The Truth Behind Plantar Fasciitis

by Dr. Christopher on June 7, 2011

Does the bottom of your foot hurt?

Then you may have plantar fasciosis.

Why It’s Not “Plantar Fasciitis

The “-itis” ending for tendonitis or fasciitis implies “inflammation.”

Inflammation is the natural bodily process of attempting to heal.  It normal and healthy in musculoskeletal conditions such as a bruise on the arm or a torn hamstring.

It isn’t normal when the body is in a hyper-inflammatory (“hyper”=too much), usually through a diet consisting of grains, processed dairy, and lots of sugar.

The hallmark signs of inflammation are:

  • rubor – redness
  • tumor – swelling
  • calor – heat
  • dolor – pain

In tendon issues, the only hallmark sign that is present is pain.  None of the others show.

Contrary to popular belief, most tendon or fascia issues are not “-itis” issues or inflammation but “-osis” issues or degeneration.  We know this because when they open up the fascia in anatomical studies, they don’t find inflammatory cells.

Degeneration occurs when a tendon is either overloaded (too much work) or underloaded (not enough work) over time.

Observe the window of a box of spaghetti.  Notice all of the spaghetti are lined parallel to eachother, straight up and down.

This is how the fibers are oriented in a normal, healthy tendon.  One that can handle the load you put on it.

Now take the box of spaghetti and cook it or worse, throw it on the ground (and waste it).  After either event, the spaghetti will no longer be parallel, but going in every which way direction.

This is how the fibers are oriented in a degenerated tendon.  One that can’t handle the load you put on it (and lets you know with fire alarm that is “pain”).

Conventional Management of Plantar Fasciosis

As mentioned above, degeneration in the plantar fascia occurs by doing too much or too little work.

It can develop in a runner who does fifty miles a day or in a tv-watcher who watches fifty tv shows a day.

Plantar fasciitis is usually diagnosed under 2 conditions:

  1. Location – plantar foot.
  2. Symptom – pain.

With a diagnosis, Wikipedia’s list of treatments for plantar fasciitis include:

  • rest
  • massage therapy
  • stretching
  • weight loss
  • night splints
  • motion control running shoes
  • physical therapy
  • Cold therapy
  • orthotics
  • anti-inflammatory medications
  • injection of corticosteroids
  • surgery

The two conditions listed above (location and symptom) are often correct to diagnose plantar fasciosis.  The issue with this list of treatments is that it does not address the cause of the problem, only a plethora of random solutions.

Let’s look at the list again.

  • rest - implies “inflamed” plantar fascia in an acute situation, and is only helpful when the tissue was healthy before.
  • massage therapy - implies a problem with the soft tissue, but is largely ineffective at removing scar tissue.
  • stretching - implies that “tightness” is a problem, which is often very true with ankle dorsiflexion.  However, scar tissue doesn’t like to stretch as much as healthy tissue, so has limited results.

    Courtesy of mattchangeslives

  • weight loss – implies “increased load from standing or walking” is a problem.  It can be, but it isn’t the first priority.
  • night splints - see the rationale for “stretching” from above.
  • motion control running shoes - this intervention assumes pronation or supination need to be controlled.  This is a valid point and a priority, just not priority one.
  • physical therapy - implies that “weakness” is a problem.  Weakness can be involved, but not often.
  • Cold therapy - implies “inflammation” is a problem.  But we’ve already clarified how plantar fasciITIS is not caused by inflammation, it is plantar fasciOSIS caused by degeneration.
  • orthotics - implies faulty bone structure and alignment.  Definitely a priority that needs to be addressed.  Unfortunately, most orthotics are garbage.  I use sole supports (as do my mentor and the community of chiropractors he continues to teach) and get great results with them.
  • anti-inflammatory medications - implies “inflammation” is a problem.  See intervention cold therapy from above.
  • injection of corticosteroids - implies “inflammation.”  Not an issue.
  • surgery - implies “something needs to be cut out or removed.”  Whoa, what are you cutting Mr. Ortho?!

How To Successfully Treat Plantar Fasciosis (Almost) Every Time

If these interventions were working, patients wouldn’t go from podiatrist to podiatrist, year after year, looking for answers as one of my patients did.

The NUMBER 1 problem in plantar fasciosis is that scar tissue develops in the plantar fascia as the fibers are oriented in a haphazard fashion.

Legitimate secondary problems are non-optimal bone alignment, scar tissue in the calf structures (tibialis posterior, flexor hallucis longus, flexor digitorum longus, flexor hallucis brevis), and risky activities of daily living.

Knowing what all of these problems are, a sweet spot solution needs to be delivered for each problem.

  • The NUMBER 1 solution for plantar fasciosis: Active Release Technique or Manual Adhesion Release - the best technique to remove scar tissue from the body.  The plantar foot is also one place where instruments such as Graston work very well, but it can only be used on superficial tissue.  Graston would not work well on the deep calf structures.
  • Orthotics - to correct bone aligment between the second metatarsal and the tibia.  As much as I used to believe that everyone should be walking around barefoot, faulty bone structure proves this belief wrong.  I learned this the hard way through destroying my own ankle with barefoot running.
  • Modification of Activities of Daily Living -the body needs to be loaded just the right amount to be healthy.  Overload (running too much without sufficient time for recovery) or underload (sitting for eight hours a day) won’t keep the spaghetti lined up nicely in the box.  Only in introducing movements such as squats and lunges into an exercise program, taking breaks from sitting, managing the amount of running one days we can prevent this problem from developing in the future.

Here’s the big picture: if you have plantar fasciosis and you’re not getting the scar tissue addressed through manual therapy, you’re not addressing the main problem.  Your symptoms may go away with Wikipedia’s interventions, but I’m confident in saying they will return.

You can find providers near you by clicking on the appropriate link: Active Release Technique, Graston Technique, and Sole Supports.

Any questions about this condition, feel free to ask.

Dr. Christopher Stepien is a chiropractor, chronic pain specialist, and A.R.T. provider, and clinic director of the Barefoot Rehabilitation Clinic in Parsippany, NJ.  He practices out of Heroes Journey Crossfit.

