Plantar Fasciitis What is the plantar fascia? (#1 in the picture to the right)

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1 Plantar Fasciitis What is the plantar fascia? (#1 in the picture to the right) The plantar fascia is a thick, ligamentous connective tissue that runs from the calcaneus (heel bone - #2 in the picture to the right) to the ball of the foot. This strong and tight tissue helps maintain the arch of the foot. It is also one of the major transmitters of weight across the foot as you walk or run. That's why tremendous stress is placed on the plantar fascia. (See article on Ligament Laxity and also Tensegrity). The plantar fascia is actually the extension of your heel cord muscle that starts in your low back and ends in your toes. It helps to hold and stabilize your back and foot in place when you are standing. For this reason, many people who have back pain will also complain of having foot pain. When the plantar fascia begins to tear, either from injury or aging, Mother Nature tries to heal it with the only weapon she has. She either tears or tries to weld the fascia together with bone. The tearing of the fascia is referred to as a fasci while an acute inflammation is called a fasci. Injury to the plantar fascia can be difficult to resolve and will require an effort on both yours and my part. Far and away the most common cause of plantar fasciitis is a series of biomechanical factors (high arch, weak ligaments, poor stability, uneven leg length, myofascial trigger points) that combine to produce cumulative micro traumas by stressing the bottom of the arch past its elastic limits. (See Ligament Laxity) Rehabilitative goals must include restoring the architecture of the foot by all means possible. They may include passive stretching, increasing the range of motion, dynamic proprioception and strengthening of the foot muscles along with restoring the health of the ligaments and bringing the ground to the body by orthotic and shoe therapy. Personal experience has taught, An ounce of prevention is still worth a pound of cure.

2 How do I know if I have plantar fasciitis? Often the pain from the plantar fascia is most severe after you stand on your feet in the morning, and your foot feels better after rest. Sometimes, the pain will cause you to limp, have leg and knee pain along with hip and low back pain. With the change to new shoes, the pain might subside but will return. Aspirin and anti-inflammatory medicine like Motrin or Relieve helps only temporarily. Who gets plantar fasciitis? Plantar fasciitis, or better still, plantar fasciosis (tearing of the plantar fascia) is most often seen in middle-aged men and women, but can be found in all age groups. Plantar fasciosis/fasciitis is diagnosed with the classic symptoms of pain and swelling that are localized over the middle area of the bottom of the foot. Plantar fasciosis has sometimes been associated with a rapid gain of weight. This is generally not the case and losing weight may make you feel and look better but won t help the foot pain. What is important to remember is that weight is not usually the culprit. No matter what your friends are doctors tell you. Plantar fasciosis/fasciitis is also seen in recreational athletes, especially runners. In these athletes, it is thought that the repetitive nature of running causes damage to the ligaments, and it is these same ligaments that help form the arch of the foot. With the loss of the ligament integrity and with all the weight and pressure on the plantar fascia, it will have small tears. There are many different factors that will also cause the plantar fascia to become inflamed. One shoe doesn t fit all feet. Some of the most common causes that I see daily are as follow:

3 Far and away the most common cause of plantar fascia pain is faulty biomechanics of the foot or leg. Faulty biomechanics causes the foot to sustain increased or prolonged stresses over and above those of routine ground contacts. Women who have gone through childbirth release a hormone called Relaxant. This hormone not only relaxes the ligaments surrounding the birth canal but also all the ligaments in the body, especially the feet. Osteoarthritis, aspirins and certain medications used in cancer treatments will also loosen and weaken our bones and ligaments. This along with metabolic problems like anemia, diabetes and protein absorption are only a very few in the myriad of causes. Could something other than the plantar fascia cause this pain? Plantar fasciosis/fasciitis can be confused with a condition called tarsal tunnel syndrome. In tarsal tunnel syndrome, an important nerve in the foot, the tibial nerve, is trapped and pinched as it passes through the tarsal tunnel, a condition analogous to carpal tunnel syndrome in the wrist. This may cause symptoms similar to the pain of a Plantar fasciosis/fasciitis. How do you treat plantar fasciosis? Treatment of plantar fasciitis can be a long and frustrating process for the doctor, the patient, and the family. If you do not have a firm grasp of why you have this problem then the results will be spotty at best. First, Mother Nature has her own timetable that may not be in sync with yours. She will win! The "down time" for plantar fasciitis will be at least six weeks and up to six months of conservative care before drastic measures like surgery should be considered. Second, Understand by discussing the treatment goals and plans. You, your family, employer and friends must know what you can and cannot do. You must understand the goals and commit to achieving them. Consenting to a pro-longed period of relative inactivity is difficult for highly motivated individuals. A partial commitment can make plantar fasciitis last forever, decreasing both the quality and enjoyment of further walking.

