plantar fascia anatomy

You may have experienced this before: pain on the heel or sole of your foot upon rising from bed in the morning, burning sensation along the arch of the foot, or pain along the arch of the foot, under the big toe and perhaps into the heel, after you’ve walked for a bit. I’m not a doctor, and can’t diagnose you, but it’s likely that you experienced plantar fascitis.  I’ve experienced it, and I know it’s not fun, nor does it “go away” quickly. Below is a description of plantar fascia, how it functions, why it might become irritated and how do we help ease the discomfort.

What is the plantar fascia?

The plantar fascia is a thick band of tissue that originates from the base of the calcaneus (heel) and extends towards the plantar (underside) of the toes (see Image above). Stretch tension from the plantar fascia prevents the spreading of the heel away from the base of the toes and maintains the medial arch.  It works like a “windlass,” or like a tightening of a rope or cable–the plantar fascia is the cable.  As we push off our big toe in walking, the plantar fascia (cable) “winds” up, or tightens, bringing the heel closer to the base of the toes and lifts the arch (supination). This produces a rigid support that we can use to propel us forward.windlass

What causes the plantar fascia to be painful?

For the plantar fascia to function optimally, there must be a balance between the muscles and tissues that allow the foot/ankle to roll out (supination) and roll in (pronation). Too much of one at a certain part of the walking (gait) cycle and you may have dysfunction and resulting pain.

Too much tension on the plantar fascia may cause lifting of the bony surface of it’s insertion on the calcaneus (heel). As the bone tries to heal, it lays down more bone, causing a bone spur. Wolff’s law states that mechanical stresses influence bone growth–the direction and amount of pull from the fascia on the calcaneus form the bone spur.  However, studies have shown that this is not always the source of pain.  They looked at 40 images of those that had the bone spur removed, only to show the bone spur had reformed. Yet, the subjects reported improved function, despite presence of the bone spur a second time around. This suggests there are other factors at play.

The biggest factors that come into play are that some muscles are weak and others are tight, setting up faulty biomechanics. So, your arch could not be supported at all, making a flimsy foot to plant off, or it could have too much support, making the foot so rigid that plantar fascia is always on tension. You might have been told to just “stretch it.”  Stretch the heck out of it if it’s already stretched out and you’re making things worse.

**Sorry, this blog does not include a discussion of the bony anomalies that may be present due to old injuries, fractures, etc…..it would take another post and another day.

So, how can we ease the biomechanics and thus, ease the pain?

For over-pronators, low or flattened arches:

  • It’s possible that you have a weak posterior tibialis muscle. This muscle allows the foot/ankle to point down and draw the toes upward (inversion/plantar flexion). It helps with supinating the foot—see above for the windlass mechanism of the plantar fascia and it’s ability to supinate the foot. The posterior tibialis has been shown to be the most significant dynamic support of the medial arch during walking.  It controls the opposite motion of pronation and thus lessens the tension on the plantar fascia. But when it’s weak, the plantar fascia becomes tensioned and lengthened.

Exercise:

  1. Seated arch lifts: keeping bottom side of the big toe into the floor, lift the arch up. Progress to standing arch lifts.  Hold 5 seconds, repeat 10x, 3 sets. Yoga Tip: think of Tadasana (Mountain Pose), equal weight on both feet, all parts of feet and then practice lifting the arches.
    Newsletter pics-001

    tadasana

    Tadasana, www.yogajournal.com

  2. Standing heel raises: first double heel rise then progress to single heel raises. Go up and slowly return back down. 3×10 single heel lift
  3. Inversion with Theraband/elastic tubing: set up the tubing or band so that you resist the motion to turn the foot in/point down. 3×10  Newsletter pics
  4. Single leg standing: Balance on one foot as you wash dishes, or brush your teeth. Yoga Tip: Tree Pose (Vrkasana) see how long you can balance for, working up to one minute. Hold onto a wall or counter as needed at first. Challenges yourself by taking your vision out of it (moving the eyes or closing them). Again, feel balanced through all parts of the foot.

tree pose

  • You may have weakness in proximal muscles, such as the gluteals (gluteus medius, maximus, minimus)  and quadriceps. These may decrease your loading power to reduce stress at the foot. The superficial and deep hip rotators also allow for decreasing pronation at the foot/ankle. There too many exercises to list here but will list some used in yoga.