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{ 49 comments… read them below or add one }

jason burnsworth June 1, 2012 at 12:06 pm

Is it true you should rest as mutch as possible for 6 weeks before you begin any streaching, message or other therapy?

Dr. Christopher June 1, 2012 at 12:20 pm

Hi Jason,

What’s the situation? Rest 6 weeks after exercise? After you have plantar fasciitis?

I assume you mean rest after having the pain associated with plantar fasciitis. If I’m correct, then the answer is a very relative one given your situation. It can mean rest from a few days to several months. It depends how much it is “inflamed.”

But remember, plantar fasciosis is often caused by adhesion in the calf and foot. So only getting it removed will help the condition go away permanently, because THAT is treating the cause.

Hope that helps?

Kayla September 4, 2012 at 12:25 pm

Hi Doctor,
I am a runner with plantar fasciosis as you described. I have been undergoing Graston and ART for two months (plus stretching/strengthening/rolling/using arch supports); the Graston has been replaced with ESWT for the last several weeks. I have a big buildup of scar tissue where my left arch and heel meet. My doc also discovered I have a leg length deficiency and I have just started wearing a lift in my right shoe. I was wondering if you could explain how the scar tissue actually breaks down with these treatments, and how my foot will eventually transition back to normal, with a healthy fascia and no scar tissue. (I’m kind of a visual learner; if I can picture what’s supposed to be going on as I’m treated, it’ll help!) My progress has been very, very slow. I used to be a 30 mile a weeker; now I can only tolerate 1 or 2 runs of about 3 miles (I’m also cross-training while I heal).
I appreciate your article; most of what I find online only recommends the usual things like ice, rest, and the sock or boot.

Dr. Christopher September 4, 2012 at 8:43 pm

Hi Kayla,

I’m very happy to hear that you’ve been addressing your issues with Graston and ART. You’re treating the cause of your problem, so I expect it to get better.

I’m not too familiar with ESWT. I’ve heard of some people getting this treatment. I’m not familiar with the physiology of why it works; I suppose it can. Be judgemental of this treatment though depending on how you are progressing.

As far as understanding how scar tissue breaks down, first, watch the FUZZ SPEECH:

http://www.youtube.com/watch?v=_FtSP-tkSug

See the spider-webbing between the muscles. That’s connective tissue. And it gets THICK for various reasons. Picture that spider webbing bundling up. I like to picture a wad of gum or super-glue.

Each treatment session of Graston or ART removes some layers of that wad of gum, allowing the muscle to STRETCH to a longer range of motion and CONTRACT to a greater capacity (or being able to run more miles).

Does that make sense?

Keep on the doctor to continue treating the plantar fascia, and especially, Tom, Dick, and Harry. Read this article to figure out who they are:

http://www.humbleobserver.net/to-vibram-or-not-to-vibram-on-minimalist-footwear-and-calf-or-foot-pain/

Be a stickler for good treatment. There is much variability depending on the practitioner. To tear scar tissue, the practitioner needs to be right on the adhesion.

Let me know how else I can help.

Kayla September 5, 2012 at 2:38 pm

Thank you for the links – that’s a lot of great information! The fuzz talk was just the illustration I needed.
RE: ESWT, it’s being used in one specific spot. Graston was done on several places on the bottom of my foot and arch. The pain I had near the ball of my big toe and arch is gone, but it continues at my heel. Even I can feel the buildup of scar tissue there as compared to the same spot on my right foot. So the EWST targets that one spot only. It does seem to be working….slowly. Your article about Tom Dick & Harry helped me understand what my doc is doing when he does ART on my calf (ouch) and the stretches he is having me do.
I have had the unequal leg length (and a lower left arch) my entire life, and have done impact activities my entire adult life, but was asymptomatic until I took a workshop called Good Form Running. (I also let my yoga practice slide about the same time, in hindsight, a bad idea!) I had just transitioned to a less supportive (but not minimalist) shoe, and I tweaked my running form a bit by focusing on a midfoot strike (the rest of my stride was pretty efficient). That’s when the problems started. Of course now I know that “if it ain’t broke, don’t fix it” should have applied in my case. So as I heal, I’m interested in learning about ways to keep this from happening again, and in reading and being treated I’m reminded how it’s not just about the foot, it’s about everything connected to that and how it can create a cascade of problems (or healing). Thanks again, and I’m going to check out the rest of your articles!

Dr. Christopher September 5, 2012 at 3:21 pm

Kayla,

There is a fat pad or a “little bunch of fat” underneath the heel. When inflamed, this can take longer to heal, so don’t worry there.

The “unequal leg length” is a dysfunction that is probably structural and therefore, irreducible, which means you can’t get rid of it through conservative means. You can only work around it, like you do with orthotics. My only point in bringing this up is that you had it all your life, yet didn’t have symptoms until years after you were born. Other factors are more likely the cause of your symptoms than the leg length.

Remember that as you LOAD and use your body, don’t forget that adhesion and scar tissue build up. ART on a maintenance basis (especially for the calves) can be very helpful. Remember that professional atheletes get treated ALL of the time!

And don’t forget to crosstrain (squat, lunge, deadlift) and increase the strength of your posterior chain. Crossfit Endurance programs do wonders for runners!

As always, any way I can help, feel free to ask.

MICHAEL DEVANEY January 30, 2013 at 12:11 pm

Unfortunately I have plantar fasciitis. I started having the symptoms in July 2012. I am a runner and being that I had this affliction (i like to call it a scourge) before I quickly stopped running and resorted to elliptical and bike to maintain cardiovascular health. I never really had the serious morning pain (thank God for that) but I had an ache and the range of motion of the foot was compromised. I wear a night splint (strassburg sock) and lately(last 4-6 weeks) I have been treating this myself with moist heat followed by 5 to 10 minutes of massage (either with opposite thumb/knuckles) or the use of the small hard plastic knobs on a thera-cane several times a day(I work the fascia pretty aggressively with this massage tool). I believe, as you advocate, that my issue is scar tissue which builds up over time without any outward symptoms but eventually the tissue becomes too compromised and the symptoms start. I don’t know if stretching is a good idea especially if it involves the plantar fascia itself since forcing a stretch on something is never a good idea so I believe step 1 should be the restoration of healthy tissue, if possible. Thus my question is whether the things I am doing are the right things to do and what other suggestions you might have would be appreciated. I should mention that I have also been treating the lower leg on the affected side by massaging them with either the thera-cane or placing leg on a lacrosse ball and slowly rolling on it in an attempt to de-activate any trigger points.

