How is this diagnosed?
The most common presenting pain with this condition is pain when waking up first thing in the morning and standing on the foot. The pain gets better initially with walking but then returns toward the end of the day after being on your feet.
The pain can be very severe and radiates up from the heel into the ankle and lower leg as well as to other parts of the foot. There is usually no history of an injury associated with this condition.
There is usually no change in shoe gear or activity level. Most people don’t really know what happened, this just seems to come on suddenly.
In some situations, though this can be triggered by the initiation of new physical activity or a new job or change in shoe gear.
The pain usually is on the inside of the heel right where the plantar fascia and muscles of the foot attach into the heel bone. When the pain is in this location, it is pretty much diagnostic.
The heel cord is usually tight. We do a test called the Silverskold test to check the flexibility of the ankle, and if there is restricted motion of the ankle this can help clarify the diagnosis.
We also check the flexibility of the big toe. If there is limited motion of the big toe from arthritis this will help substantiate the diagnosis.
If there is not arthritis present, then we check for a condition called Functional Hallux Limitus or Functional Hallux Rigidus. This test is always positive with Plantar Fasciitis and suggests the cause of the problem.
We do this test with the ankle up and down to see if there is any change in the tension of the joint, and if so the tendon on the bottom of the big toe joint is likely a contributing factor.
We do the Cluffy test and see if by elevating the big toe before applying weight-bearing force we can overcome this restricted motion.
I have found this always overcomes the joint restriction if there is no arthritic change in the joint or spurring to restrict motion of the joint This is done with the ankle dorsiflexed and plantarflexed.
I do what is called a Windlass Activation Test. This test checks the stability of the arch with the motion of the big toe upward. It is important for the arch to stabilize with the maximal extension of the big toe.
If this is not possible this suggests instability of the foot which may make conservative care more difficult. Sometimes spurs are restricting the ability to move the big toe normally.
If this is the case, then removal of the spurs may be necessary at some point. If the big toe is capable of unrestricted motion, but the arch is still unstable this represents a flat foot deformity that may require surgical stabilization.
We also check the position of the heel of the foot while sanding to see if the heel is rolling too much to the inside or the outside.
This is called pronation or supination.
We also test the nerve on the inside of the ankle to make sure that there is no pain when we palpate this nerve.
This is called Tinels sign. if this is positive, then there may be some nerve entrapment involved with the plantar fasciitis or this may be the primary problem.
Ankle reflexes are checked to assess for lower back nerve impingement. Further testing is ordered with neurology if indicated.
We do a visual check of the heel to make sure that there’s no skin lesions present. We also palpate the heel to make sure that there is no obvious soft tissue swelling or tumors present.
If the history and physical examination confirms the diagnosis, there is really no need initially to obtain x-rays. X-ray examination is performed if there is a question about arthritis in the big toe joint and it’s possible effect on the heel pain.
Further work up of this condition is warranted if the initial conservative care does not provide relief of symptoms within a short period of time
Causes of Plantar Fasciitis
Plantar fasciitis is a disease of the plantar fascia which is a ligament in the bottom of the foot that supports the arch of the foot and goes all the way from the base of the toes back to the heel and continues on into the gastrocnemius tendon going up into the Achilles tendon in the lower leg. For years it was thought that the cause of plantar fasciitis was primarily secondary to the posture of the foot being incorrect. When the foot pronated too much, or rolled too much to the inside, it would cause a lengthening of the arch which would cause the plantar fascia to stretch and become inflamed. While this theory still has some popularity, we believe plantar fasciitis has more to do with the mobility of the foot largely related to mobility of the big toe.
Research shows that the plantar fascia is capable of stretching more than other ligaments in the foot. It does stretch when you come down on the ground to a certain degree but most of the stretching occurs as you move forward on the big toe and as the big toe moves upward, it causes the plantar fascia to become tighter and the foot arches are raised and shortened. This is referred to as the windlass effect. When this happens, the plantar fascia actually undergoes a therapeutic stretch of about 5 mm. on average that maintains the health of this ligament.
When the mobility of the big toe is restricted, the arch raising effect of the foot is not able to take place. This results in compromised muscle function of the smaller muscles in the foot as they are placed on stretch and cannot function to the same level as they are normally designed to function. It does this by increasing the length of the muscle so that it is not able to have a strong contraction, as when it’s in its normal length. It also causes the ligaments in the bottom of the foot to overstretch which can causes significant fatigue and pain. This can also result in the foot becoming significantly flatter overtime. Stretching of a ligament called the spring ligament is felt to be one of the main causes of a significant flat foot deformity.
There is a high correlation between a lack of movement of the big toe when walking, called Functional Hallux Rigidus, and plantar fasciitis. Those two conditions go hand-in-hand. When someone is not standing they can have normal motion of the big toe joint. When they stand on the floor, the motion of the big toe is restricted so that it cannot move. This has to do with a ligament in the big toe joint called the medial collateral ligament. There is no stabilizing ligament on the bottom of the first metatarsal Phalangeal Joint .This allows the joint to deform and puts the medial collateral ligament in a position where it does not allow the big toe to bend correctly.
The tendon on the bottom of the big toe, called the Flexor Hallucis Longus, can also become tight contributing to this condition.
Other situations that can lead to this problem are;
- Obesity (Body Mass Index greater than 35.)
