Plantar Fasciitis

Plantar Fasciitis is the most common cause of heel pain in adults.

Plantar Fasciitis

Top 10 most common conditions of the lower body

1. Patellofemoral Pain Syndrome 2. Iliotibial Band Friction Syndrome3. Plantar Fasciitis4. Meniscal Injuries Of The Knee5. Tibial Stress Syndrome6. Patellar Tendonitis7. Achilles Tendonitis8. Gluteus Medius Injuries9. Stress Fracture Tibia10. Spinal Injuries

Plantar Fasciitis AKA• Plantar fasciitis is often called “heel spurs,” although this

terminology is somewhat of a misnomer because 15 to 25 percent of the general population without symptoms have heel spurs and many symptomatic individuals do not. (9)

• The other names for plantar fasciitis are plantar fascitis, plantar fasciosis, fasciitis plantaris, plantar fascial fibromatosis, plantar heel pain syndrome, policeman's heel, heel spur syndrome, painful heel syndrome, and inferior calcaneal exostoses.

Relationship to Heel Spurs

Around 50 percent of patients with plantar fasciitis have heel spurs, but they are most often an incidental finding and do not correlate well with the patient's symptoms. (8)

What is Plantar Fasciitis?

• It is by definition, a painful inflammation of the plantar fascia.

• It is an abnormality or injury at the site of attachment of a ligament or tendon to bone) of the origin of the plantar fascia at the medial tubercle of the calcaneus due to excess traction often characterized by pain on the first step in the morning (2) or when they stand up after prolonged sitting. (1)

Incidence

• Plantar fasciitis is the most common cause of heel pain with ten percent of the population will pull up with plantar fasciitis in their lifetime. (5)

• The condition accounts for eleven to fifteen percent of all foot symptoms, affecting two million people in the United States alone. (4)

What are the symptoms of plantar fasciitis?

• The tenderness you would feel is usually noted on the medial calcaneal tuberosity (see image) and along the plantar fascia. The classic sign or plantar fasciitis is pain on first few steps in the morning. The pain usually decreases after you walk it off, but can return throughout the day the longer you are on your feet.

• Most feel the symptoms of pain when standing on feet too long. The pain can come on worse at the end of the day. Its more common and more severe in those who are overweight, obese or weakness in specific muscles of the foot.

• The pain often increases with stretching of the plantar fascia, which is achieved by lifting your foot (dorsiflexion) and toes up. (8)

Causal Connection to Heel Spurs

• Fuller stated that fascial stretching caused pain either to the plantar fascia itself or at the attachment to the bone. High tension in the fascia could also cause a periosteal lifting at its insertion on the calcaneus, and bone healing could cause growth of a spur that might be seen at the calcaneus. (61)

• Plantar fasciitis is generally believed to be due to repetitive partial tearing at this enthesis with associated chronic inflammation. (2)

• These results support the belief that pain occurs not from the bone spur but from the excessive tension applied to the plantar fascia (11)

Doesn’t Plantar Fasciitis Only Effect Athletes? No!

• Plantar fasciitis is usually seen as an overuse injury in athletes, runners in particular (accounting for nearly 10% of running injuries), but is also seen in non athletes too. (3)

• Most non-athletes have it in the subclinical state, which means that there is inflammation of the fascia but not enough to cause pain you can feel unless you press into the fascia called deep tissue palpation.

• If non-athletes have this form of non painful inflammation of the fascia and walk a few blocks barefoot or run with or without shoes they will feel the pain in their fascia as the inflammation rises to a point where the nerves and brain together sense the higher concentration of inflammation.

• I check the plantar fascia and the health of the feet for all conditions because I feel the status of the foundation of our body or the bodies spring suspension system

What Causes Plantar Fasciitis? • Plantar fasciitis is one of the more common soft-tissue

disorders of the foot, yet little is known about its etiology.

• The fascia foot pain is caused by stress and strain in the area, that leads to the release of inflammation and when the inflammation gets high enough you feel pain.

• Although the pathology of plantar fasciitis is understood the development or causes of plantar fasciitis is less agreed upon.