Dr. Christopher January 30, 2013 at 12:35 pm

Hi Michael. Unfortunately or maybe fortunately. We all get symptoms from something. They come from whatever we overload. Symptoms allow us to learn about our bodies. In that case, fortunately.

As far as your self-treatment goes, it sounds like you are doing all the things you should be doing: stretching, self myofascial work, deloading (through staying away from running), and heat. Continue to do this and see how it responds.

Myofascial work is good, just not as good as Instrument-assisted work or ART. So if the symptoms don’t go away in a matter of 1-2 months, then seek out a qualified provider.

Irene February 9, 2013 at 6:08 pm

I find your article very interesting. I had constant muscle contraction for the past 4 months due to neuromyotonia. Now the muscle spasm is semi under control with medication. The remaining symptom is thickening of my plantar fascia bilaterally. I also have mixed connective tissue disease which makes me scar 10x faster than a normal person (that’s probably how I got plantar fascosis at the first place). The autoimmune issue is still not under control. Would you suggest waiting on astym/active release/graston until my mixed connective tissue is under control? I’m worry any kind of manipulation to my plantar fascia will make things worse. How do I know how long to wait before starting physical therapy treatment?

Dr. Christopher February 12, 2013 at 12:02 am

Hi Irene! I’m glad you find it interesting! Please forgive me for delay in responding.

The first thing I’d like to comment on is the observation that you have two autoimmune issues, or two significant signposts that your diet needs overhaul. Before I make that assumption, how is your diet? What do you eat mainly? Whatever you are doing now, I strongly suggest that you look into an anti-inflammatory diet (or something similar to the “paleo diet”). Gluten, lactose, casein, substances in nuts, eggs, nightshade vegetables …. all of these things promote inflammation inside the body. Without being as anti-inflammatory as possible, you wouldn’t be setting yourself up for much success. A great new resource on diet overhaul and anti-inflammatory foods is “Practical Paleo” by Diane San Filippo at balancedbites.com.

As far as your physical system and “waiting”, I don’t have an answer. My gut says to try a few treatments and see what occurs. I can’t imagine any serious risk to the treatments for then the average person. Soft tissue manipulation should only make it worse if the dosage of treatment is very high. But if you let the practitioner know about your autoimmune issues and your fears, they should provide you with a lighter dosage of manipulation.

In conclusion, I don’t think you should wait. After you have a treatment, you should be very conscious of your recovery. Eat lots of vegetables and protein. Move tissue (be active, stretch). Sleep lots. Don’t stress. Know that scar tissue (or “adhesion”) only forms from a prolonged lack of bloodflow.

Last thing, you might want to research fibrinolytic enzymes. There isn’t that much research yet supporting it, but the idea is that they help break down adhesion. Maybe they can combat the autoimmune issues. Look up specifically, “bromelain, serrapeptase, and nattokinase”.

Hope this helps. Let me know if I can be of further assistance!

Katherine February 15, 2013 at 10:02 am

Hi! I have been suffering with PF for over two years and have tried everything and I am now suffering with it in my right foot. How do you know for sure when scar tissue has built up? Doctors have been going back in forth with tarsal tunnel and PF with my left foot and I dont know what to do anymore. I have tried the graston Technique on my left foot for a short period of time and it didnt help. What do you think?

Dr. Christopher February 15, 2013 at 7:34 pm

Hi Katherine!

I’m sorry you’ve had it for so long.

There are a few data points that contribute to knowledge of “scar tissue” in the calf and foot.
1. ANKLE DORSIFLEXION: Go to 2:10 in this video: http://www.youtube.com/watch?v=uIMx9vhidGw
Normal is about 5″ over the toes. People with achilles tendonosis or plantar fasciosis issues usually have 2″ over the toes or less.
2. PALPATION: An experience provider will palpate (or feel) the tissue not only in the bottom of the foot, but especially in calf itself. This is the BEST and MOST DIRECT way to know if scar tissue is present.

Graston works extremely well for scar tissue on the bottom of the foot. But it works very poorly for the calf. Did the practitioner treat the calf at all? The calf structures MUST be treated if you want to resolve any foot issue. Specifically, these muscles (tibialis posterior, flexor hallucis longus, and flexor digitorum longus).

With the right structures being treated, resolution CAN happen. But know that treatment could take many visits for this type of pathology. I’d say that most cases can be resolved in 10-20 visits. But I’m also currently treating one gentleman who I’ve treated 75-100 times! He’s made progress, but still isn’t completely resolved for various conflicting factors.

Where do you live? What’s your zip code? I’ll help you find a practitioner.

Katherine February 18, 2013 at 10:00 am

I live in Louisiana 70360.
As of right now I am doing a lazer therpay and then a 15 minute massage. I tried ASTYM with my PT and he did the calf along with my foot.

Dr. Christopher February 18, 2013 at 10:33 am

Hi Katherine,

NO ASTYM anymore? I found this video about it: http://www.youtube.com/watch?v=7t91bStIuW0 It looks similar to an instrument-assisted technique I would do, just not very specific as the woman in the video is getting her whole upper extremity treated. Just be sure the patient is being specific.

I typed your zip code into this website: http://www.activerelease.com/providerSearch.asp.

Unfortunately, there aren’t many providers in your area. 50 miles away is this doctor: http://www.sourcechiro.com/. And I recognized his face. I got certified with him a few years ago and believe he is the New Orleans Saints doctor. I think he is your best bet.

There are closer therapists, but they don’t appear to have as many certifications as this guy.

Hope this helps. Feel free to reach out if you need more assistance.

