0
0
I mentioned a few weeks (months?) ago that I’ve been dealing with Plantar Fasciitis since prior to the first of the year, so probably five or six months now. This isn’t the first time I’ve had to deal with this but I’m determined it will be the last.
First, let’s start with the usual disclaimer that I’m not a doctor and that my experience may not mirror yours. Do your research, talk to your doctor, consult multiple sources and generate your own conclusion. Or just trust me and hope for the best. You’ve got options.
Also, not to wax overly philosophic but although I believe my thought process in dealing with this is sound, I am also sure that there is some confirmation bias involved here. Confirmation bias is the tendency to seek out and follow advice and thoughts that confirm our own pre-existing beliefs and ideals. The internet and entities such as Google have created a culture of confirmation bias that I am convinced contribute to the strife we see all around us. Everyone screams about tolerance but they’re only tolerant of beliefs that align with their beliefs and everyone else should be shouted down. Prior to the internet our main circle of friends and acquaintances were our neighbors, relatives and those we worked with. If you wanted relationships you were forced to be involved with these people regardless of their views and out of that involvement you were exposed to differing opinions and ideas. Over time you might even come around to their view and if nothing else you had to live with these people no matter how much you might have disagreed. With the advent of the Internet you can now ignore all those opposing views and hang out exclusively with a community of like-minded individuals who agree with and reinforce your convictions. If you watch a Youtube video on how the moon is a projected hologram you’ll instantly see another video in your feed that supports the idea that the moon doesn’t exist and in short order you are surrounded by people for whom the moon is a conspiracy foisted on us by aliens who have lived among us for millennia and driven our beliefs on how the universe exists. Before you know it these are the only videos being suggested in your feed and over time you come to think that most everyone agrees there is some Illuminati-type group who has controlled humankind from antiquity and anyone who thinks otherwise is a fool. There’s no one to dispute your beliefs because you shut them out of your life long ago since that confrontation would be uncomfortable and it’s far easier to just find others that agree with you. I think about this a lot. Am I wrong? I’m sure I can find a community online who supports my belief in how this idea of confirmation bias is destroying our tolerance for the ideas of others!
Umm….where was I? Oh, yeah. This is going to be a long post.
What’s this got to do with my treatment of Plantar Fasciitis? Well, there are a lot of differing opinions on what PF (that’s what I’m calling it from here on) even is and what causes it. Assuming it’s not truly understood what causes PF then the treatment similarly isn’t universally agreed on. Even if it were definitively understood there would be a myriad of opinions on treatment and there are different camps, each of whom believes the other is wrong. That said I have determined a path that makes sense to me and somewhat matches my philosophy on self-care and wellness.
First, what the heck is Plantar Fasciitis?
Well, to understand that you have to know something of the anatomy of the foot. I’ll probably get some of this wrong but I think I have the basics. Your feet are some of the most complex structures in your body. Each foot is made up of 28 bones with 30 joints. Another way to think of it is that over 25% of the bones in your body are in your feet. They’re all connected and moved around by over 100 muscles, ligaments and tendons.
Tendons connect muscles to bones, ligaments connect bones to other bones and muscles obviously stretch and contract as needed to move your bones back and forth in case you want to go somewhere. Tendons cannot stretch themselves but they do stretch when they’re pulled and can act like a spring. Your achilles tendon is a great example of this. A major portion of your forward progression is aided by the tendon snapping back to its original position as the muscle relaxes, with the spring action propelling you forward. Muscles do contract and in general if a joint has a back-and-forth function there is a muscle on either side and one muscle will relax and stretch while the other opposite muscle contracts and pulls. Ligaments though? They hold everything together. They aren’t designed to stretch and that’s a good thing. Without your ligaments you wouldn’t have much structure. Just a bag of bones flopping around.
Here’s where we get to the plantar fascia. It’s the main (thickest and longest) tissue in your foot and this tissue (called the fascia) is a type of ligament. It runs from the heel to the ball of your foot and your toes like a fan and connects all this mess together into a nice little package. It’s also what forms your arch and acts as a sort of spring. Note the spring action is up and down in the vertical direction so the plantar fascia itself is not stretching, it’s just flexing. It doesn’t want to stretch in the horizontal direction, which is a critical element in the discussion. The plantar fascia provides the strength for the foot and is a key to helping you balance.
-istis means swelling or inflammation so similar to tendinitis being the inflammation of a tendon, plantar fasciitis simply means inflammation of the plantar fascia. The controversy begins immediately because although lots of websites I looked at still say that PF is inflammation it seems like most newer research doesn’t really call it inflammation but more of a micro-tearing of the fascia. Remember that ligaments don’t want to stretch so if you’re constantly pulling on them they can tear. Obviously not a good thing.