What Causes Plantar Fasciitis?• Also, although plantar fasciitis is a

prevalent problem, little scientific evidence exists concerning the most appropriate treatment approach or intervention. (3)

• Why?

• Because doctors cannot agree on the cause of plantar fasciitis it makes it difficult for physicians to diagnose and treat this common injury.

• I explain why in this presentation

Three Schools Of Bio-Mechanics

• Inverted Pendulum Model – and The Lever Series Model (1685)

• The Spring- Mass Model (1989/1990)

• The Integrated Spring-Mass Model (2012)

Borelli Giovanni Alfonso 1680 Inverted Pendulum & Lever Model

• De Motu Animalium, Pars prima or On the movement of animals

• In his seventeenth century volume ‘De motu animalium’, Borelli discussed walking as vaulting over stiff legs using a pair of compasses and noted the importance of rebounding on compliant legs in running (97).

• From that early account up to the present, walking and running have been treated as different mechanical paradigms, and the two corresponding models, the inverted pendulum model for walking (5) (98)

Spring-Mass ModelBlickhan 1989; McMahon & Cheng 1990

Harvard University

• The planar spring-mass model is a simple mathematical model of bouncing gaits, such as running, trotting and hopping (105)

Inverted Pendulum vs Spring-MassGeyer H., Seyfarth A., Blickhan R. 2006 (13)

• Recent modeling analysis has shown that Inverted Pendulum applies well to walking

• The basic mechanics of human locomotion with the Inverted Pendulum model are associated with vaulting over stiff legs in walking and rebounding on compliant legs in running.

• However, while rebounding legs well explain the stance dynamics of running, stiff legs cannot reproduce that of walking.

• With a simple bipedal spring-mass model, we show that not stiff but compliant legs are essential to obtain the basic walking mechanics

• We argue that not stiff but compliant legs are fundamental to the walking gait.

• In fact, they concluded the spring-mass model was best for describing the walking gait

• With a simple bipedal spring-mass model, we show that not stiff but compliant legs are essential to obtain the basic walking mechanics; incorporating the double support as an essential part of the walking motion, the model reproduces the characteristic stance dynamics that result in the observed small vertical oscillation of the body and the observed out-of-phase changes in forward kinetic and gravitational potential energies.

Spring-Mass Model vs

Integrated Spring Mass Model

• The Spring-Mass Model embodies that during walking and running, the whole leg were a linear spring. (15)

• The Spring-Mass Model models the legs as springs and the torso as the mass

Spring-Mass Model vs

Integrated Spring Mass Model

• Integrated Spring-Mass Model suggests the legs are the combination of a Progressive Rate Spring and Torsion Spring

• This new model models the legs as Progressive Rate Torsion Springs the body as a Progressive Rate Spring and Torsion Spring.

• The head is the only mass

Spring-Mass Model vs

Integrated Spring Mass Model

• Lever Defined:

A simple machine consisting of a bar that pivots on a fixed support, or fulcrum, and is used to transmit torque. A force applied by pushing down on one end of the lever results in a force pushing up at the other end.

• Spring Defined:

In classic physics, a spring can be seen as a device that stores potential energy, specifically elastic potential energy, by straining the bonds between the atoms of an elastic material.

Inverted Pendulum Model vs Spring-Mass Model

Spring-Mass Model

Potential Energy of Springs

Plantar Fasciitis Examination, Treatment and Prevention

Inverted Pendulum/Lever Series Approach

vs Integrated Spring-Mass Approach

How do they differ?

Inverted Pendulum/Lever Series Approach

• Many “lever model only” thinkers believe we ambulate with levers in linkages.

• That is why they are validated when they note the symptom of pain in the fascia when we have tension on the Achilles tendon through the gastroc/soleus muscle contraction. (2)

• Unfortunately, “Pendulum-Lever model only” thinkers cant provide much of an explanation for how the mechanism breaks down to cause the stress on the plantar fascia.

• They have few theories

Inverted Pendulum/Lever Series Approach

• the human lever model says that the primary reason for why the fascia has stress is because of a tight fascia due to a tight Achilles.

• I have never found the Achilles tight in one of the patients I have examined with plantar fascia in my life.