- Occupations where standing for prolonged periods of time is required or walking in very small spaces regularly, or carrying heavy loads regularly.
- Wearing the wrong shoes. Shoes that do not bend well in back of the toes and do not support the heel properly.
- Shoes that bend too much in the middle of the foot.
- Having a flatter foot or a foot that rolls to the inside too much.
- Walking on hard concrete surfaces most of the time.
- Not wearing proper insoles to allow normal motion of the foot to occur.
- Doing strenuous activity without proper shoes, stretching, and insoles to allow the foot to move normally.
- Walking downhill for prolonged periods without proper stretching of the Achilles tendon.
- Short steps and a shuffling walking pattern.
When to see a doctor
If you have followed every aspect of our program to get better, and are not seeing any improvement within 3 months, it is probably a good idea to see a doctor to obtain a diagnosis and consider other things to improve your condition.
Further work up for heel pain may involve x-rays, CT scans, MRI scans, bloodwork, and possibly nerve conduction velocity and EMG studies. Specialists may be consulted in making a diagnosis and managing care.
If plantar fasciitis is the diagnosis, there are other things a doctor can do to help with your pain. These include injections of various medications, shock wave therapy, and various surgical procedures. Generally, the longer you have had your condition , the more likely one of these more aggressive therapies may need to be considered. A referral to physical therapy or a Chiropractor may be beneficial as well. They have other means of addressing the pain that may also be beneficial to you.
How does the Cluffy Solution help with this pain?
Cluffy Lux Step Shoe Insole has been designed to address all areas of concern for Plantar Fasciitis. We are very proud of our product that brings relevant solutions to you for this condition.
Changing the position of the big toe joint can overcome the limitation of motion in the foot that can be a primary cause of Plantar Fasciitis. Cluffy holds the patent for elevation of the big toe and the Cluffy Wedge has been a significant product to correct the limitation of motion of the foot that is a primary cause of plantar fasciitis.
When the mobility of the ball of the foot improves, this results in stability through the arch of the foot structure and increased motion of the ankle. The ankle moves better because the arch structure is more stable. Once mobility of the ankle is improved then the gastrocnemius tendon, part of the Achilles tendon, can be stretched normally when walking and this results in proper tension of the plantar fascia. When the ankle moves correctly then the knee can become more stable, the hip can move better and the lower back becomes more stable. Body mechanics dictate that a mobile segment is followed by a stable segment that is followed by mobile segment, etc.
So not only does improving motion of the foot have a significant impact on plantar fasciitis but it can cause a total realignment of the whole lower extremity bone structure and a considerable change of foot function.
Padding of the heel is important. As people age they may lose some of the compliance of the fat pad on the bottom of the heel. This can also result from some medications that people take. Providing some additional padding underneath the heel tends to be of some benefit in providing some cushioning of the heel resulting in almost immediate pain reduction.
Support of all three arches in the foot structure is also important, particularly when standing. The Cluffy Lux Step Shoe Insole is the only insole on the market today that supports all three arches in the manner we do , worthy of a utility patent from the US patent and trademark office.
With the purchase of a Cluffy Lux Step Shoe Insole you will be entitled to be enrolled in our free foot pain guide program where one of our foot pain specialists will guide you through some other important steps in getting optimal results. These steps are outlined below.
Proper shoe selection is very important for plantar fasciitis. It is very important that the shoe allows the foot to bend properly but support the heel in a normal position. Please see our shoe selection guidelines for further details and recommendations concerning the choice of a shoe. It is important to state that the shoe alone is often not going to be enough to overcome the symptoms of plantar fasciitis.
It is often necessary to stretch not only the plantar fascia but some of the other muscles that have become too tight as a result of improper function of the foot. The most common muscles to become tight are the flexor hallucis longus (tendon on the bottom of the big toe) the gastrocnemius tendon,(part of the achilles tendon and calf muscle) the hip flexor tendons Including the iliopsoas and the rectus femoris, (these muscles allow you to bend the hip upward for the next step). Please see our home therapy kit for instructions on proper stretching technique, and ask our guide to review these with you.
Walking properly is also important for the resolution of plantar fasciitis. Often times when people have pain from plantar fasciitis they tend to walk with a very short stride and a shuffling type of gait pattern. It is necessary to walk at a faster pace, take a longer step and roll through the big toe properly as well as swing the arms and walk like you mean it. This will allow for proper flexibility of the foot structure and proper stretching of the muscles which have become tight over time.
Other symptomatic treatment can be employed by using topical analgesics on the plantar fascia, oral anti-inflammatory medication, and cryotherapy or cold packs applied to the heel twice a day. These treatments are considered symptomatic and not addressing the root cause of the problem, but can be very useful in the resolution of symptoms once the root cause of the problem is identified and properly addressed.
What we are recommending to you is what I tell most of my patients with Plantar Fasciitis. We have seen resolution of plantar fasciitis pain in 88% of our test population within 12 weeks. This is very high and good success rate. We feel we are able to do this by identifying the core problem that needs to be addressed for the resolution of this pain and providing the proper stretching exercises to overcome the inherent tightness that has developed from years of malfunction. This is a completely treatable condition that makes life so much more enjoyable when you are free from the nagging pain of Plantar Fasciitis.