Katherine February 19, 2013 at 11:48 am

No I stoped doing ASTYM becuse it wasnt working but my doctor is now leaning towards Tarsal Tunnel. Know of any good doctors who do surgery for Tarsal Tunnel?

Dr. Christopher February 19, 2013 at 4:29 pm

Regardless of whether your diagnosis is plantar fasciosis or tarsal tunnel syndrome, I’d see an ART provider first as they should be able to fix both.

As far as tarsal tunnel, where is the pain? Is it burny or nerve-like? How is your ankle dorsiflexion range of motion?

Only a minority of tarsal tunnel diagnoses would need surgery. Because surgery is very invasive, please see an ART provider first!

Katherine February 22, 2013 at 9:33 am

The pain is where the arch and heel meet. The doctor did an ultra sound and found it on the side of my foot. At times I get a burning feeliing up my leg. My doctor recently gave me a nerve block and I havent had pain since and that was on Monday. my range of motion is fine but I have been doing alot of PT, massage therapy and lazer therapy at the chiropracter.

Dr. Christopher February 22, 2013 at 11:45 am

He did an ultrasound and could visualize the mass/adhesion? Or he could visualize the nerve being caught? The same doctor is the one who did the nerve block? That’s great news that you haven’t had pain.

Glad you’re still getting the soft tissue worked out. The nerve block is effectively “blocking the pain” without taking care of the actual problem. So those adhesions removed as well and set yourself up for feeling good after the nerve block wears off!

Katherine February 25, 2013 at 9:46 am

I have an appt today and I will ask him exactly what he saw because all I remember was him saying tarsal tunnel. I got the nerve block from a local neurologist because this podiatrist is located out of town and all he wanted to do for it was give me long term cortizone injections.

Dr. Christopher February 25, 2013 at 10:35 am

Sounds good Katherine. Just remember to treat the PRIMARY PROBLEM as well. Here for consultation if you need it.

Michele March 4, 2013 at 11:29 pm

Hello. I have been suffering with plantar fasciitis for a year now on and off. I’m a runner and it started when I was training for my first marathon one year ago. At the time I was also working in a standing job on a concrete floor. It was a new job. I never had plantars before the job and had been running for three years.
I have not run for five weeks hoping the plantars would go away (and I have a new job at a desk) and have tried all sorts of therapies: KT tape, electric stimulation, stretching, icing, night splint, I had insoles (all last year) that I stopped using, ART (getting my 4th treatment this week, and I am still having pain. Last week I tried the elliptical and and it seemed to bring on more pain. I have been crossing training with stationary bike and strength traing, but although my foot has some good days and bad, since the elliptical it seems like I’m back to square one. I’ve started taking bromelain yesterday.
Just losing hope and feel like this is never going to get better and all I want to do is run again.
Do you have any suggestions for me?

Dr. Christopher March 5, 2013 at 6:46 pm

You’re only on your 4th treatment for ART! Give it some time.

Although, is the therapist treating the foot AND the calf? If he isn’t getting you results, find another ART therapist. It works. Believe me.

Also, don’t ice anymore. It might stop the pain, but it stops the inflammatory process as well.

Stacey March 13, 2013 at 9:40 am

Hello,
I, too, have been suffering from PF in the right foot for close to 2 years now (had a bout approximately 5 years ago and it resolved with orthotics after about 6 months). I have gone to two different podiatrists for this current episode and it’s slowing affecting my left foot now. I have had very little relief with the use of orthotics, anti-inflammatory meds, ice/heat, stretching, night splints and 3 cortisone injections. I have desperately been doing lots of research on the internet in hopes of finding alternative treatment options as I’m no longer wanting to resort to cortisone injections. It’s my understand that this is a short-term resolution with potential long-term effects. I was particularly interested and intrigued with ART. Therefore, I came across this blog and the link to ART providers. I have an appointment today with an ART provider close to my area. I’m excited and cautiously optimistic about this treatment alternative. Thank you for this blog and your expertise. It’s amazing how PF or any other injury for that matter can sideline a person.

Dr. Christopher March 20, 2013 at 5:38 pm

Hi Stacey, Glad you’re giving ART a try. Please consult with me and let me know how you’re doing. Would love to make sure you’re on the right track.

Allison Alan-Lee June 18, 2013 at 1:39 pm

Hi Dr. Christopher,
Exasperated after being a runner of 30-45 miles a week over the last year, I have had plantar Fasciitis for two months and am going stir crazy. I would love to try just a one mile run on the dirt at the park, but I don’t want to make it worse. This morning, I woke up and felt the hard lump on my heel and get that it is scar tissue. My pain is greatly decreased but I am extremely fearful of running too soon when I can feel that lump. Unfortunately, financially I am too strapped to spend money on treatment and wonder what I can do on my own. With a $7,000 deductible, the costs are prohibitive. I gather that ice is counter-productive from what I have read here. I had been using a plastic water bottle that is frozen on my foot. I would love some of your guidance, please. Thanks so much,
Allison

Dr. Christopher June 20, 2013 at 8:49 am

Hi Allison,

I understand. It’s not fun being hurt and being prevented from doing what you love.

Unfortunately, you’re going to get very limited results with anything but effective treatment. But, you can try stretching the calf. You want to work on the getting the knees forward over the toes.

Here’s a video that can help. http://www.mobilitywod.com/2011/09/episode-313-improving-ankle-range-super-friend-addition/

Stretch this as much as possible. See if it works. Know that at some point, you will very likely need treatment. And the sooner the better, because adhesion/scar tissue snow balls. : ( Maybe you can barter somehow with a provider?

Let me know how else I can help.

With gratitude, Chris

Allison Alan-Lee June 24, 2013 at 11:05 am

Dr. Christopher,
Thank you for your timely response. Can you recommend a facility for treatment in the Los Angeles area? Isn’t it possible to massage the scar tissue region on my own without going to a therapist? I would say that I am 80-85% better just from the resting without running for almost 3 months. I would like to try to run a lap around the track slowly. What is your opinion in regards to heat or ice at this point?
Allison

Allison

Dr. Christopher June 24, 2013 at 1:35 pm

Hi Allison,

Here’s my top recommendation.
Active Therapy Center: Chiropractic & Sports Medicine
3435 Ocean Park Blvd, Suite 101
Santa Monica, CA 90405 United States
3103990337
http://drroynissim.com

He studied under my mentor with me.

