When your heel pain fix lies elsewhere

There are a lot of people out there with foot pain, heel pain, and sometimes even plantar fasciitis. Plantar fasciitis (PF) certainly has a reputation on the streets. The patients I encounter recant a long experience with this mythical beast. It makes waking in the morning an unpleasant experience, walking barefoot in the house impossible, and half filled bottles of water in the freezer a common experience.  

The internet is a chock full o' DIY solutions for PF. Between YouTube binges, painful injections, and overpriced orthotics, many people are stuck without resolution. Despite an already targeted and expert approach, I often find these patients are victims of neglect: a failure to address an obvious breakdown of the trunk, pelvis, hip, knee, and ankle. 

My name is Dr. Allan Buccola, PT, DPT, physical therapist and owner of Impetus Physical Therapy in Greensboro, NC. Not all cases of plantar fasciitis are created equal, but a majority of cases have one thing in common: a breakdown of the kinetic chain from top to bottom.

To stop a sinking ship, you can continue to bail water, or you can fix the hole. If you are dealing with PF, here are a few signs to look for that could indicate that the real solution lies not in the foot, but elsewhere. 

Sign One: the Bunion and callus don't lie

The bunion, or hallux valgus as it is clinically named, is the gradual inward drift of the big toe. This is a problem that can stem from altered bio-mechanics in walking/running, but is just as easily mediated by excessively narrow footwear, even more so when combined with an elevated heel. 

As the big-toe, (the piggie that went to market) begins to drift toward the other toes, a few things begin to happen. Firstly, all of the muscles and connective tissue that run along the inside of the arch from the heel to the first metatarsal joint elongate and weaken. 

Secondly, the joint where the hallux joins the foot begins to change shape, and often becomes stiff over time. This can result in exaggeration of the walking/running mechanics that contributed to this problem in the first place.

Once that hallux loses mobility, the remaining muscles attached to it also elongate and weaken, the longitudinal arch collapses. To move around the stiff toe while walking, you may find yourself moving with toes pointed outward, rolling through your arch as you toe-off.  This mechanical deviation further stresses that joint and excessively loads the plantar fascia. 

Footwear choice can be harsh on the feet, so choose your shoes wisely. 

Footwear choice can be harsh on the feet, so choose your shoes wisely. 

There are limited non-surgical options for bunions, but physical therapy can play a huge roll in preventing additional breakdown, restoring mobility, and correcting walking mechanics. Addressing the contributing factors here are just as important as addressing the pain alone. Corrective footwear, correction of joint loss at the ankle and hip, and strengthening of the intrinsic foot muscles, can all be effective enough to create some relief.

Often times, I have found that in many of these cases, the intrinsic flexors of the foot are more pain producing than the plantar fascia itself. It can be difficult to differentiate between the two. This means that misguided medical treatments will provide either no relief or only short lived relief. It is easy to see how addressing the problem with injections and anti-inflammatory meds alone will be of minimal benefit to some.  

Sign Two: core and abdominal weakness change Lower Limb function

Lower crossed syndrome is a postural profile that accompanies plantar foot pain and heel pain. It can easily be overlooked, but changes as high up in the trunk alter alignment in the hips, knees, ankles and feet. This is especially seen in the presence of high heeled shoes, which exacerbate the problem with excessive arching of the lower back. 

A detailed understanding of this isn't required, but you should look for a few things. The weak core starts with maintaining excessive arching in the back, which allows the pelvis to shift forward over the feet. This forward shift is countered by hyper-extending in the knees, but the knees do not extend without internally rotating.

When the trunk is in an abnormal position, there's no telling what the feet will do.

When the trunk is in an abnormal position, there's no telling what the feet will do.

This internal rotation of the tibiae results in load transfer from the center of the feet toward the inside of the feet. Over time, the arches fatigue and elongate, as they were meant to provide mechanical advantage during movement but not withstand prolonged static loading. 

Many practitioners will immediately throw an orthotic device at this type of patient, but there is fairly limited research to support it's role here. It could play a short term role in addressing mechanics, but ultimately, addressing weakness of the core is the what will be needed for a true long term solution. Addressing this on the first visit is some times enough to resolve the pain completely, depending on how serious the case is.   

Sign Three: Wide-Based Stance, Hip Weakness, and Excessive pronation

Although wide stance and weakness in the hips are common bedfellows, trying to determine which comes first will result in a lengthy discussion. As interesting as this chicken/egg conversation may be for PTs like me, it's likely not worthwhile for most decent people. 

Wide based stance may look cool in an L.L. Bean catalog, but it's not the way to go. 

Wide based stance may look cool in an L.L. Bean catalog, but it's not the way to go. 

Weakness in the hips will often lead to a wider stance, mostly because it is more stable; however, standing with a wider stance also takes away a substantial effort imposed upon the hip abductors and rotators, resulting in progressive weakness over time. Regardless, the posture becomes more common, and overtime postural loading on the ankles and mid foot moves away from a central foot loading to one more heavily through the arches, similar to above. 

Hip abductor weakness can be addressed and ameliorated. Habitual tendencies can be addressed to some extent, although this isn't always necessary. Long-term effects from these habits can be difficult to fix without addressing the system as a whole. 

What other things mimic Plantar Fasciitis?

Plantar fasciitis most commonly is associated with isolated pain at the junction of the arch and heel on the inside of the foot. Patients often report pain that is worst first thing in the morning, but gradually worsens throughout the day with walking or standing.

PF can also be painful in other areas of the bottom of the foot as well, but there are several layers of other types of tissues that could be considered as well. Metatarsal stress fractures are often in the midfoot, but tend to be toward the outside of the foot and not as centralized to solely the bottom of the foot. Any type of burning pain in the foot is almost certainly nerve related.

Isolated heel pain could include calcaneus stress fractures, fat pad syndrome, or referred pain from trigger points in the calf. These can all be less predictable in symptomology, but seem just as localized. Pain in arch on the inside of the foot also describes posterior tibialis tendonopathy, but is more midfoot in orientation, whereas PF is in the rearfoot. A bone spur at the calcaneus can be just as much a culprit as it can be a scapegoat. 

These are all things that range in seriousness and prognosis, but they all have one thing in common: the longer you wait to have it checked out, the longer it will likely take to resolve. Aches and pains come and go, and are not the same thing as an injury. An injury is something that alters the way you perform a task, and is often worsened by activity.

If you find yourself consistently unable to perform or complete an important task because of pain, or regret it immediately after, it may be time to take a rest and/or have it checked out by a professional. The doctor is often the first place most of us go with these things, but I'd prefer to start with conservative management and evaluation offered by a physical therapist.

I certainly have a bias, but I'll try stretches, massage, icing, and exercises long before I take a needle in my foot. PT can offer a big set of solutions to help with pain, address areas of weakness, and offer education about self care and activity modification. If additional medical management is needed down the road, hopefully your PT will be the first to let you know.

Until next time: don't stop moving! 

-Allan