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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{ 3 comments… read them below or add one }

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!

William Prowse IV July 19, 2015 at 5:58 pm

Nice article! I will have to refer people to it. Very concise and to the point. And I agree about using graston and active release technique first. Very true.

Jason November 16, 2015 at 5:17 pm

This diagnosis is spot on. I am an experienced ultra marathon runner and it is exactly the issue with my foot. The treatment is in line with what works for me.

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