Why Tight Achilles is Not a Cause of Plantar Fasciitis

1. The Achilles is not a contractile element

2. The plantar fascia has no contractile elements.

3. There is no research that shows increased electrical activity in the Achilles muscle group coincides with plantar fasciitis (no proof)

Lever Series says Tight Achilles is the Cause?

• For example: the human lever model says that the primary reason for why the fascia has stress is because of a tight fascia due to a tight Achilles.

• I have never found the Achilles tight in one of the patients I have examined with plantar fascia in my life.

• No biomechanical explanation why Achilles Tendon Muscle group is Tight or in Spasm in the Scientific Literature.

Primary Cause

• Standing on your feet too long

Spring Elastic Recoil Spring Suspension Muscles

The Effect Of Flip-flops On Dorsiflexion

and Tibialis Anterior Electromyography.• The study also showed that female subjects had a

more vertical attack angle in flip-flops when compared to athletic sneakers

• Specifically, as the non-support leg swings through, the tibialis anterior (TA) demonstrated an increase in muscle activity, yet less dorsiflexion (DF) was noted compared to barefoot walking.

• This finding was counterintuitive, as the TA is a primary dorsiflexor, and more activity should have been realized with an increase in dorsiflexion.

• the counterintuitive finding of increased dorsiflexor muscular activity and less observed dorsiflexion angle leads the author to conclude that the increased activity of the TA in the presence of less dorsiflexion could be the result of the flip-flop wearer’s attempt to “grip” the flip-flop using the plantar surface of the foot.

• Reciprocal inhibition, Internal Compressive Forces - Bang and Twist Plantar Fasciitis and Shin Splints

• In addition to decreased dorsiflexion during the swing phase of gait, the activity of the toe flexors to “grip” the flip-flop may also affect the windlass mechanism of the foot. The windlass mechanism functions in the foot as the first metatarsophalangeal (MTP) joint extends. As the 1st MTP joint extends, the plantar fascia tightens. This tightening of the plantar fascia has two functions; (1) the medial arch of the foot is packed tighter and is increased in height, allowing for improved loading capacity and shock absorption

• The foot becomes more rigid and has improved function as a propulsive lever

If Spasms or Tight Achilles then..• If the cause of plantar fasciitis is spasms or tightness in the Achilles

Tendon Group then how does this relate to the normal cause which is standing on the feet too long?

• If the cause of plantar fasciitis is spasms or tightness in the Achilles Tendon Group then you should find trigger points or muscle spasms in the area.

• If tension in the Achilles then the plantar fascia would still pull only harder and the windlass mechanism would still work because the fascia is connective tissue and not muscle.

• It doesn’t make sense!

Achilles Spring

The gastrocnemius and soleus do not push the body forward when walking or running – They spring it forward

• An average of 38 J of energy was recovered from the elastic recoil of the tendon, which contributes 16% of the total average mechanical work of the hop (254 J). (65)

• In conclusion, the properties of the elastic Achilles tendon can contribute significantly to the total mechanical work of the body during one-legged hopping; however, individual variation in the properties of the tendon vary the energy storing capacity of this structure. (65)

• The results indicated that the AT does indeed act like an energy storing spring by contributing a considerable amount of energy to the total mechanical work performed. (65)

• The results of this study demonstrated the energy storing capabilities of the AT, whereby the tendon stretches in proportion to the force applied during the downward motion of the body and then recoils to release most of the energy stored (74%) during the upward movement. This provides a substantial amount of the total mechanical energy of the hop (16%). (65)

More Evidence of Spring vs Push• This study we investigated in vivo length changes in the fascicles

and tendon of the human gastrocnemius medialis (GM) muscle during walking.

Two important features emerged: • the muscle contracted near-isometrically in the stance phase, with

the fascicles operating at ca. 50 mm; and • the tendon stretched by ca. 7 mm during single support, and

recoiled in push-off.

The spring-like behavior of the tendon indicates storage and release of elastic-strain energy

What is the plantar fascia?• The plantar fascia, also known as the plantar aponeurosis is a broad, flat, fibrous,

tendon-like structure, which consists of non-contractile irregularly ordered collagen fibers with minimal elastic properties. (13)

What does that mean?

