The Clinical Coach: Plantar Fasciitis

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It’s about time don’t you think?

I’m sure you’ve seen plenty of patients who ask you about dealing with plantar fasciitis.

I pretty much get one every other week it would seem so.

Specially patients who work in the administration side of the businesses.

If you do a quick search to refresh your memory. You’ll find out that the most common reasons for plantar fasciitis are:

• Increased physical activity (running, jumping, dancing, etc)

• Standing or walking for long periods

• Wearing shoes with poor arch support or cushioning

• Obesity

• Tight calf muscles

• Sudden changes in activity levels

• Foot deformities, such as flat feet or high arches

But… in our office patient evidence would say otherwise.

• 90% of patients presenting with plantar fasciitis are not obese.

  • As a matter of fact, they are relatively fit.

• They have not had a sudden increase in activity levels.

• Both calves are equally tight, but only one foot is symptomatic

• And many of them have relatively “normal” arches and foot anatomy.

The only trait they all share, is wearing narrow shoes.

So what’s the real issue?

By now you should be open to the idea that the body is an amazing 4-dimensional machine with the ability to adapt to the anatomical and physiological changes of time.

Biomechanics change as our body adapts to better movements, or as our bones adapt to the stressors of life.

Plantar fasciitis is no different.

Let’s just take a look at who’s presented with plantar fasciitis in our office:

• 15 year old cross country runner (f)

• 13-15 year old soccer players (f)

• 22 year old runner (m)

• 22 year old bodybuilder (m)

• 45-49 year old administrators (f+m)

• 30-35 year old fitness enthusiasts (f+m)

• 36-39 year old waiter/bartender (f+m)

What did their feet look like?

• 90% had normal foot anatomy

• 3% had a mild hallux deformity

• 10% had a low arch (flat foot)

What did their biomechanics look like?

• Passive & active range of motion was within normal limit in all, except those with hallux deformity, extension was limited.

• All of them were unable to control isolated hallux extension in the painful foot.

• All of them noted pain at the first MCP joint during heel elevated walking

• All of them avoided the windlass mechanism on the painful foot.

• All of them demonstrated weakness in the abductor hallucis of the painful foot.

With all of this data, what do you think is the main driver of plantar fasciitis in these population?

Over the last 7 years, I’ve worked with about 80 patients that have complained about plantar fasciitis. It just doesn’t come as often as shoulder pain to my office.

And the one key motion that I look for, is wether or not they complete the windlass mechanism of the foot.

That’s it.

Does my patient have proper hallux extension?

Can my patient load their hallux in extension?

Can my patient complete a full windlass mechanism?

I break all of this down during our evaluation, and I use this to build their treatment program for the next 12 weeks.

Why 12 you may ask? Because my goal is not simply to get them out of pain. We can do that in as little as 4 weeks. My goal is to engrain them with the right biomechanics, load them and create long term positive adaptations.

You don’t have to do a 12-week program - but you can follow the principles I’ll outline below.

The 12 week hybrid program

Now this won’t work if you don’t spend the time to outline the expectations of your program. Like I mentioned above, you don’t have to do a 12 week program.

Let’s get to it.

Week 1 and 2

During these two weeks, the goal is to work on the sensitivity of tissues, and the mechanics we are aiming to change.

Here are the therapies we use at the office (twice a week):

• Dry Needling for abductor hallucis

• Dry Needling for Tib Post/Anterio

• Dry Needling for Gastroc/Soleous

• Dry Needling for Tom/Dick/Harry

• E-stim as necessary for deep muscle stimulation

• Pin and stretch of the plantar fascia

• Manual mobilization of the hallux

• DNS Bear position

• Toe splay isometric holds.

• Joint manipulation of the foot, ankle and hip as needed.

Here are the exercises prescribed for HEP (daily)

• Intrinsic foot muscle towel exercise

• Backwards barefoot walking

• Toe Walks.

• Heel Walks.

All exercises are performed at bodyweight without additional load for time.