No, it is not possible to manage the scar tissue on your own. Foam rolling/lax balls/massage are purposeful (recovery through improved blood floor and neurological relaxation). However, these tools will NOT removed adhesion. I know because I tried for a long time on myself. To this day, I have issues that I know how to fix but can’t unless I see a very skilled provider.

After 3 months, any inflammation should be out. Anything left over should be structural or adhesion-related.

You can try running a lap. Consider it a TEST. Not symptoms during or after and the location of symptoms.

I don’t have anyone ice unless they absolutely need to. Here’s why: http://www.mobilitywod.com/2012/08/people-weve-got-to-stop-icing-we-were-wrong-sooo-wrong/

Let me know how I can help!

Chris

michael Devaney July 2, 2013 at 8:54 am

Hi Dr Christopher you responded to me back in January. I started Graston a few weeks ago to get at what you say is the heart of the issue (scar tissue). The graston is quite painful at times but i know that as the therapy becomes more tolerable that means the tissue is becoming healthier. I have had 5 treatments so far (2 X per week) and I usually wait at least 72 hours after a treatment to attempt a short run on the treadmill (15 or 20 minutes). Although i get through these runs ok it is later on that it stiffens up somewhat and when i get up in the morning the first few steps are a bit troublesome although not really painful just that it seems the tissue is not able to achieve normal range of motion and so body weight loading stretches the tissue further than it wants to go. I feel that ground zero for the locale of the scar tissue is right at the insertion to the calcaneus(on the medial side). Does the fat pad make it harder for the therapist to get at this location? I feel that aggressive treatment, even though it is painful, is the way to go if you want to get over this. One can rest until the cows come home and that does nothing for the scar tissue.

Dr. Christopher July 30, 2013 at 5:30 pm

Hi Michael,

I’m happy you’re pursuing treatment and that you’re also sharing your results. A couple of thoughts.

Be very specific with yourself as far as how your symptoms are progressing. For example, if you HAD symptoms after 10 minutes of running consistently but can now make it for 20 minutes of running, your capacity has DOUBLED. Good improvement. Or if you’re having 1/2 as many minutes of soreness in the morning, that’s also tissue improvement.

Pay attention to Load/Capacity and Symptoms to understand how you are doing.

Secondly, yes, the majority of plantar fascia symptoms occur at the insertion at the calcaneus. This is NOT to be confused with the bulls-eye of the fat pad, or right in the center of the circle in the diagram above (see b. and c.). In c. above, the practitioner probably wants to focus in the “6%” section at the part closest to the heel, not the circle.

Also, graston works wonders for the plantar foot. But it’s not possible to treat flexor digitorum longus, flexor hallucis longis, or tibialis posterior with an instrument (they’re too deep). Make sure he is using his hands and getting ankle dorsiflexion range of motion improvements.

Let me know how you’re progressing!

michael Devaney August 1, 2013 at 9:46 am

I am up to 30 minutes of continuous running 2-3 X per week (although quite slowly) without experiencing any symptoms during the run. I still have a few moments of stiffness and slight soreness when I wake up(or in the evening after loading the area after sitting for a while) and load the area. I am closing in on 10 treatments thus far. I am now having treatments 1X per week to enable the soreness from each treatment to dissipate before I have another one. My treatements follow the same pattern each time: 5-6 minutes of cold laser which increases blood flow to the area followed by some hands on work on the area then several minutes of graston and some more hans on followed by more cold laser and more graston. I will mention to the therapist the issue of range of ankle dorsislexion work and she is not addressing the various muscles you mentioned above. I am doing calf stretches a few times per day including stretches to get at the deeper calf muscles.
The therapist is quite aggressive during the graston portion and it is quite painful but i just endure it.
Do you think there is any benefit to wearing a rigid foot brace while sleeping while this is going on?
What can i do myself to improve ankle dorsiflexion?

Dr. Christopher August 1, 2013 at 10:56 am

It sounds like you’re having progress. Keep paying attention to load/capacity and symptoms.

Alas, your therapist is doing the best she can with the knowledge she has. Perhaps mention to her that you’ve read some resources that explain the benefit of getting those structures treated.

I don’t have much experience with the rigid foot brace. However, there are some resources that I trust that use it to good measure. These same resources do neglect “adhesion” though, so I’m not sure how much value you’d get.

The only other thing you can do on your own is stretching. Value and results with this technique will be limited. I recommend holding downward dog and rocking on one calf at a time and also the eccentric achilles exercise hanging with one heel from a stair.

michael Devaney August 14, 2013 at 10:44 am

I am tolerating the graston much better…seems this is sign of healthier tissue. Working on the stretching now several times a day. Hopefully I am turning the corner on this. I am currently running 30 minutes at a time on treadmill with some interval work for 1-2 minute in duration where i pick up the pace. I am now on 1 treatment every other week with previous treatment this past thursday.

Dr. Christopher August 17, 2013 at 10:29 pm

I love it. More workout time. Less tissue sensitivity. Increased Capacity. Right track.

Lauri September 19, 2013 at 11:58 am

Hi,

My mother, who is 81 years old, began having intermittent heel pain for the last several months. Sometimes rest would help. This summer, she did a lot of yard work, which required her to walk up and down the stairs to get to the back yard several times a day, and many days she complained of pain, mostly in her left foot. The pain has gotten progressively worse. Someone told her to never go barefoot, and she started wearing her running shoes all the time which helped a bit.

Several days ago, she cleaned out her storage room and spent the day carrying things up the stairs. The next day she could barely walk, limping badly on her left foot. After another day of this, her right foot has also flared up and now she can’t really walk at all. I had to get a wheel chair for her to get around the house.

Her pain is localized under her foot near the heel, but is starting to spread around to other sides of the heel and her left ankle is swollen. She went to an instacare clinic, and he said yes it seemed to be plantar faciitis, gave her a prescription for lortab, and a referral to a PT.

