As I do research around the internet including social media sites, forums and blog posts there is an abundance of information about plantar fasciitis. Unfortunately much of it’s outdated and just regurgitated principles, theory’s and treatment options that simply have been proven wrong or don’t work.
As a hand and foot chiropractor in Melbourne, FL I have spent the past 15 years studying foot conditions, especially plantar fasciitis. What was taught as factual in school has now been proven to be outdated and ill logical. What I am going to express are not just my views but, are all backed by scientific literature. I am constantly evolving in my quest of offering the best possible treatment options for my patients and therefore research is essential. The knowledge I have gained from this research has altered the treatment I now use today to treat a patient with plantar fasciitis compared to what I used early on in my practice.
So what are these outdated principles, theories and treatment options I continue to read about. Lets start with the name itself. Plantar Fasciitis. In medical terms this tells us that the plantar fascia (actually it’s called the plantar aponeurosis) of the foot is inflamed. It is common knowledge on the internet that the plantar fascia is inflamed typically at the insertion on the heel. The latest’s research suggest that inflammation has very little to do with plantar fasciitis. Initially there may be some inflammation although the condition becomes more of a degenerative disorder as opposed to an inflammatory condition. So what does it matter whether it is inflammatory versus degenerative? It is important because it changes the kind treatment that should be administered. An example. If a patient has inflammation they would be treated with over the counter anti-inflammatory medication (NSAIDS) such as Advil, prescriptive anti-inflammatory or with an anti-inflammatory injection such as a steroid. These may be effective treatment options for reducing inflammation however, they won’t help much if there is little or no inflammation present such as in degenerative conditions.
So what does the scientific literature have to say? A 2003 review of 50 cases performed by Lemont et al stated that plantar fasciitis is a “degenerative fasciosis without inflammation, not a fasciitis.” 1. In medical terms a suffix of –itis means inflammation where –osis means degenerative. Andres et al. wrote in the journal Clinical Orthopedics & Related Research “Recent basic science research suggests little or no inflammation is present in these conditions”. 2. An article titled Overuse tendinosis, not tendinitis, part1: a new paradigm for a difficult clinical problem published in Phys Sportsmed states “numerous investigators worldwide have shown that the pathology underlying these conditions is tendonosis or collagen degeneration”. 3. I can go on citing many more although you can see that the experts agree that the theory of inflammation present in plantar fasciitis no longer valid.
Another common mis-conception is that Plantar Fasciitis is caused by bone spurs. When a patient presents to my office with Plantar Fasciitis and a heel spur is noted on an x-ray I say something which may sound very strange to the patient “A heel spur is your friend”. I always get the look of “Did you just say what I think you said?” I then continue with “Let me explain… “. I then continue, “Plantar fasciitis is caused by chronic irritation of the plantar fascia, typically at the insertion on the heel where the bone is present. Over time the plantar fascia begins tearing away from the bone. The body responds by calcifying (hardening) the tendon and keeping it intact preventing it from tearing off the bone!”. Thus, why it is refrenced as a “friend”.
Even though spurs are common with plantar fasciitis the spur itself does not cause pain but, the fascia or surrounding soft tissues actually cause the pain. 4. Surgery typically is not successful for relieving the pain and the spurs often return since the root of the problem has not been eliminated. 5
What about flat feet (pronation-often found with flat feet) or tight calves. I believe these do place increased stress on the plantar fascia and contribute to plantar fascitis although I don’t believe they are a root problem of plantar fasciitis. There are many people with dropped arches, pronation and tight calves that do not have plantar fasciitis. There are also many people with plantar fascitis that do not have flat feet, pronation or tight calves. Early on in my career I treated patients with plantar fasciitis who were flat footed by fitting them with a custom orthotic to restore the arch. Although this did help reduce the pain very often it did not eliminate it. If flat feet was the cause then the patient should have been cured. It’s been my own clinical experience that has show me that high arches and supination are just as problematic as being flat footed or having a foot with pronation.
So as a hand and foot chiropractor what do I believe is the root cause of plantar fasciitis? In most cases I believe it is a foot that is not properly functioning. This may be from a bone out of place such as the Talus or Calcaneous (which I see all too often) a traumatic injury or a congenital deformity. The human foot has 26 bones, 33 joints, 107 ligaments, 19 muscles and tendons and is very complex. When all these parts are not working properly in sync it places undue stress on the foot and causes degeneration to occur.
- Lemont et al. Plantar fascitis: a degenerative process (fasciosis) without inflammation Journal of the American Podiatric Medical Association. 2003.
- Andres et al. Treatment of tendinopathy: what works, what does not, and what is on the horizon. Clinical Orthopaedics & Related Research. 2008.
- Khan et al. Overuse Tendinosis, not tendinitis, part 1: a new paradigm for a difficult clinical proble.m Sportsmed. 2000.
- Tountas et al. Operative Treatment of subcalcaneal pain. Clinical Orthopaedics & Related Research. 1996.
- Fishco et al. The instep plantar fasciotomy for chronic plantar fasciitis. A retrospective review. Journal of the American Podiatric Medical Association. 2000.