All of a sudden joints and tissue adjacent to the improperly working ligament becomes inflamed due to taking up the work of the dysfunctional/ damaged ligament.  And in some cases, a ligament can impair the function of tissues, nerves, and vessels adjacent to it due to the ligament becoming thickened (i.e. carpal tunnel syndrome).  

Here's something that's very important to understand!  It's not the ligament that hurts when damage is done to it.  It's the adjacent structures that become painful and inflamed due to the dysfunction of the ligament.  So, if the plantar fascia is a ligament, but the ligament is unable to produce pain signals when damaged, then is it really the plantar fascia that’s causing the pain? 

Remember, per peer literature review, the plantar fascia is considered a "ligament" (no blood supply and no nerve supply).  This ligament is the support structure in the arch of the foot.  It acts as a guy wire that maintains the arch of the foot. With out this support structure failure of the adjacent joints and soft tissues in the foot are imminent.  Pain will then originate from these adjacent joints and tissues.

With that being said, let's now look at the properties and characteristics of a tendon as would be present in PF: 
  • ·       A tendon is attached to a contractile tissue.  It is not a passive stabilizer.  
  • ·       A tendon attaches muscle to bone.
  • ·       A tendon can be altered regarding its density and circumference via specific strengthening techniques.
  • ·       A tendon has a blood supply as well as a nerve supply.  The nerve supplies are those that sense stretch and pressure and in cases of chronic inflammation, pain. 
  • ·       As with a ligament, pain arises from the outer surface of the bone that the tendon is attached to.  
  • ·       A tendon receives its nutrients where it attaches to the muscle as well as at the bone attachment vs. synovial fluid in the middle of the tendon.
  • ·       A tendon can become inflamed.
So where do we go from here?  A good start is to compare the properties of a ligament and a tendon side by side and see which characteristics the plantar fasciitis is most alike.  From there, a proper treatment protocol can be established.  So, I'm going to do this in the easiest format possible and hopefully of which makes the most sense.  Knowing the properties will give us a good idea of the proper approach to treatment.  OK, here are the side-by-side comparisons:

A ligament can become larger in diameter via instability of the bones it is anchoring.  Once the ligament becomes enlarged, it will remain enlarged unless it is immobilized over a long period of time.
Diameter and density can change via specific applications of loading and unloading the tendon with resistive training.
Blood & nerve supply are absent.
Blood & nerve supply are present.
A ligament cannot become inflamed but adjacent tissues can become inflamed.
A tendon can become inflamed and become painful once the inflammation has reached a chronic stage.  Arch pain is not present early on in PF.  Heel pain is present at the origin site on the calcaneus early on.
A ligament cannot be intentionally strengthened.
The diameter and density of a tendon can be manipulated via strengthening activities.
A ligament does not have the ability to repair itself.
 A tendon can repair itself because of its ability to become inflamed and trigger the body to begin a healing process.

We know that when excessive loading of the plantar fascia occurs, it will hypertrophy and thicken.  When the excessive load on the plantar fascia is taken away, the thickness of the plantar fascia will reduce to a more normal thickness.  This change in thickness of the plantar fascia can be confirmed with imaging studies such as an MRI or ultrasound.  We also know that when the plantar fascia becomes overworked, inflammation occurs in the foot and pain becomes present.  

It is in these physical properties of the plantar fascia that define the best treatment approach for PF.  The plantar fascia has also been referred to in peer-reviewed literature as a continuance of the achilles tendon.  However, this is debated with other healthcare professionals.  This claim has been strongly based on how the plantar fascia works when the foot is actively pointed or plantar flexed.  This claim states that when the foot is pointed or plantar flexed, the arch of the foot does not raise and there is an absence of tension on the plantar fascia.  This would indicate that the plantar fascia is a non-contractile tissue as mentioned above because it does not cause the arch of the foot to raise.  However, this statement does not take in to account the position of the foot.  When this statement is made, no parameters were placed on the position of the foot.  Let me try to explain this better. 