What can I do to help her? She really can’t be this incapacitated and live by herself. I need to know what I can do to help her be independent again. I doubt that I can get her to follow a complicated recovery program. It has to be fairly simple. What is the first step or the biggest priority? She is on medicare. I know that if I take her to a foot doctor, they will want to do steroid shots, and from what I have read, that isn’t a good long term idea. How do I find a practitioner that will treat her integratively? We live in area code 84043.

Thank you for the information on this site, and for your help.

Lauri

michael Devaney September 19, 2013 at 12:18 pm

There are a number of things that a person can do with this type of injury. I think initially one should deal with trying to get the inflammation under control. Naprosyn should help with this. Also seeing a podiatrist that can design a custom orthotic is also a good idea. The key to recovery is those first few steps in the morning because initial weight loading tends to reinjure the area over and over again. This is because the injured area relaxes while sleeping and gets stretched when you place your weight on it. There are rigid braces (some that are quite comfortable) that one can wear while sleeping or during periods when you are off your feet for a while (watching tv etc) that gently stretch the area so the weight bearing becomes more tolerable. I think it is important that she not go barefoot and if she gets orthotics to also place them in her slippers etc while indoors.

michael Devaney September 19, 2013 at 12:28 pm

the next step in the process has to do with stretching. Stretching should not be done while your mom is experiencing the pain since stretching will only exacerbate the problem. Once the symptoms are under control one wants to get at the cause for the injury in the first place. Many times this injury is simply the result of tightness in the calf muscles/achilles tendon as this pulls on the heel and the plantar fascia attaches to the front of the heel and fans out to the toes so this becomes tight as well. Restoration of better range of motion in the calves/achilles can work wonders on resolving this affliction.

Dr. Christopher September 19, 2013 at 9:14 pm

Hi Lauri,

I’m sorry for your mom’s suffering. Yes, it sounds like plantar fasciosis. Because she continued to do work and put stress on the foot, it sounds like the leg/foot compensated, putting stress onto other tissues, resulting in inflammation of the ankle joint itself. The lesson there is that she simply overworked WAY TOO MUCH. If this metaphor works, picture a faucet spouting water into a bucket. If a little bit of pain is that water slightly spilling out of the bucket, your mom turned the faucet on all the way and the water gushed out of the bucket, knocking the bucket over in the process.

Like Michael said, helping the pain, symptoms, and inflammation die down can be a helpful 1st step. Oral anti-inflammatories, topical arnica montana, restricting inflammatory foods (sugar, grains, dairy), and ice can all do this, although at the cost of stopping the inflammation that she needs to heal.

The next step is to get the scar tissue (adhesion) removed that is causing her calf and foot tightness. This is the cause of her problem. I typed your zip code into activerelease.com/providersearch.asp. There are some providers 10-15 miles away from you. GO to that site and type your zip code in.

As far as a simple, cheap solution, I would assume that this will take a lot of time (knowing your mom’s age) and also a high cost (most providers who do this don’t take medicare because how poorly they treat doctors). I do this type of treatment and I do not take medicare because I couldn’t sustain my practice. I’m afraid you should expect to pay a decent amount to help her.

Without treating the scar tissue, I don’t see this issue getting better in any sustainable way.

Hope this is helpful. I’m here if you have more questions.

Dr. Chris

William Errol Prowse IV October 10, 2013 at 3:57 pm

Great article, thank you for writing this up! Straight to the point and absolutely correct :)

One thing that I do disagree with is the about the graston. It may not be able to get deep calf structures such as the tibialis posterior muscle etc, but it works MIRACLES at breaking up the scar tissue around the ankle and big toe joint that contributes to the biomechanical stressors to the plantar fascia. Such as the abductor hallucis brevis/flexor hallucis brevis etc. It is also similar in effectiveness as ASTYM at breaking up scar tissue on the superficial fascia in the soleus/gastro that are huge contributors as well. When the fasical of fascia that encapsulates the soleus/gastro muscles has cross link adhesions, the muscle bellys cannot contract outward how they should and this can perpetuate the problem greatly.

I just think that ART/Graston/ASTYM should all be used in conjunction :) And trigger point therapy before working on the scar tissue.

Just my two cents haha Let me know what you think!

William Prowse
Author of plantar fasciitis survival guide

Dr. Christopher October 13, 2013 at 12:00 pm

Hi William! Thank you for your feedback.

You may be right. In my brief experience as a manual therapist, I like to focus on bang for my buck. I have had good experience with tools and the bottom of the foot and occasionally around the flexor retinaculum and anterior shin. But I have not been able to get into the deltoid ligament or the ligaments on the lateral side (because of their location between the ends of the long shin bones and calcaneus or navicular bone.

Your website is brilliant. I’m going to take a deeper dive into it.

Christopher

William Prowse November 24, 2013 at 3:23 pm

Hey Chris,
Totally see what you mean. Especially with more bang for your buck ideology. I am glad you have an understanding of the underlying biomechanics of the problem, and that you use that knowledge with soft tissue manual therapy. I also agree about retinaculum mobiliaztion for plantar fasciitis, surely needed for most!!

Interesting that you tackle those ligaments, what are some ways you go about doing that? Ankle biomechanics are extremely important with plantar fasciitis, glad you keep those in mind :) I love looking for external tibial torsion/excessively externally rotated femurs that can lead plantar fasciitis. Fun stuff!

And thank you for saying that about my website! I was so tired of reading the same kind of articles on the internet that lacked information that people actually need to fix plantar fasciitis. I’m trying to make it a complete source for plantar fasciitis information.

William Prowse
Author of plantar fasciitis survival guide

Dr. Christopher December 8, 2013 at 2:16 pm

Hi William,

I tackle the ligaments with “Manual Adhesion Release”. It’s just like A.R.T. (using your fingers), but more specifically taught. I have to get the very corner of my index finger between the talus and the malleoli. Then, bringing the ankle into dorsiflexion, feel for tension. If there’s tension, the posterior tibiotalar ligament and posterior fibulotalar ligaments need treatment.

