Plantar Fasciitis Under the Microscope;
The True Cause of Plantar Fasciitis
Introduction To Plantar Fasciitis
The term plantar fasciitis (pronounced plantar fash-ee-eye-tis) is somewhat scientifically outdated – its literal translation meaning ‘foot inflammation’ specifically in the plantar fascia.
The plantar fascia is ligamentous sheet made of flexible, fibrous tissue – and it stretches from the heel bone to the ball of the foot. The plantar fascia forms a stiff but elasticated arch that distributes and absorbs the daily impact of weight bearing movements – like walking, running and Zumba.
The feet themselves are a pair of natures engineering marvels – and as such they are able to bear the brunt of the 3-5 millions steps that the average adult takes each and every year. This insanely high work rate leaves the entire foot open to injury, overuse and repetitive strain.
Living in the space between hard ground and bone the poor plantar fascia is open to damage in the form of small tears – micro-injuries & scarring.
In an effort to reinforce the fascia and it’s boney anchor points, the body sometimes even develops bone spurs which are somewhat like a callus formation. It is thought that in partularly bad cases these bony protrusions can dig into the fatty pad of your heel and exacerbate the pain of plantar fasciitis pain.
But What Is Plantar Fasciitis Really?
Plantar fasciitis was once thought to be an inflammatory condition but on closer scientific scrutiny it is now known to be more of a degenerative disorder. This is why the term plantar fasciitis is a little outdated.
Under the microscope plantar fasciits is made up of the aforementioned degeneration – micro-tears, disorganised collagen fibres, scar like adhesions and compromised blood flow. It’s hypothesised that constricted blood flow is responsible for localised nutritional deficits that impaired healing.
Modern medical researchers including Dr. Kendrick Allen Whitney, DPM have developed a preference for the term Plantar Fasciosis or Plantar Fasciopathy instead of “Plantar Fasciitis”. This is because these medical terms more closely reflect the actual degenerative cellular changes we see in plantar pain sufferers.
And What Causes Plantar Fasciitis?
All this is very interesting but of course. It is all the more important however that we are able to turn these insights into the underlying causes of ‘plantar fasciitis’ pain in the tissues into something that brings you lasting relief!
There are really only 2 mechanical ways to cause degeneration in healthy tissues. Either by a single event injury – like jumping off a high wall onto hard ground and hurting your foot – or through a repetitive stress that the bodies tissues can’t sustain over time. The cause of almost every case of plantar fasciitis is the latter – repetitive strain, which is what all those changes under the microscope is really showing .
Putting this build up of repetitive strain in context – it is very important to be aware of how many people there are without plantar fasciitis. It is estimated that 1 in 10 of us suffer from plantar fasciitis in their lifetimes – which is clearly no the same as 10 out of 10.
So the real juicy question we might ask about plantar fasciitis is that given approximately the same mileage, same footwear companies, same environment, same hobbies, same foods – why is it that some are dealt the plantar fasciitis card and other are not? Here is a list of commonly implicated factors…
Excessive Pronation and Other Gait Abnormalities
Pronation is a natural movement of the the foot that occurs during weight bearing. Excessive pronation however can cause problems on the theme of repetitive strain to tissues and plantar fasciits is one of them. My experience has been that excessive pronation and the factors that tend to go alongside it are a major cause of plantar fasciitis.
Excessive pronation is caused by a combination of genetic, environmental and lifestyle factors. Some of these factors can be addressed while others are obviously non negotiable. It excessive pronation is a significant cause of your plantar fasciitis it is highly likely you would benefit in the longer term from a combination of rehab exercises and insoles both of which have the power to limit excessive pronation.
Failure to give your feet the amount of time they need between exercise sessions and/or long periods of standing can overload the plantar fascia and be a significant cause of plantar fasciitis.
One classic patient who finds overuse is the cause of their plantar fasciitis is perhaps unsurprisingly the high mileage endurance athlete. Another classic would be the patient who finds the cause of their plantar fasciitis is standing all day on concrete in their retail job.
There is a subtle layer of understanding hidden within the topic of overuse that a percentage of us find is important. ‘Overuse’ to some degree is a relative concept, there are many cases of overuse in which the actual ‘mileage’ is reasonably low but the individual still finds it to be the cause of their plantar fasciitis. This is essentially due to a lack of strength in the lower limb and foot.
To a massive degree plantar fasciitis is prevented via the support provided to the foot by the muscles in the lower limb. Weakness of those muscles if they fail to provide adequate support and sustain alignment during active times can mean that a simple 10k walk twice a week qualifies as overuse and as such can cause plantar fasciitis. .
Both very high and very low arches ( flat feet ) can cause plantar fasciitis. Your ancestors walked mostly on soft ground like that you find on grasslands, in forests and sandy regions. You walk on rock solid flat ground like concrete, paving and tarmac. If you reflect for a moment on the human footprint it’s pretty self evident that there is an arch supporting nature to it. As your ancestors ran and walked they left footprints much of the time – and every time they did so they received the benefit of a nice soft arch support made of mud, sand or vegetation.
