Plantar Fasciitis Overview
Plantar fasciitis is the most common cause of heel pain. There are an estimated 78 million people in the United States that have experienced heel pain, and plantar fasciitis is responsible for over 90% of heel pain. Two million visits are made to physicians annually for this condition. If you do not have this condition, most likely you know someone who does or who has had it.
If you look at your foot like a bow, with the arch being a bow, the bowstring on the bottom of the arch would be the plantar fascia. As we push down on the arch, the arch gets lower. You can see that the bowstring will stretch. When excessive stretching of the bowstring occurs, it pulls on the heel bone. The heel bone is covered with a very thin layer of tissue called the periosteum. The periosteum is full of nerves and blood vessels. When you pull on it, it is almost like you’re pulling saran wrap off of a bowl as it tents away from the bowl. This is what happens to the heel bone. The pulling of the ligament causes the periosteum to pull away from the bone and this causes significant pain. Eventually, as this occurs over time, a bone spur will develop where the periosteum is pulled away from the bone. The bone spur is not the reason for the heel pain, but rather a result of the pulling of the plantar fascia on the bone causing the pain. It tells us that this pulling has been occurring for a while.
When the bowstring, or the plantar fascia, becomes tight and unable to stretch normally, tightness of the plantar fascia develops because of the way we walk. We will go into this in more detail, but this all stems from a lack of normal motion of the front part of the foot when walking.
How is Plantar Fasciitis Diagnosed?
Disclaimer: We are unable to make a diagnosis of your condition. What we are describing are common conditions of plantar fasciitis. For a diagnosis, you will need to see a qualified medical professional.
The most common presenting pain with this condition is when first waking up 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. This pain can be very severe, radiating 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, nor any change in shoe gear or activity level. Most people do not even know what happened, it just seems to come on suddenly. In some situations, though, this can be triggered by the initiation of a new physical activity, a new job, or a change in shoe gear.
The pain is usually 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, 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 a restricted motion of the ankle this can help confirm the diagnosis.
If there is not arthritis present in the big toe joint, then we check for a condition called functional hallux limitus or a limitation of motion of the big toe with standing and walking. This test is always positive with plantar fasciitis and suggests the cause of the problem.
I have found elevating the big toe, using the Cluffy test, always overcomes the joint restriction. We do this test with the ankle, moving it up and down to see if there is any change in the tension of the joint, and if there is change, then the tendon on the bottom of the big toe joint is likely a contributing factor.
We will do what is called a Windlass Activation Test. This test checks the stability of the arch with the motion of the big toe upward. The arch needs to stabilize with the maximal extension of the big toe. If this is not possible, it 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 check the position of the heel while standing 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 Tinel’s 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 are no skin lesions present. We also examine the heel to make sure that there is no obvious soft tissue swelling or tumors present.
If the history and physical examination confirm the diagnosis, there is 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 its possible effect on the heel pain. Further workup 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, stretching from the base of the toes to the heel, and continues 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 is pronated too much or rolled too much to the inside, it will 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 the mobility of the big toe.
Research shows that the plantar fascia can stretch 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. 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 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 were designed to function. This happens by increasing the length of the muscle so that it is not able to have a strong contraction, as when it is in its normal length. It also causes the ligaments in the bottom of the foot to overstretch which can cause significant fatigue and pain. This may also result in the foot becoming significantly flatter overtime. Stretching of another ligament, the spring ligament, is felt to be one of the main causes of significant flat foot deformity.
There is a high correlation between a lack of movement of the big toe when walking, called functional hallux limitus, with plantar fasciitis. These two conditions go hand-in-hand. When someone is not standing, they can have normal motion of the big toe joint. When they stand, the motion of the big toe is restricted so that it cannot move. This has to do with the medial collateral ligament in the big toe joint. There is no stabilizing ligament on the bottom of the first metatarsal phalangeal joint, which can cause the joint to deform, putting 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, 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 which require standing for a prolonged period, walking in very small spaces regularly, or carrying heavy loads regularly
- Wearing the wrong shoes
- Shoes that do not bend well in the 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.
How does the Cluffy Everyday Insole help with Plantar Fasciitis?
The Cluffy Everyday insole (formerly Lux Step) 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 the 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, a 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 becomes more stable, the hip moves better, and the lower back becomes more stable. Body mechanics dictate that a mobile segment is followed by a stable segment then is followed by a mobile segment, etc. Improving the motion of the foot not only has a significant impact on plantar fasciitis, but it can cause a total realignment of the whole lower extremity bone structure and a positive change of foot function.
The padding of the heel is important. As people age, they may lose some of the fat pad on the bottom of the heel. This can also be a result from some of the medications that people take. Providing additional padding underneath the heel benefits most people, and can provide immediate pain reduction.
Support of all three arches in the foot structure is also important, particularly when standing. The Cluffy Everyday 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 U.S. Patent and Trademark Office.
It is very important that the shoe allows the foot to bend properly but supports the heel in a normal position. It is important to state that the shoe alone is may not be enough to overcome the symptoms of plantar fasciitis. Proper shoe selection is very important for plantar fasciitis.
It is often necessary to stretch not only the plantar fascia but some of the other muscles that have become too tight because of improper function of the foot. The most common muscles to become tight are the flexor hallucis longus (the tendon on the bottom of the big toe) the gastrocnemius tendon (part of the Achilles tendon and calf muscle), and the hip flexor tendons including the iliopsoas and the rectus femoris, these muscles allow you to bend the hip upward for the next step.
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 best to walk at a faster pace, take a longer step and roll through the toes properly, 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 helpful treatments are topical analgesics on the plantar fascia, taking oral anti-inflammatory medication, and cold packs or cryotherapy applied to the heel twice a day. These treatments are considered symptomatic and are 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.
With these recommendations, we have seen the resolution of plantar fasciitis pain in 88% of our test population within 12 weeks. This is a good success rate. We recommend the Cluffy Everyday insole to help people overcome years of poor foot motion. Plantar Fasciitis is a completely treatable condition that makes life so much more enjoyable when you are free from the nagging foot pain.
When to See a Doctor for Plantar Fasciitis
If you have followed every aspect of our program to get better and are not seeing any improvement within three months, it is probably a good idea to see a doctor for a diagnosis to consider other things to improve your condition. Further workup 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 will 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 benefit you.