• What that means is that it is like gristle on a steak. • It means it doesn’t stretch much.• It means it does not contract like a muscle.

What roll does it play? • The plantar aponeurosis plays an important role in transmitting Achilles tendon pull

forces to the forefoot when you are about to push off when you walk. (46)

Basis of Lever Model Treatment

• There is an indirect relationship whereby if the toes are dorsiflexed, the plantar fascia tightens via the windlass mechanism. If a tensile force is then generated in the Achilles tendon it will increase tensile strain in the plantar fascia. Clinically, this relationship has been used as a basis for treatment for plantar fasciitis, with stretches and night stretch splinting being applied to the gastrocnemius/soleus muscle unit. (18)

This is what the lever model thinkers say causes plantar fasciitis

• Increasing tension on the Achilles tendon is coupled with an increasing strain on the plantar fascia. Overstretching of the Achilles tendon resulting from intense muscle contraction and passive stretching of tight Achilles tendon are plausible mechanical factors for overstraining of the plantar fascia. (24)

• What is causing the overstretching or strain on the Achilles and fascia is the magic question to solving this riddle

Cause• Series-elastic springs• Direction and timing of the flow

of energy• How can the fascia be the issue

when it doesn’t have a contractile element to it?

• How can the achilles be the problem when its tension isnt effected by muscle spasms?

• As a lever, at pushoff when it pushes you would expect it to elongate more so why doesn’t it?

cause

• How does standing on your feet too long cause any effect on the achilles tendon?

• If the arch collapses the achilles tendon slackens

Slow Motion Video of Loading• If the tibialis posterior

muscle is cut the result is adult flat foot deformity. So why is the plantar aponeurosis responsible for raising the arch of the foot

• If the dissent of arch of the foot is controlled by the tibialis posterior then why isnt the tibialis posterior responsible for raising of the arch of the foot?

Cause: Preloading by Dorsiflexors• The results show that the PA experienced tension

significantly above rest during early stance phase in all subjects (P<0.01), thus providing support for the PA-preloading hypothesis. (128)

• In contrast to their finding, however, in this study the PA appeared to be pre-loaded at heel-strike. (128)

• The simultaneous action of the ankle dorsiflexors and toe extensors, which prevent foot-slap and dorsiflex the toes at the MTPJ, and the plantarflexion moment applied to the calcaneus by the vertical ground reaction forces could account for some pre-stretching of the PA. (128)

• A MTPJ dorsiflexion angle of about 30 deg. was measured for the three subjects thus confirming the action of the toe dorsiflexors at and prior to heel-strike. (128)

Slow Motion Video Of a Gait with Preloading Of Dorsiflexors

• further experimental and/or modelling studies, we can only speculate as to the possible advantages of such preloading. Loading the PA at heel-strike is likely to reduce the crimp present in unloaded collagenous tissues (132)

• thereby resulting in earlier arch stiffening and helping to ensure that, as the propulsive phase begins, a greater proportion of force is transferred by the foot to the ground. (128)

Windlass Effect• During dorsiflexion of the toes, as

occurs in late stance, the PA is stretched as it wraps around the MH. This is the so-called windlass mechanism which, in the late phase of stance, is responsible for raising the arch of the foot. (130)

• and contributing to stiffening of the foot by pulling on the heel, causing inversion at the subtalar joint and `locking' the midtarsal joint (131)

What Suspends The Load Of The Arch Off The Plantar Fascia?

• Throughout the literature you see contradictions.

• For instance one paper says that the plantar fascia prevents foot collapse by virtue of its anatomical orientation and tensile strength.

• One biomechanical model estimated it carries as much as 14% of the total load of the foot.

• What holds up the rest?

Windlass Effect

• In this paragraph again the treatment is to the plantar fascia. We have to address this enemy as it has wronged us. In reality the plantar fascia has done no wrong. In fact it is a victim being stressed because other structures that assist the fascia by suspending the remaining 86% of the load off the fascia haven’t been doing their job to keep the load off the fascia.

