Plantar Fasciitis

Everybody recognizes it, even if they’ve never had it. You can’t turn around these days without seeing an article or product to treat this dreaded condition. What is worse is actually suffering from it. Who do you listen to? Who do you believe? For us a day doesn’t go by without having to treat someone who has painful heels but where did it come from? I had a client who came to me with a referral for Orthotics to treat plantar fasciitis. As usual we go through a detailed history and examination of the feet. We tend to treat these conditions like 500 piece jig saw puzzles. Each piece we collect sheds more light on the how and why of the problem and what to do to help you get through it. This man had seen his Doctor after 3-4 weeks of hobbling around with a painful right heel. By the time he saw his Physician the left heel was starting to bother him too. He was referred to Physiotherapy where he received treatment, a stretching program and some helpful things that he could do at home to help ease the pain. Fortunately the Physiotherapist recognized that the underlying problem was a mechanical one and that Orthotics could probably help. In talking to this fellow, he had a long tale of all the useful advice he received before he finally saw his Doctor. Heat, cold, bedrest, gel heel pads, readymade “arch supports” and on and on.

As Pedorthists we labour under an overwhelming weight of opinions, expert and otherwise about the dubious effectiveness of custom made foot orthoses. Much of this cautionary advice comes from people who don’t wear or have never required them or from those who have had singularly bad experiences associated with orthotics. Many see orthotics as a crutch which should be avoided. Do we feel this way about eyeglasses? I don’t think so, yet glasses are orthotics too. In fact the analogy can be taken further by describing the orthosis as a lens that focuses faulty alignment, muscle imbalances and forces to create a better mechanical relationship. This is what is supposed to happen when the rubber meets the road.

So what is the problem? From my side it’s the assertion that research shows that there is inter and intra provider unreliability in the effectiveness of foot orthotics. What this mean is that many providers don’t interpret the problem properly, don’t design the appliance correctly or don’t counsel the client in the use of the appliance or what their expectation of healing should be. Unfortunately there will probably never be good research on the effectiveness of orthotics as there are too many different types of providers and the variations of assessment, manufacture and implementation are diverse as well. I can only hope that the reason we are still here is that we are practising above the average.

Now, the problem from your side? Well it’s you, of course. Go look in the mirror (preferably floor length). Look carefully – head, shoulders, arms, hips, knees, ankles and feet. Tell me about that sciatica, the medial knee OA, those old ankle sprains or the appearance of one foot rolling in and the other rolling out. We are conditioned to think of ourselves as symmetrical but between what we are born with and what we add to it in injuries and overuse during our lives, we get less symmetrical as time goes on.

So if I ask you what your goal is, you are likely to want pain freedom. Symptomatic relief. I might be able to do that with a simple orthotic, but I’ll warn you right now that there’s nothing simple about it. Wouldn’t you rather, while I’m at it, also deal with the sciatica and the knee pain? What is your stake in all this? Most people come to us expecting a pill. Put this thing in my shoe and I don’t have to do anything other than complain about how it doesn’t work or sing your praises if it does. You are a stake holder and you have to manage all the stuff I can’t. I can make you a perfectly designed orthotic but I can’t make sure that you are going to follow all the advice I gave you about exercise, proper shoe choices, ergonomics and other avenues of therapy. For Pete’s sake, tie up your shoes and don’t just drive your feet into them!

The real problem is more fundamental. 60,000 years ago you might not live long enough to have osteo arthritis, just living to be an adult was painful enough that injury and disease were only a problem if they didn’t kill you. In this age of progress we need to take better care of ourselves at least until technology can step in and replace that worn out and abused joint or organ. I’m sorry, I don’t want to detract from this important concept. When we get right down to it all these postural aches and pains start out as muscle imbalances. Causes may be congenital or acquired but our bodies are amazingly adaptable. Adaptation is made possible by compensation, and compensation changes the loading of weight bearing structures.

OK, here’s the punch line. Think of your skeleton. By itself without any of the structures that bind us it would just be a pile of bones. But think of those bones wrapped in a web of tissues (fascia). Muscles, tendons, ligaments and joints all fascia differentiated by size shape structure and task. All designed to work with each other. Any part that has an issue has adjacent structures to help share the load (compensate). If we don’t deal with those issues when they occur other structures will have to be recruited to share the load and help you heal while you still get the laundry done.

I hope I haven’t put you to sleep but this is the most fascinating stuff and after so many years doing Pedorthic Therapy I’m still figuring out how it all works together. My apologies to all those people I have used as guinea pigs but this is my conventional wisdom: You cannot apply a force anywhere on or through a structure without repercussions. Why Plantar Fasciitis? The Plantar (aponeurosis) Fascia is symptomatic because it is the weakest link in the web that attenuates the forces of walking and standing. Recruiting the strength, flexibility and support to repair it and keep it from happening again takes a multidisciplinary approach in which the client, patient, subject is at the center and clearly understands their role. The rest of us will do our utmost to help you get better. My best advice: If it doesn’t clear up within a few days, get it dealt with and beware of repercussions.