Before this statement can be considered true or false, one question needs to be asked. 

Is the foot in a closed chain position and pushing against an object when pointing the foot or is the foot hanging free in space? 

If the foot is not in contact with the ground then this statement is true and the plantar fascia takes on the properties of a ligament.  This now obviously leads to another question.  If there is no force going through the foot and plantar fascia and there is no repetitive dynamic impact on the foot and plantar fascia, then can acquiring PF even be possible?

Here's my argument regarding this one defining property of which will strongly influence the treatment of PF.  When the foot is pointed or plantar flexed, you have to consider whether the foot is in contact with the ground (a closed chain position) or is the foot dangling free in space (in an open chain position).  ”Open chain” means the foot is not in contact with any object such as the ground/floor, or a footrest, or any other surface.  It would be like a gymnast or diver in mid air pointing their feet for style points.   "Closed chain" refers to the foot being in contact with the ground such as when you would stand on your toes to look over the neighbor’s fence.  When force is applied through the achilles tendon in a closed chain position, the arch of the foot does raise.  If the arch of the foot is rising, then the plantar fascia is being drawn tight and it is under tensile force.  Therefore, put in these terms, the plantar fascia is acting as tendon!  The plantar fascia is becoming tight due to the toes having to extend or bend backwards.  This is what draws the plantar fascia tight in a closed chain position.  Therefore, under this interpretation, the plantar fascia does take on the characteristics of a tendon!

By now, you've probably already made up your own mind on what characteristics the plantar fascia mostly resembles.  And if we're thinking the same, the plantar fascia in my opinion is much more like a tendon!  This is especially true under a functional or weight bearing interpretation.  

Now that we know what tissue type the plantar fascia is, it's much easier to determine a proper treatment protocol in regards to strengthening of the plantar fascia, the adjacent tissue, and the muscles up stream in the lower extremity.

The Basic Concepts of Treatment

Several years ago I developed a "Tilt Board" that I use in the clinic which reduces the amount of pain that often presents when applying forces on the plantar fascia.  The tilt board was designed to work the foot and ankle through normal ranges of motion with flexion at the ankle and extension at the ankle.  It also works via specific muscle contractions such as eccentric muscle contraction/exercises and concentric muscle contraction/exercises.  Other exercise and strengthening apparatus that is used includes foam pads, bosu balls, and plyometric training exercises.  It sounds like a lot, but it's really quite simple and doesn't require a significant amount of time.

Now, before I go further, I feel I need to give definition to some of the terms that I've mentioned in the above paragraph.  You might be saying, "OH CRAP!  I've no idea what concentric, eccentric, and plyometric exercises are!".  Don't worry, I'm going to tell you all about it.  The tilt board that I've designed and use in the clinic is designed to mobilize the bones and connective tissue of the foot in a very therapeutic manner.  It also causes recruitment and forced use of muscles in the leg and foot that have not been contributing in the manner that they should and thereby adding to the onset of PF.  This tilt board also causes what is called a co-contraction of the leg and foot muscles.  Some of you may know what a co-contraction is but for those of you that don't, well, a co-contraction is when one muscle and then its' opposite muscle are working at the same time to allow movement in a controlled and balanced manner.  This co-contraction elicits eccentric and concentric muscle contraction at the same time.  Eccentric muscle contraction is when the muscle is contracted or what some people refer to as flexed but is lengthening instead of shortening.  Concentric muscle contraction is what most people are familiar with when speaking of contracting a muscle or flexing a muscle.  Concentric muscle contraction is when you bend your elbow to show off your biceps.  The muscle fibers are grouping or coming together and shortening making the muscle bulk and stand out.  So, when performing an arm curl or biceps curl and your hand is coming up towards your shoulder or torso and the biceps is taking form, this is a concentric muscle contraction.  When you are lowering the weight from your shoulder to your side, this is an eccentric contraction; the muscle is still contracting at the same time it's lengthening instead of shortening (here's a little side note of importance.  Eccentric muscle contraction when performed properly causes greater strength gains of a muscle vs. concentric muscle contraction)  Got the concept now!?