Often in life it is those of us at the extreme ends of any spectrum who show up in the stats. When it comes to body mass for example you don’t want to be at the extremely skinny or extremely ‘unskinny’ ends of the spectrum for ideal health.
People with very high or very low arches are more dependent on natural arch support to limit strain in their plantar fascia than those with more average arch height. If you work with pain sufferers for a couple of decades it becomes very apparent that high arches and low arches are a significant cause of plantar fasciitis.
Weak or Tight Surrounding Tissue
Weak glute muscles, reduced ankle mobility, or tightness in the Achilles tendon are all key players in many plantar fasciitis cases. The poor old human foot has an unimaginably hard life.
The heel bone hammers down onto hard ground preferably more than 10k times per day and that’s before we take into account it having to then support the entire body weight through the delicate bones of the arch. Then transition all that weight to the long Bones for the Herculean task of propelling all that weight forward. Endlessly!
Perhaps the most surprising and impressive thing about what the feet do is that they perform their task without any of their own muscle mass. If you reflect on any of the other major ‘joints’ in your body like your hips, knees or shoulders they are all wrapped up by big strong muscles that stabilise them. Amazingly the poor old feet only have very tiny muscles that are responsible for microadjustments of angle and position.
Obesity or Rapid Weight Gain
Obesity is sometimes a major factor in cases of plantar fasciitis. That said there is a difference between ‘factor’ and ‘cause’ so it’s wise to be very suspicious of any professional who tells you that ‘you justneed to lose weight’.
The role that weight gain can play in being a cause of plantar fasciitis is fairly straight forward. The more weight that presses through the plantar fascia with each of your countless yearly heel trikes the more stress there is in the tissue.
The key to understanding the true cause of plantar fasciitis is held within seeing that there is never a single factor. Muscle weakness in the leg and foot, fallen arches, poor footwear, scar tissue and overuse will always play their role regardless of what your body mass index is.
When you are born your tissues are in their most supple and elastic state and the day you die they will be at their most tight and ridgid, the plantar fascia comes along for this ride. The normal aging process in combination with the type of mild neglect most of us treat our feet with can result in a loss of elasticity and play its part in causing plantar fasciitis.
The world we live in embraces the age related decline of muscle, joints and soft tissue in a way that it does not when it comes to the decline of dental health. We are very aware of the possibility of maintaining the health of our teeth but not so wise to how much can be done to maintain the musculoskeletal system. The truth is that through stretching and strengthening the stiffening of our tissue we can manage it very nicely. Age is a factor in plantar fasciitis but not the cause of plantar fasciitis for those who are willing to embrace the necessary exercises and good old fashioned hard work.
Ill-Fitting or Old Footwear
Shoes that don’t fit right, or don’t provide proper cushioning and arch support, can play a significant role causing plantar fasciitis pain to manifest. Running shoes should be discarded as the soles wear out and their support is depleted.
Shoes that are narrow through the forefoot contribute to increased tightness in the plantar fascia over time, they also narrow the foot and decrease its intrinsic stability. The more we wear spacious and supportive shoes the less likely footwear is to cause plantar fasciitis.
We owe our feet alot ! The species-wide benefit of the astonishing job our feet do has been the liberation of our forelimbs from the dirt – freeing them from the task of weight bearing.
Freedom for the forelimbs ultimately lead to us developing the trump card of all evolutionary trump cards .. the opposable thumb. This leap from trotting around in the dirt on all 4’s to the microscopically skilful use of our forelimbs that has shaped the human world was made possible by our feet taking a hit for the team. Plantar fasciitis is juts one of the problems out feet have inflicted upon them – partly by our decision to only have 2 of them!
Plantar fasciitis like most stubborn pain conditions is complex but the solutions thankfully are often reasonably simple and easy to execute givent the right understanding. Pain relief is the necessary first step for most of us. Once the feet are more comfortable the door opens to rehabilitiation and the prescription of arch support. The health of our feet is desperately important to maintaining our quality of life as we get older, they are worth whatever effort becomes necessary to heal them and prevent further issues from manifesting later on.
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Pain is a symptom. Symptoms are the feedback that the body generates when it faces problems with its delicate internal balance (homeostasis). Without symptoms like pain, thirst, nausea and fevers, it would be very difficult for us to maintain a healthy body in the same way that it would be hard to drive a car safely with no dashboard display.
John is one of those rare gentlemen who has continued to play competitive soccer well into his late 50s. He is in really good shape, which you need to be to play football at that age—good shape except for his left leg. His left leg is not in good condition at all. In fact, once you get to know his left leg a bit better, it becomes apparent that it’s miraculous that he’s able to run at all, Let alone the type of running required to play competitive soccer against younger men.