Week 3-5

Here are the therapies we use at the office (once a week):

• Dry Needling for abductor hallucis

• Dry Needling for Tib Post/Anterio

• Dry Needling for Gastroc/Soleous

• Dry Needling for Tom/Dick/Harry

• E-stim as necessary for deep muscle stimulation

• Pin and stretch of the plantar fascia

• Manual mobilization of the hallux

• DNS Bear position with opposite foot elevated.

• Toe splay isometric holds.

• Toe splay hold into heel raise

• Joint manipulation of the foot, ankle and hip as needed.

Here are the exercises prescribed for HEP (4-5x/week)

• Intrinsic foot muscle towel exercise

• Banded iso hallux abduction

• Backwards barefoot walking (longer distance)

• Bear position with alternating foot elevation

• Assisted toe squats (weighted)

• Lunges (bodyweight)

• Toe Walks & Heel walks

• Pace walking is introduced during week 4.

At this time we tend to make some pretty quick jumps in load. Wether it is with bands, dumbbells or kettlebells. Always ensuring minimal discomfort, or pain that resolves within an hour.

Week 6-10

Here are the therapies we use at the office (once every two weeks):

• Dry Needling for abductor hallucis

• Dry Needling for Tib Post/Anterio

• Dry Needling for Gastroc/Soleous

• Dry Needling for Tom/Dick/Harry

• E-stim as necessary for deep muscle stimulation

• Joint manipulation of the foot, ankle and hip as needed.

• Exercise progression

Here are the exercises prescribed for HEP

• Intrinsic foot muscle towel exercise (as needed)

• Banded iso hallux abduction

• Backwards barefoot walking (longer distance)

• Bear position with alternating foot elevation

• Assisted toe squats (weighted)

• Lunges (weighted)

• Sissy Squats (weighted)

• Toe Walks & Heel walks (weighted)

• Pace jogging and running is introduced dependent on individual progress

Starting week six most patients will transition either to a 3x/week or 4x/week program dependent on their level of interest, allotted time, and goals.

Week 11+

At this time in-office appointment become more virtual appointments and the patient begins to transition into a general preparedness program with a warmup and various exercises geared to their specific needs and rehab.

By now you should’ve seen plenty of progress in your patients symptoms and biomechanics. While you are not going to fully correct a hallux valgus, your treatment, education, and HEP should work in concert to reduce the patient’s pain.

Let’s talk about shoes.

You wouldn’t think I’d forget about it correct?

This is a conversation that I make sure to discuss with patients regularly.

As they go through their program, we talk about the different shoes they already have. Which ones seem to aggravate the foot the most and when, and which ones seem to provide more relief.

It’s hard for a patient to purchase brand new shoes that you recommend, simply because you recommend them. Remember, they most likely already spent hundreds, if not, thousands of dollars in different shoes, insoles and treatment.

As your patient progresses through care, you do want to educate them on what type of shoes they should purchase next. In most cases, the next best shoe should be a shoe they can wear comfortably all day.

Do not shy away from shoes that have a heel lift.

Yes, I know there’s a huge uptick in zero-drop/barefoot shoe because they are natural… but not every patient will be able to safely and efficiently transition into those without re-aggravating their feet. You could incorporate this in your program if thats part of the goal.

When in doubt, send them to an actual running store (Fleet Feet comes to mind), and ask them to measure their feet (not their arch).

The goal of a new shoe should be to work with your patient’s foot. Not against it, or it will cause some issues.

Take one of my patients for example. He was hell-bent on getting barefoot shoes. He tried (and purchased) 4-5 of them. Spent over $750 in shoes that didn’t work for his foot.

I sent him to try out some “training” shoes at Fleet Feet (it’s the only running store in town) that were recommended to me by a colleague who spends a lot of time reviewing shoes.

Lo-and-behold. He showed up in those shoes to his next appointment.

“Best shoes I’ve ever worn.” He said. “They sure are ugly, but that was the only color they had.”

We are not getting into the whole shoe debate on this newsletter. We can have that later.

Now you should have a better understanding at how to manage plantar fasciitis, and this work great because you can adapt it to meet the demands of your patient.

If your patient is fitter and needs more of a challenge to begin with, there are variables you can change.

If they are not as fit, then you challenge them enough and leave room for improvement.

Until our next issue!

In health and strength,

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