So, what is the main symptom of PF? Well, it’s foot pain, usually along the bottom of the foot and most often mainly in the heel. Imagine you take a tack and step on it with your heel. Leave the tack in your heel and just start walking. At it’s extreme conclusion that what it can feel like, although mine has never gotten to that point. This pain was bad enough though to start me on a journey to figure out what is happening and try to implement a cure.
So….that’s the introduction…. Next I’ll talk about what I’ve found in my research and the path I’ve taken towards eliminating the issue…
One train of thought is that PF is a foot problem and the way to cure it is to get off your feet and/or treat the foot. That can involve orthotics, walking boots, splints you wear at night, cortisone shots in the heel and at the extreme, surgery. The main idea is that the PF is caused by over-pronation of the foot where, as you put your foot down, the foot folds inward and the arch collapses, pulling on the plantar fascia. This makes some sense but a lot of people with PF don’t have an obvious problem with pronation. Similarly, there are plenty of people with flat arches or even high arches who don’t have foot problems. Bone spurs are also mentioned but, again, not everyone with bone spurs in the heel have issues.
On the other end of the spectrum you have those who say PF is just a symptom caused by other forces outside the foot and just focusing on the foot won’t solve the root cause. I’m firmly in this camp so that’s what we’re going to focus on here.
Orthotics and the other items may be helpful in initial treatment but in the same way that you don’t leave a cast on your arm when you break it, you don’t want to be dependent on orthotics long term either. Even after a couple of months with a cast on your arm, that arm will be weak and malnourished and need exercise and conditioning to get it’s strength back. Orthotics are the same. If the goal of orthotics is to hold the foot in place and prevent it from moving, even if that intention is good, the long term effects will be negative because the foot is now not functioning like it was intended to function. The muscles in the foot will atrophy and lose their ability to support the plantar fascia and the arch and then you’re stuck wearing orthotics the rest of your life. You can extend this theory to most athletic shoes on the market that are designed to support and coddle the foot. Using these supportive shoes ultimately weakens the foot and causes it to become ever more dependent on the shoe to support it.
There are many that hold this belief but I’ve really latched on to two who I think are spot on.
One is a guy by the name of Chase Tucker. His youtube channel is “Chase Mountains”, which I love and immediately gives you an idea of his focus. Chase has a lot of content on hiking and mountaineering as well as product reviews on hiking gear but most of his content is on strength training and conditioning with the goal being the ability to hike and be outdoors into old age without injury. He has programs that focus on knees and hips, two key areas you need strength and flexibility in if you want to stay mobile. He also talks about foot health quite a bit.
The other person I think is right on is Matt Hsu and his channel, “Upright Health”. He’s got several great tag lines like “pain sucks, life shouldn’t”, but one thing that he constantly goes back to is “ATM”, Always Think Muscle. He is a bit more vocal than Chase in his disdain of standard western medical practices but Chase and Matt’s thoughts are similar in practice. Matt’s main message is that the vast majority of us don’t have bad bones or anything wrong with our skeletal structure, we only have weak and underdeveloped muscle groups, mainly caused by our seated, sedentary lifestyles. These improper habits cause all sorts of aches and pains that get diagnosed as untreatable skeletal issues, or worse, skeletal issues which need surgery to “fix”. Matt would say that most of this is just plain wrong and that by focusing on proper exercise and stretching you can fix the majority of these issues without resorting to surgery or other artificial means of manipulating your bones into place.
Although they have different focuses both Chase and Matt are saying effectively the same thing which is, focus on strength and flexibility and your body will respond as God designed it.
I’m not going to go into all the specific different exercises and whatnot but more just give an overview and if you’re interested there are plenty of better resources than me that can provide the actual programs you can work on.
Here are two good tests for you though. These aren’t specific to PF but give a good idea where you are as far as flexibility and foot strength.
First test: With no shoes on, preferably on a hardwood floor or other hard surface (ie, not carpet), stand on one leg for 45 seconds and then try standing on the other leg for 45 seconds. No problem? Do it again but this time with your eyes closed. You might find it a challenge. This is a test of your balance for sure but is also a great exercise for your feet and ankles as well as the rest of your leg, up to and including your hips.
Second test: The Asian Squat (or Slav Squat if you’re so inclined). Ok, so it’s a deep squat and the culture really doesn’t matter, but most cultures outside of our modern western culture have always been able to deep squat. For hundreds of generations this has been the main way to relax. No seated toilets, no chairs, nothing around you to sit on, you deep squat.