How do lever doctors diagnose?Video of examination of arch joint play

• Palpation• Ultrasonography (37) (38)

(39) • Doctors may use MRI to see

the total volume of plantar intrinsic foot muscles to see if they are smaller on the involved side. (42)

• If they are then it could be that the joints they act on are locked preventing contraction?

How do spring-mass model diagnosevideo of gait at all speeds

• Advanced Video Gait Evaluation Study at all force increments

• Double leg• Single leg• Walking• Fast Walking• Jogging• Running• Plyometrics

Response to Traditional Lever Based Treatment Approaches

• (44%) respondents favored initiation of plantar fascia-specific stretching (PFSS)

• (24%) supervised physical therapy

• (20%) night splinting• (6%) steroid injection –

(4%) custom orthotics• (2%) cast or boot

immobilization (70)

Lever Model Therapy• Conservative care

(chiropractic therapy, electric modalities)

• Patient education, soft tissue therapy/massage, acupuncture, taping, night splints, stretching, ice, heat, strengthening, orthotics)

• Extra-corporeal shock wave therapy

• Injections and medication• Surgical intervention (70)

Stretching• First, how can the plantar fascia tighten

when it is a non-contractile tissue? • Why would anyone recommend stretching

connective tissue just because it is strained?

• They think it is tight from being too short. How did it get so short with the excess weight on it?

• It cannot tighten because it is not a muscle.

You will find out later that this is the opposite of what you do. In fact stretching of an already overloaded strained tissue could increase its risk for tearing.•

Taping

• Taping provides only transient support, with studies showing that as little as 24 minutes of activity can decrease the effectiveness of taping significantly. (88)

Orthotics• The aim of orthotic therapy is

to reduce strain on the plantar fascia by cushioning and elevating the heel and/or providing medial arch support.

• Orthotics may also be useful for overweight plantar fasciitis patients, as they help to reduce shock and cause more even weight distribution over the plantar fascia and its insertion on the calcaneus (90)

• Also if there is too much stress on the plantar fascia isn’t it from the structures that hold up the arch 86% that are weak that we need to address?

Adjustments and stretching vs orthoticsVideo of Adjustment of arch

• As mentioned previously, the study by Dimou, Brantingham and Wood of chiropractic adjustments/manipulation of the foot and ankle along with a daily stretching regimen). (94)

• The custom orthotics group reported significant improvements in almost all outcome measures, but these improvements were not statistically different or superior to those obtained in the chiropractic and stretching group. (94)

• Dimou et al reported a significant difference for pain between the manipulation treatment group and the CFO treatment group, with the chiropractic group being superior. (94)

Night splints• Night splints usually are designed to keep a

person's ankle in a neutral position overnight. • Most individuals naturally sleep with the feet

plantar-flexed, a position that causes the plantar fascia to be in a foreshortened position

• A night dorsiflexion splint allows passive stretching of the calf and the plantar fascia during sleep

• Disadvantages of night splints include mild discomfort, which may interfere with the patient's or a bed partner's ability to sleep. (99)

• How can fascia stretch when it is not a muscle?

Cortisone injections• All of the patients found the corticosteroid

injection painful. The post-injection pain was said to have continued for a mean duration of 5 and 7 days respectively (101) (105)

• This pain in the injection site can lead to an abnormal gait. Walking with a stiff painful foot causing a limp can alter foot biomechanics or your pattern of walk and make your plantar fasciitis worse.

• Lee and Ahmad’s study reported the corticosteroid group to show a significant reduction in pain on the visual analog scale at both 6 weeks and 3 months in comparison to the autologous blood group.

• However, this change was not significant at 6 months. (105)

•

CORTISONE INJECTIONS Georgia Baptist Medical Center, Atlanta,

1992 to 1995

• The authors injected 122 of the 765 patients, resulting in 12 of the 44 plantar fascia ruptures. Subjective and objective evaluations were conducted through chart and radiographic review.

• Thirty patients (68%) reported a sudden onset of tearing at the heel, and 14 (32%) had a gradual onset of symptoms.