Your knowledge of external tibial torsion/excessively externally rotated femurs is beyond mine. I only start with ankle DF, palpation, and then including standing lumbopelvic flexion and hip flexion, to determine function.

Let me know how I can help with your website. I think it is definitely needed and I hope that it become successful for you.

Chris

Fidan January 10, 2014 at 4:51 pm

Hello,
I have this problem for 7 months.ı tried icing streching and psyhical therapy. Nothing seems to work. I am now trying ESWT, i didnt see any development yet. ( 4th session)
Do you think i can make art sessions to myself cause i live in istanbul and there is no art clinic around here.
Also do you recommend a radiotherapy which destroys the nerves so that you can not feel pain anymore ? There is a hospital here which does this procedure for relief.

How about deep tissue massage ? I found some place here maybe i will go to get rid of this pain.
I am ready to listen to your comments i am do depressed of this constant pain.

Dr. Christopher January 15, 2014 at 3:39 pm

Hi Fidan,

I’m sorry to hear what you’ve been going through. Please read this article if you get a chance: http://www.humbleobserver.net/you-cant-screw-a-nail/

Unfortunately, if you’re problem is adhesion/scar tissue, only removing it is your true answer. You can’t screw a nail, you need a hammer.

You will not be able to do ART on yourself. Many ART practitioners are incompetent and you aren’t even a practitioner.

I definitely don’t recommend radiotherapy unless it’s a last option.

Deep tissue massage MIGHT be helpful, especially if you can get your deep calf worked on as well.

Please let me know your thoughts. I’ll help any way I can.

Fidan February 11, 2014 at 3:21 pm

Hello Christopher,
Thank you for your answer and help! This is one the the worst injuries anyone can get i swear ! There seems no cure to relief the pain and so depressing.

I compeleted the eswt sessions (5 sessions) and it did no help. I decided to rest the feet for 5 weeks at home with only doing daily needs at home. This is not worked either ! I thought maybe i should get off the poor tendon for a while and it might heal but no, it only calmed downed the symptoms a little bit. Infact till i walked 40 minutes around and the symptoms like inflammation is back as hell. I found a sports doctor, which is responsible also for basketball teams and other sports. He wanted to be sure about other issues , so he wanted a blood test. I also got a cortisone shot under my heel , but unfortunately this doesnt help either. Do you think he did the right place, some docs stab the needle under the foot and some stab near the foot to the fascia ?

I tried birkenstocks and they made the contidion worse because they have so hard surface. I can only walk with soft cushioned shoes only for 45 minutes with bearable pain.

I Bought a tennis ball today also, do you think it can help ? And also what do you think about footlog ? I bought footlog, but i realised that after using footlog, after a while my feet wants to be masseged so bad, they got used to it and i am not sure if this is good or bad. After masseging with footlog or tennis ball , i get relief as i iced the foot. Why do you think i need to torture my feet to get relief ? Maybe this is the most important question.

I wear night splints for 4 weeks and i dont need to do streching exercises anymore through the day. I can touch my toes while i try to catch them standing or sitting easily. At the bottom of my feet, my left foot is tighter but my right foot is worse ! So i am not sure it is about releasing the fascia ?

I also got 2 therapies of graston here. The guy was not a licenced one, but learnt to give the therapy for a 6 hours of training from somewhere he said. That made me scary about the therapy because he was so aggressive with the foot that i could hardly walk on it after 3 days. Do you think i should go on with the therapy ?
In my right foot, i can address the painf quite easily , when i walk, i feel like i am walking on a bruised part of a body. Not a sharp pain in the mornings.

What do ou think i should try next ? Doc told me that i might need a release surgery but i think i should better get a radiotherapy which burns the nerves. Which one is better do you think? What are disadvantages of nerve burn operation?

I know i asked so many questions ,i will be glad if you can answer and help me. Thank you a lot !
Fidan

Dr. Christopher February 13, 2014 at 1:55 pm

Hi Fidan,

Again, I’m sorry about the pain you’re going through. I know it’s not easy.

Cortisone works well into joint spaces, not so well into fascia/tendons. I’m not surprised it didn’t work.

Yes, I think the tennis ball and footlog can help. It’s because you’re trying to address the soft tissue (and likely adhesion) in those muscles that is causing the overload and symptoms are the insertion point of the plantar fascia. I don’t think it’s a long term cure at all though.

Yes, I think your best bet is to continue with the graston. If you were sore for 3 days, the practitioner likely gave you too much dosage of treatment.

Remember, while Graston is great for the bottom of the foot, it’s not effective at all in the calf. You NEED (capitalized for emphasis) deep calf soft tissue work. If not this therapist, find another one to do the calf. You might need to put the work of 2 providers together to chip away at this.

Given how far your pathology has progressed, you should expect to be in this for 10-30 visits depending on how well you eat, sleep, deal with stress, and how good the therapists are. But if you’re not seeing results at all after 10, you know you’re not on the right track.

Let me know how I can serve you Fidan.

Chris

Michael May 10, 2014 at 5:16 pm

Dr. Christopher,

I’m not sure if you still answer to questions on this comments section, but I figured I’d try you anyway.

After three years of very relaxed post-collegiate running, I hit an acute case of PF last summer that came on suddenly while walking around my backyard one night. My guess is that it was a result of moving out west and running solely on uphill, mountain trails for a few too many weeks, or possibly from running a handful too many runs in a favorite racing flat. Regardless of the cause, I was in denial for a few months about the PF diagnosis, partly because I’d never had PF in my past while I was doing much higher mileage, and partly because the podiatrists where I live all insisted on orthotics and condemned any mention of foot strengthening. I’m no full on minimalist, but I lean more toward strengthening and mechanics than control shoes, and I was unwilling at the time to stop wearing my old Chacos and traditional loafers to work. It wasn’t until after about five months with no improvements, despite lots of icing and no running, that I realized I needed to talk to more people.