What does your ability to do a deep squat say about you? Well, first, it has nothing to do with your heritage or age. Cultures all over the world have no problem squatting and in cultures where chairs aren’t a thing people squat regardless of how old they are. Once we sit in a chair for years though everything all goes haywire. Our hips don’t want to move, our ankles are too stiff, our glutes aren’t used to doing anything, let alone supporting us in that position. The ability to squat (or not) says a lot about your overall flexibility and lower body effectiveness. Two months ago I couldn’t deep squat, and I still can’t completely get my heels flat, but I’ve come a long way and am certain that at some point I’ll be able to.
Why does this matter and what does it have to do with PF? Well, if we go back to the idea that PF really is just a symptom of another issue, and the biggest issue is our inability for our bodies to flex and move like they’re supposed to, then it’s all connected. Matt doesn’t specifically link it to PF but still explains the benefits far better than I can.
Starting at the bottom, your feet provide the platform for the rest of your body and need to be strong. There are two camps here. One tries to support and cushion the foot, effectively lessening the work the foot needs to do. The other tries to strengthen and encourage the foot to respond to the stimulus of walking, running, jumping and whatever else it is you’re doing. You can guess which camp I’m in but there is probably room on both sides. You could wear barefoot shoes for training and cushioned shoes for long days on concrete, for example. The only issue with this is that as you encourage the foot to strengthen and take on more load you’ll find the foot will spread and widen out and at some point the narrow and pointed profile that most cushioned shoes maintain won’t even fit any longer.
Looking at this picture you can see the difference between what shape most people’s feet are (on the right) vs someone who has spent a lot of time barefoot or wearing non-restrictive shoes. The foot on the left provides a much better platform for the rest of the body than the one on the right and is how the foot should naturally look.
When most people think of barefoot shoes they think of the Vibram FiveFingers shoes that have individual toe pockets but for most (including me) that’s a bridge too far. There are a lot of brands now who are dedicated to a wide toe box and no heel lift (zero drop) that will encourage foot strength without looking totally out of place. Xero and Vivobarefoot are good examples of these. There are even companies starting to make more formal looking shoes that fit a barefoot style. Altra makes great athletic shoes that are zero drop and have a wide toe box whilst still having moderate cushioning and that’s what I’ve worn for several years when hiking.
One thing to remember though is that most people’s feet are out of shape and to jump right into a minimalist shoe is probably going to not end well. It takes time and exercise to get the foot back to where it can do it’s proper role and so maybe at first it’s just walking barefoot around the house for 30 minutes a day or wearing a barefoot style shoe for an hour at a time. I was reading a blog where one person said it took them six or seven years to fully transition back to a natural foot shape. There is some marketing in this article but I still think it’s a good overview of how to transition.
Obviously exercises for the feet are critical to transitioning back to a natural foot shape. You can easily find tons of great resources online but here are some simple ones to get started with. This is a great playlist from Chase and he makes the point that just passively wearing barefoot shoes is not likely to solve any problems. Exercise and mobility training have to go along with it and if you aren’t willing or simply don’t have the time to put in the effort then you may be better off staying in the rigid, conforming shoes you’ve always worn. If you’re really into it you might even use a tool such as toe spreaders to force the toes to spread. If you think about it, your feet have been crammed into pointed, restrictive shoes your whole life and this force is what shaped the foot into what it is today. It’s unlikely that the toes are magically going to move back where they should be without something helping to move them in that direction.
Up next are the knees. Chase has a whole program on “mountain proofing” your knees but what you find is that the knees are designed to pivot in a full range of motion. I was always told that bending my knee beyond 90 degrees or allowing my knee to travel out over my toes was to be avoided. Now we’re finding that this was bad advice. Natural movement, such as the squat, requires the knee to flex from straight to fully closed and if the knee isn’t trained to do this then it’s not going to perform well. The focus then is really on proper bio-mechanics, primarily in making sure the knee follows a proper path, which is that as your knee bends you want it to track out toward and over your small toe. If you pay attention, even walking up stairs requires your knee to be out beyond your toes. It’s a natural movement so going back to what Matt says over and over on his Upright Health channel, train muscles in all positions. That said, the knee isn’t designed to lift weight. Going back to our seated lifestyle, we’ve trained our knees and quads to do the heavy lifting and that is a recipe for bad things to happen. The knee is a joint to pivot, it isn’t designed to be under constant stress.