• At an average 27-month follow-up, 50% had good/excellent scores and 50% had fair/poor scores

CORTISONE INJECTION

• The risk factors for the use of CSI include plantar fascial rupture, hypoglycemia in diabetic patients, skin and fat-pad atrophy, and sepsis. These findings suggest that treatment regimens such as serial corticosteroid injections into the plantar fascia should be reevaluated in the absence of inflammation and in light of their potential to induce plantar fascial rupture. (106)

BOTOX• Reserve for chronic injuries, after intensive use of other approaches for at least 2 months has failed• Use when rehabilitation is inhibited by symptoms• Informed consent should be obtained from the patient, who must be willing to follow postinjection

guidelines• The practitioner should have full knowledge of the local anatomy• Select the finest needle that will reach the lesion• The practitioner's hands and the patient's skin should be cleansed and a no touch technique used• Use short or medium acting corticosteroid preparations in most cases, with local anaesthetic• Injection should be peritendinous; avoid injection into tendon substance• Minimum interval between injections should be 6 weeks• Use a maximum of three injections at one site• Soluble preparations may be useful in those patients who have had hypersensitivity/local reaction

to previous injection• Details of the injection should be carefully recorded• Do not repeat if two injections do not provide at least 4 weeks' relief (107

ORTHOTICS WHY DON’T WORK• By placing a support under the arch it could inhibit full depth of loading

of the arch in its descent. You have a shoe which causes a compressive force on the arch and fascia from the top and the arch support occupying space at the bottom. If the arch must raise up to accommodate the windlass effect there is a possibility that the windlass effect could be sabotaged or reduced. This could place more stress on the plantar fascia.

• A binding device can possibly restrict the mobility of the loading and rolling. If there is restrictiuon of movement there is reduction in maximum muscle contraction and relaxation. This could inhibit the adaptation strengthening of the intrinsic and spring suspension system muscles.

•

10 months no relief – Surgery or ECSWT

• What was the surgeon's preferred treatment after 10 months of non-responsive to treatments. (70)

• • 62 (74%) respondents chose surgery or ECSWT

(extracorporeal shock wave therapy) as their next step (70) rewrite

• 46 (55%) Some form of surgery with the most popular operative interventions were gastrocnemius recession (alone or in combination with another procedure) and open partial plantar fascia release with nerve decompression. (70)

• Time for the rational argument based on their research:

• Here are the common factors which predispose a patient to plantar fasciitis

• • The risk of plantar fasciitis

increases as the range of ankle dorsiflexion decreases.

• Obesity• and work-related weight-bearing• pronation

HOW DOES THE FOOT ABSORB IMPACTS• The Arch Leaf Spring - There have been

studies on the arch with all muscles removed leaving just the bones and ligaments. These were extracted from cadavers. What the study showed was that the arch complex itself has the ability to spring back forces without the aid of the muscles.

• The Spring Suspension System Muscles - I coined these muscles as the spring suspension system muscles, the landing muscles or the pronation-supination cuff muscles. I identified this new medical terminology myself in order to better explain the function of this area.

• The Windlass Mechanism - The plantar fascia does not stretch much during push off, so the arch of the foot must bend up to accommodate the forces generated at push off. This is like a spring from a bouncing ball.

First How The Body Absorbs The Stress Of Landing?

It absorbs Impacts two ways, rolling and loading…

• 1. Rolling the load from the outside of the foot to the inside of the foot Supination (outside of the foot) to Pronation (Inside of the foot)

• 2. It loads the force of the impact into the arch of

the foot

FORCES ON THE BODY• Standing (50% of

bodyweight on each foot)• Walking (1.25 x

bodyweight on the foot at landing)

• Running (3x bodyweight on the foot at landing)

• Plyometrics (3-5x+ bodyweight on the foot at landing)

Spring Suspension System Muscles (Your Landing Gear)

• Tibialis Posterior AKA Posterior tibial tendon dysfunction is the most common cause of acquired flatfoot deformity in adults. he arch is further supported by the plantar aponeurosis, by the small muscles in the sole of the foot, by the tendons of the Tibialis anterior and posterior and Peronæus longus, and by the ligaments of all the articulations involved. Henry Gray (1821–1865). Anatomy of the Human Body. 1918. rewrite

• • The Peronæus longus also everts the sole of

the foot, and from the oblique direction of the tendon across the sole of the foot is an important agent in the maintenance of the arch. Henry Gray (1825–1861). Anatomy of the Human Body. 1918.