4 The goal of this rehab program is to initially increase the muscle and ligament strength. This should lead to improvements in body balance and flexibility of the foot and ankle, followed by a full return to function. Rehab begins with your shoes. The proper heel height and fit is crucial for good foot function. Remember your foot touches the ground in your shoes. Inspection of the footwear is critical. You should make every effort possible to wear shoes that are comfortable and do not foster poor foot posture. Try different heel heights until you find the one that is just right for you. Managing plantar fasciitis. The next phase of care involves management of plantar fasciitis in conjunction with the activities of daily living. Steroidal anti-inflammatory injections into the plantar fascia are only temporary and of questionable affect. Effectiveness of the steroids depends on the accuracy of the injection and your compliance with this period of reduced activity. It should be noted that cases of spontaneous rupture of the plantar fascia following steroidal injections have been reported. Low Dye Taping A second consideration is to tape or strap the foot. The Low-Dye method of taping is recommended. Dr. Ralph Dye was a podiatrist in the1930 s from Pennsylvania. He was a personal friend of my father. Dr. Jack P. Horwitz, DPM. The idea behind the use of tape is to reinstitute proprioception (knowing where your body is in space) and to allow the ligaments in the foot to react better to the weight placed on the foot during walking. Debate has raged for decades as to whether or not orthotics are necessary or simply a crutch. The Russians have no translation for foot orthotics and subsequently do not use orthotics. When asked about the severity of their athlete's foot problems I was told, "We have no foot problems. We strengthen the foot." This is also one of our goals.

5 The theory behind orthotics is simple.. Pain is caused when the body tries to reach the ground. This effort leads to hip and low back pain because the affected leg, back, shoulder joints and neck bones go out of balance. This stresses the supporting muscles and ligaments of the hips and low back. Can physical therapy and exercise help? The ability to maintain general physical fitness and specific cardio-vascular fitness is an important goal throughout the rehabilitation period. There are several proven methods that can maintain fitness levels while at the same time not placing stress on the plantar fascia. An overall weight-training program can be instituted as soon as possible. Event specific routines can be developed. You should avoid all calf work, toe raises, etc. Two other commonly used rehab modalities that you might want to consider are bicycle riding and water training. Bicycle riding, either stationary or street, usually do not stress the plantar fascia and probably should be avoided until there is no pain for several weeks. Water training, on the other hand, can begin immediately. There are several flotation devices on the market that you can use. The water should be deep enough so that there is no ground contact. The goal of this type of work is to maintain some cardiovascular fitness, with the secondary benefits being improvement in running technique and strength of the hip flexors. What is ligament enhancement therapy? One of the non-surgical treatments for chronic foot or ankle pain due to lax ligaments is prolotherapy. Prolotherapy involves injecting the lax ligaments with a solution containing sugar water, a local anesthetic, and highly refined cod liver oil. Researchers using before-and-after microscopic exams of the ligament have shown that these injections actually repair the damaged ligaments and restore them to health. Remember that ligaments have a poor blood supply, and that is one of the reasons ligaments do not heal as fast as we would like them to heal.

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