Exercise:

  1. Bridge (setu bandha): Hold at top, 1-2-3, then slowly lower down. Repeat 3×10. emphasizing both feet stay planted, relax shoulders. bridge
  2. Warrior Poses (Virabhadrasana I, II, II): where you have to work on keeping the knee from rolling inward or are standing on one leg. Again, balanced through all parts of the foot. Warrior collage
  • Your calf muscle complex may have limited flexibility. The ankle must dorsiflex to allow propulsion in walking. The Achilles tendon and it’s attachments to the heel bone and calf muscles (gastrocnemius and soleus) limit dorsiflexion. If the calf is tight, you will get this extra motion from the plantar fascia, stressing it. So stretching these out may be helpful. However, if you already have overstretched plantar fascia, you want to protect the arch of the foot during your stretch.

Exercise:

  1. Calf stretches (gasatrocnemius with leg straight and soleus with leg bent): ***You may do these stretches, but please NOTE this—-place the end of a rolled up hand towel under your inner heel to prevent your arch from flattening while you do these stretches. see pic belowcalf stretches collageIMG_0129
  2. Yoga Tip 1: Strap stretch for calf and hamstrings (supta padangusthasana); Hold for 30 seconds to a minute, repeat each side. Make sure the strap is at the ball of the foot. You may want to bend the opposite knee if you have less flexibility. supta padasgusthasana

        Yoga Tip 2: Downward Facing Dog (Adho mukha svanasana)–try it with legs straight for a gastrocnemius stretch or with knees bent for a soleus stretch. Use a rolled up towel or blanket to help your feet meet the floor. Yoga pics1

  • External supports: Arch supports: You may need to buy over the counter arch supports to place in your shoes (all of your shoes you wear most). I like Superfeet, but you may find another brand that works for you. You may also need a supportive walking/running shoe–these are called Motion Control shoes that have a wide last (the sole of the foot is wide throughout the base).

For Under-Pronators: High arches

  • Stretching the calf/plantar fascia as noted above is indicated. In this case, you do not need the towel under the heel to protect over-stretching the plantar fascia. You can also use one of those toe-separators that people use when they paint their toe-nails. Place your toes in these to stretch out the plantar fascia. 
  • Massage: self massage (or therapeutic massage by another if you’re lucky) of the entire calf and bottom of the foot. This may also be indicated in those with pronation if you have tight calves. This can be done with a foam roller for the calves, or a soup can, frozen water bottle or golf ball (if you’re brave) for the plantar fascia.IMG_0132plantar fascia rolling
  • External Supports:  An over the counter arch support may be indicated here as well, to allow the floor to meet the foot and reduce the stress on the fascia. And using a more flexible shoe, as these feet are generally more stiff. These shoes would have more of a curve last.

General Advice: Take breaks–give yourself the permission to rest from the activities that stress your feet. Cross train–if you run/walk, try biking and vice versa. I find that those with plantar fascitis are those that push themselves and don’t heed the warning signals (myself included). You might push past the warnings, thinking it will just get better. It’s ok to rest, sit back and take your sensations seriously.

Conscious breathing is something I teach all of my patients, whether it is a stress related injury or one that seems just physical.  For the most part, people are not even aware of their breath. Utilizing a diaphragmatic breath can help calm your parasympathetic nervous system.  Ekerholt, et al states, “In experiencing their own breathing, the participants were able to access and identify the muscular and emotional patterns that, linked to particular thoughts and beliefs, had become their characteristic styles of relating to themselves and the world.” Change the breath and alter the body.

If you don’t know what your foot/ankle is like (or your tension-holding habits), it would be a good idea to visit a physical therapist that you trust so they can asess your biomechanics, flexibility, strength and lifestyle to make sure that you are not doing more harm than good.

I welcome your comments and if you find this helpful, share with your colleagues and friends. Contact Tianna to see how she can help you with your health.

Check out, Heel That Pain for an even deeper look into heel pain in general.  Several of my patients have had success with their heel cups.

1. Bolgla & Malone. Plantar Fasciitis and the Windlass Mechanism: A Biomechanical Link to Clinical Practice. J Athl Train. 2004 Jan-Mar; 39(1): 77–82.

2. Ekerholt K, Bergland A. Breathing: a sign of life and a unique area for reflection and action. Phys Ther.2008;88:832–840.