Important to the movement of the knees and the rest of the body in general are the hamstrings, hip flexors and glutes. These are broad categories because there are multiple muscles that make up each group but they all work together and all three groups are negatively impacted by sitting. The hip flexors get shorter and tighten when seated and this is at least partially responsible for the forward pelvic tilt which pulls on the muscles in the back of the leg. The hip flexors, which are responsible for bending your knees as well as rotating the upper leg also get tight and inflexible. The glutes, which are some of the strongest muscles in the body (specifically the gluteous maximus), are responsible for providing forward locomotion as well as stabilize the hips and pelvis. They assist in balance and posture. Weak glutes contribute to all sorts of problems including low back pain, that forward pelvic tilt (again) and all sorts of other problems, including issues with the knees. There is very little engagement of the glutes when seated so they atrophy and cease to function correctly. There is actually a name for this, gluteal amnesia or the more entertainingly named “dead butt syndrome”. It’s amazing to me how different a squat feels when I concentrate on engaging the glutes on the upward movement. It feels almost effortless compared to not engaging them. It takes a conscious effort to engage them though because our seated lifestyles largely take the glutes, hip flexors and hamstrings out of use most of the time. Again, you can find many programs and exercises online to work all these muscle groups and get them back to engaging as they should.
One last thing I’ll mention. The goal here is to build strength and flexibility throughout the range of motion. Flexibility is important and it doesn’t just come from stretching. Both static (passive, where you hold a stretch in one place) and active (where you move slowly in and out of the stretch) stretching are valuable but they won’t truly build flexibility on their own. If you stretch the hamstrings for two minutes you might feel temporarily better but as soon as you sit down your muscles go right back to the position they know and are comfortable with. The only way to truly build flexibility that lasts is to work the muscles through the complete range of motion so they learn to engage in any position. This doesn’t mean massive weight when doing a deep squat but it could mean holding five or ten pounds or it could be as simple as squeezing and flexing the muscle when at the edge of the range of motion. For example the pigeon stretch is a great stretch for the glutes and you can squeeze and relax the glutes while doing the stretch and this teaches the muscles that it’s ok do work in that extended position.
So that’s what I know. What you want to know is “how did all this impact your Plantar Fasciitis?”.
Well, I’m not totally cured. My left heel in particular still bothers me, but it’s certainly better than it was a few months ago. I also still can’t do a full squat with flat heels but, again, I can squat a few inches lower than I could a few months ago. This is going to take some time.
What I can say is that I’m confident that all the exercises and stretching that I’ve started doing are having a positive impact and in the long term I believe my body will be better positioned to get me through the more “mature” part of my life. I called PF “my frenemy” in the title because, although it’s not a pleasant experience to have to continually deal with PF on an ongoing basis, without it I most likely wouldn’t have explored all the other aspects of how the lower body functions and I wouldn’t be on this journey to transition to natural shoes and foot shape, strengthen and gain flexibility in my core and legs, or learn any of the other things I’ve learned in the past few months.
My knees in particular feel better than they have in many years. For the past five or six years I hadn’t gone on a hike without wearing braces on both knees. So far this year I’ve hiked over 150 miles and have completely stopped wearing the knee braces.
Also, for years my low back has bothered me when just standing still in one spot. I could work outside or hike all day with no pain but five minutes standing in the kitchen cooking a meal or something similar and my low back would be hurting. This pain has definitely improved over the course of the past few months.
Another odd benefit of paying attention to the alignment of my knees and hips and exercising them properly is that my right foot has straightened out. For as long as I can remember my right foot has splayed out at ~15-20 degrees. I have no idea why but don’t remember ever having any injury to it that would have caused it to do that. I’ve noticed the past month or so though that it’s more correctly aligned and although it never seemed to cause a problem, it’s always kind of bugged me and it’s amazing to me that some simple exercises move it back into a more correct and symmetrical alignment without even trying.
To wrap up, what does this mean to you? Well, firstly most people probably aren’t going to jump off the couch and start working out a couple of hours a day to strengthen all these weak muscles. Realistically though there are easy things everyone can do to help the body though. Things like taking a break from sitting every twenty or thirty minutes and walking around for a few minutes, or better yet getting a standing desk and using it. It’s funny that I had a standing desk for my last ten years at work but rarely even used it to actually stand…. I do think that it’s worth doing a bit of research and building a simple exercise routine around the lower body. As little as 15 or 20 minutes every couple of days could provide lasting benefits as we age.
Hopefully this has been helpful. If nothing else it reinforced for me the things I’ve found and have been working on over the past several months.