• Posterior tibial tendon dysfunction is the most common cause of acquired flatfoot deformity in adults. Although this term suggests pathology involving only the posterior tibial tendon, the disorder includes a spectrum of pathologic changes involving associated tendon, ligament, and joint structures of the ankle, hindfoot, and midfoot

How does this Landing Gear Spring Suspension System fatigue or weaken?

• Sudden gain in body weight or obesity (50)

• Occupation involving prolonged weight bearing (50)

• Unaccustomed walking or running (50)

• Increased running distance or intensity (50)

• This just so happens to be the same factors that predispose you to plantar fasciitis!

• • How does this suspension

system breakdown or weaken to allow the excess weight not held by the suspension system to strain the plantar fascia?

•

What do I find (that other doctors don’t) when examining a patient with plantar fasciitis.

• Over Pronation – Im Not The Only One

• Weakness and tense painful spasms In The Tibiailis Posterior – Im Not The Only One

• Locking Of The Metatarsal Cuneiform Joint

• Thordarson et al found that the posterior tibialis muscle provided the most significant dynamic arch support during the stance phase of gait. The posterior tibialis eccentrically lengthens to control pronation and reduce the tension applied to the plantar fascia during weight acceptance. Excessive pronation can cause posterior tibialis weakness and plantar fascia elongation. (62)

most common factors that predispose the patient to plantar fasciitis

• Sudden gain in body weight or obesity (50)

• Occupation involving prolonged weight bearing (50)

• Unaccustomed walking or running (50)

• Increased running distance or intensity (50)

• Changes in the walking or running surface (50)

• Shoes with poor cushioning (50)• Tightness in the achilles tendon

(50)

• During the mid-stance/pronation phase the arch flattens to absorb the shock of ground contact. Again the elastic qualities of the plantar fascia are tested. There is a limit to how much repetitive trauma this tissue can sustain before micro tears happen with pain usually presenting on the calcaneus. (49)

• IMPOSSIBLE THAT THE PLANTAR FASCIA IS THE ONLY STRUCTURE ABSORBING THE FORCE OF THE LANDING

• These data indicate that a history of plantar fasciitis in runners may be associated with greater vertical ground reaction force load rates and a lower medial longitudinal arch of the foot. (54)

• The most frequent training error seen with plantar fasciitis is a rapid increase in volume (miles or time run) or intensity (pace and/or decreased recovery). (49)

• A final training error seen in athletics is with a rapid return to some preconceived fitness level. Remembering what one did "last season" while forgetting the necessity of preparatory work is part of the recipe for injury. (49)

• Training errors can be responsible for up to 60% of injuries. (124)

• A change in shoes was cited by 14 percent of patients with plantar fasciitis as the treatment that worked best for them. (73) Motion-control and stability shoes also have a firm heel counter and a firm midsole to control the amount of pronation. (75)

•

The biggest mistake made in stretching is:

• People don’t stretch the foot• When they stretch the foot

they don’t stretch the foot in 3 dimensions

• They don’t stretch the foot in the right direction

• They don’t stretch individual bones of the foot (metarsal cuneiform joints).

• They don’t stretch during walking or running

• They don’t stretch enough

• This study provides evidence that the addition of TrP manual therapies to a self-stretching protocol resulted in superior short-term outcomes as compared to a self-stretching program alone in the treatment of patients with plantar heel pain. (82) (83)

• Manual therapy consisted of either grade III or grade IV joint mobilization and/or high-velocity, low-amplitude chiropractic manipulation to the affected joints in the foot and ankle, and home-based exercise.

SPRING RESISTANCE TRAINING

• Exercises to Control Excessive Pronation*

• Improved tibialis posterior strength

• Improved plantar-flexor strength

• Improved intrinsic foot muscle strength

• Improved proximal hip muscle strength

• Weakness can cause increase force on the plantar fascia

• The tendons of the posterior tibialis, flexor digitorum longus, flexor hallucis longus, peroneus longus, peroneus brevis, and Achilles tendon were attached to force transducers. (65)