Plyometric exercise is when there is a dynamic loading on a specific muscle.  Very simply, jumping up and down is a plyometric exercise.  Stepping up on to the top of a box and then jumping down is a plyometric exercise with an eccentric muscle contraction.  Jumping up on to a box is a plyometric exercise using more of a concentric muscle contraction.  An eccentric plyometric drill is very effective in the latter stages of treatment when resolving PF.

When "core" strengthening first came about some years ago.  The whole idea of core strengthening is to produce co-contractions throughout the hips and trunk in order to build stability and muscle balance between a muscle and its opposite muscle.  This concept is very important when talking about increasing the strength and stability of the foot and ankle.  If one muscle over powers another, then with time, this can cause an imbalance of opposite muscle groups and eventually elicit poor mechanics in the foot that then can lead to TPT or PF.  This tilt board has been part of a very successful treatment protocol because of it's ability to teach a person good control of their foot, leg, and ankle motion through controlled co-contractions of the muscles throughout the entire lower extremity.  The tilt board, however, puts special emphasis in the muscles of the leg (remember, the leg is from the knee down to the ankle) and in the foot.  In addition, it significantly improves single leg balance through controlled co-contraction (concentric/eccentric contraction), coordination, and strengthening in the affected lower extremity.

Here's the reason why I felt I needed to really explain this.  To effectively resolve PF, a sound understanding of the plantar fascia tissue type is necessary.  Understanding the pain process is necessary, and having a good knowledge base of effective exercises are all a must in resolving PF.  Palliative treatments can now be applied in addition to the strengthening of the lower extremities to promote muscle balance, reduce irritating forces throughout the lower extremity and foot, and normalize the tensile forces on the plantar fascia.

Finally and in conclusion, doing a proper gait analysis, strengthening of the hip, thigh, leg, ankle, and intrinsics in the foot via concentric, eccentric, and dynamic plyometric training will resolve plantar fasciitis!  Also, when strengthening a muscle that is attached to a compromised tendon, pain is going to be a normal response, especially in the adjacent tissues as we've discussed.  This pain however should be managed and only worked to a certain amount.  Palliative treatment such as ultrasound, icing, night splinting, etc are still part of the treatment protocol.  However, if these are done by themselves, PF will not be permanently resolved, only the pain symptoms of PF will be affected by this palliative treatment.  The function of the plantar fascia will not improve and the synergistic muscles will continue to be imbalanced and dysfunctional.  It's important that gait mechanics, muscle imbalances, foot type, and prior level of physical fitness will all have persuasion on the resolution of PF.  Not mentioned previously, ASTYM (augmented soft tissue mobilization) treatment to the leg and plantar fascia significantly increases the healing rate of PF.   

So this is what I want you to take from this post.  PF can be resolved permanently.  When someone says they specialize in treatment of PF, all of the above should be considered.  If they are not, and the first thing your healthcare provider wants to do is provide you with very conservative and palliative treatment or send you out for custom orthotics, then look for someone else...or you could just email me for free advice!  Once all is considered, we can arrange an online e-meeting and at this time I can provide you with a customized training and treatment protocol. 

So feel free to email or call!  Oh yeah, if this post has you more confused more than helping you clear things up, again, please feel free to contact me via email.  I will be more than happy to help out! 

There are other arguments that can be made about this treatment approach.  However, I've not encountered any better treatment approach to this point.  Not to toot my own horn, but I've had great success with treating PF with this approach.

Look for my next post about specific approaches and treatment to tibialis posterior tendonitis (TPT).  TPT is very often misdiagnosed as PF.  Treatment protocol is similar to PF, but mechanics of the foot have to be assessed in a different manner and with a different treatment intention.

So, for now, happy bipeding!

Brad Senska, PT, DPT, BS, ASTYM.