I met a PT who worked with me for six weeks doing foot/hip strengthening exercises, and doing several 10 minute treatments of ASTYM to work on what he said was “too much of the wrong kind of inflammation.” Unfortunately, I saw no improvement in my pain, although I had some relief when he suggested wearing a slightly beefier running shoe to work (which I still wear) to counter some of the stress from all my foot exercises. Anyway, about a month later I started chatting with a yoga teacher/massage therapist who showed me some stretches and some ways of massaging my foot manually that have finally led me to feel like things are becoming more bearable. I have no doubt that the yoga and massaging made a dramatic improvement in my heel, but I feel like I’ve plateaued with that approach.

Right now, my heel has mostly good days after stretching/rolling and a few really bad days – it’s all pretty unpredictable. I don’t have any of the classic “morning pain.” My days are pretty even and the first steps out of bed actually always feel fine. And if anything, my foot seems to feel best when it’s actually in motion and working, rather than standing still. I’ve also noticed that over the course of all of this, I’ve had a handful of strange heal flare-ups in my healthy foot, which seem to always happen when I don’t do as much walking during the day, and I’m thinking that my other foot is starting to develop PF because of atrophy or underuse. I’m not really sure about that.

After reading through your site, I’m fairly certain that the ropey mess I feel all over my heel is A LOT of scar tissue buildup (not to mention a little inflammation in the support areas like my shin and ankle from standing differently to offset pain) from me mismanaging this injury for over half a year now, and I’m trying to decide if I should do ART or Graston. Because I’ve already spent a lot of money on this, I’m wondering if you have suggestions about how to narrow in on the providers in my area who can properly practice those techniques (addressing the calves, etc.). And lastly, I’m wondering where you stand on running while managing scar tissue. I have tried running a handful of times throughout this injury and it has never hurt during, but only before and after. And very recently, I started doing some very slow barefoot runs (never more than 5 min) at a grassy park, which has done a number for my sanity and hasn’t been making anything worse.

I think I understand now that I probably should have protected and rested the heel initially, worked on the tissue health and range of motion, and THEN started strengthening to get at the root cause of this and future PF prevention, but I here I am.

Sorry this was so long! Hope to hear anything from you.

Thanks!

Michael

Michael May 10, 2014 at 5:20 pm

Dr. Christopher,

I’m not sure if you still answer to questions on this comments section, but I figured I’d try you anyway.

After three years of very relaxed post-collegiate running, I hit an acute case of PF last summer that came on suddenly while walking around my backyard one night. My guess is that it was a result of moving out west and running solely on uphill, mountain trails for a few too many weeks, or possibly from running a handful too many runs in a favorite racing flat. Regardless of the cause, I was in denial for a few months about the PF diagnosis, partly because I’d never had PF in my past while I was doing much higher mileage, and partly because the podiatrists where I live all insisted on orthotics and condemned any mention of foot strengthening. I’m no full-on minimalist, but I lean more toward strengthening and mechanics than control shoes, and I was unwilling at the time to stop wearing my old Chacos and traditional loafers to work. It wasn’t until after about five months with no improvements, despite lots of icing and no running, that I realized I needed to talk to more people.

I met a PT who worked with me for six weeks doing foot/hip strengthening exercises, and doing several 10 minute treatments of ASTYM to work on what he said was “too much of the wrong kind of inflammation.” Unfortunately, I saw no improvement in my pain, although I had some relief when he suggested wearing a slightly beefier running shoe to work (which I still wear) to counter some of the stress from all my foot exercises. Then, about a month later I started chatting with a yoga teacher/massage therapist who showed me some stretches and some ways of massaging my foot manually that have finally led me to feel like things are becoming more bearable. I have no doubt that the yoga and massaging made a dramatic improvement in my heel, but I feel like I’ve plateaued with that approach.

Right now, my heel has mostly good days after stretching/rolling and a few really bad days – it’s all pretty unpredictable. I don’t have any of the classic “morning pain.” My days are pretty even and the first steps out of bed actually always feel fine. And if anything, my foot seems to feel best when it’s actually in motion and working, rather than standing still. I’ve also noticed that over the course of all of this, I’ve had a handful of strange achy heel flare-ups in my healthy foot, which seem to always happen when I don’t do as much walking during the day, and I’m thinking that my other foot is starting to develop PF because of atrophy or underuse. I’m not really sure about that.

Anyway, after reading through your site, I’m fairly certain that the ropey mess I feel all over my heel is A LOT of scar tissue buildup (not to mention a little inflammation in the support areas like my shin and ankle from standing differently to offset pain) from me mismanaging this injury for over half a year now, and I’m trying to decide if I should do ART or Graston. Because I’ve already spent a lot of money on this, I’m wondering if you have suggestions about how to narrow in on the providers in my area who can properly practice those techniques (addressing the calves, etc.). And lastly, I’m wondering where you stand on running while managing scar tissue. I have tried running a handful of times throughout this injury and it has never hurt during, but only before and after. And very recently, I started doing some very slow barefoot runs (never more than 5 min) at a grassy park, which has done a number for my sanity and hasn’t been making anything worse.

I think I understand now that I probably should have protected and rested the heel initially, worked on the tissue health and range of motion, and THEN started strengthening to get at the root cause of this and future PF prevention, but I here I am.

Sorry this was so long! Hope to hear anything from you.

Thanks!

Michael

Dr. Christopher May 31, 2014 at 11:27 pm

Hi Michael!

Sorry for the delay.

ART for the calf. Graston for the foot. If a practitioner doesn’t do both, pick ART because you can ART the foot, you can’t Graston the calf.

When pain goes away with activity, that’s hallmark fasciosis, which means it’s “degenerated fascia”. I’d stop running until you started getting treatment on the scar tissue. Then I would gradually increase load (in this case, running) constantly measuring symptoms response to the treatment and load. You should be able to load a little more over time with effective treatment.

At this point, I would get a good pair of orthotics. I’m for minimalist running in some cases. However, I learned the hard way that when you too much running in Vibrams when you shouldn’t be doing it that you’ll inflame your ankles for 6 months – 1 year like I did (and like you’re doing).

Check out Sole Supports. Amazing orthotics that my patients love!

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