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Plantar fasciitis: Treatment options to consider
when not getting relief with NSAIDs, cortisone
injections, custom made orthotics, night splints,
foam rollers, or surgery. My goal for you is that
you will be up and running again real soon without
pain. Oh, and lets avoid surgery all together. It
rarely works and has all kinds of risks associated
with it.
Please note that when you see P.F. it refers to
plantar fasciitis for the purpose of this ebook.
Brian McKay, DC
Core Health Darien
555 Post Road
Darien, CT 06820
203-656-3636
[email protected]
Introduction
Hello, my name is Brian McKay. I am a
chiropractor in Darien, CT with over 20 years of
clinical practice. You may be wondering why
anyone would see a chiropractor for plantar
fasciitis. I would think the same thing so let me
explain how I got started treating P.F.
I studied a soft tissue technique called Graston.
It was started by an English osteopath many years
ago. Dr. Graston tried to bring this soft tissue
technique to physical therapists in the U.S. but
failed to gain traction. Instead of giving up on his
technique for dealing with chronic soft tissue
injuries he put it in the direction of chiropractors.
Not every chiropractor really embraces the soft
tissue component of chronic injuries. I would like
to think that the more enlightened chiropractors
truly understand the relationship between muscle,
bone and connective tissue.
I firmly believe in understanding the relationship
between bone, muscle and connective tissue leads
to better treatment outcomes. You cannot have
bone involvement without muscle involvement.
They are all interrelated and need to be addressed
together to resolve chronic repetitive sprain strain
injuries such as P.F.
I was treating a patient for a condition commonly
referred to as tennis elbow. I had studied Graston
and had been getting some real solid results with
tennis elbow cases. This same patient who got
incredible results for her tennis elbow asked me
to do the same thing for her troubling P.F. We had
nothing to lose. The treatments were so
successful that her doctor who had been treating
her foot asked to meet with me to discuss the
treatments.
You may not be aware of this but there is a huge
wall between chiropractors and real doctors.
Breaking down this barrier that still exists today is
a huge achievement unto itself. So I was more than
happy to meet with him. I explained the treatment
which he seemed to understand. He was then
happy to tell his physician friends and his patients'
that they had to see me when they had difficult
cases of P.F.
When cases resolve with NSAIDs or cortisone the
patients never get to me. Why would they if they
got better? My experience has been with the
tougher cases that have tried many things that
failed. My experience grew with each new case that
came in to see me. I got better and started adding
additional therapies to the underlying Graston
technique.
There is no greater feeling in the world than
getting results for tough cases. It makes going to
work like not working at all. I really enjoy helping
people.
Truth be told that not all cases get better with my
particular treatment for P.F. I do my best to weed
these people out as quickly as possible. I only take
the cases where I am certain I can make a
difference. I hope this information makes a
difference for you.
Dr. Brian McKay
Page 1
Plantar fasciitis is a painful condition that
irritates the plantar (bottom) surface of the foot.
Typically, it affects only one side. I have seen both
sides have it, but it is far less common to have it
bilaterally. The diagnosis is fairly easy to derive
and 99% of the patients being referred here
already have a diagnosis from their referring
physician.
The pain is unbearable and can prevent the
person from doing many activities that are weight
bearing. There are many nerve endings in the feet
so the pain in the bottom of the foot can be quite
intense. Many people have to give up their sports
when conventional therapy fails to help.
Standing is a problem so people with P.F. will
need special footwear just to get through the day,
especially if they work on their feet. Most athletes
have to curtail their activities around P.F.
The pain is often unbearable and it prevents
much activity. These people need help. There are
many therapies that sometimes offer minimal results.
The latest craze is foam rollers to knead the
tissue and smooth it out. This is of some value
when used throughout the lower extremity.
Ice can stop pain but only for so long. Anti-inflamatories
are often used with varying degrees
of success. The rationale is that if inflammation
reduction brings down the tissue swelling there
should be a corresponding decrease in pain. This
view is rather shortsighted because it does not
consider the factors that caused the inflammation
to begin with.
Custom-made orthotics are very helpful at times.
They provide needed support to stabilize the foot.
I usually recommend that people try store bought
orthotics first. Very often they do the trick and
cost a whole lot less. Most people will require
additional support for their feet as the aging
process takes place.
Cortisone injections I find to be of little value
and a last ditch attempt at fixing the pain
associated with P.F. Cortisone injections are super
powerful anti-inflammatory that suppress
everything including your immune system. You can
only have so many cortisone injections before you
do real damage to the joints. Only in extreme
cases is this recommended and should be used
judiciously to say the least.
Let's try to explain the basic concept of what I
feel is the underlying cause of plantar fasciitis. The
tissue in the foot becomes bogged down as a
result of muscle imbalances as far up as the
stomach muscles. The connective tissue of the foot
is very sensitive because it is nerve rich. The brain
relies on sensory input from the feet for balance
purposes. The unusually large number of nerve
fibers contribute to the intensity of the pain. It is
like having several alarms going off all at once
making even more noise. To you this is pain but
think of pain as an alarm telling you that
something is wrong.
Understanding the Adhesion and its Role in P.F.
I have often referred to plantar fasciitis tissue as
bacon after it has been cooked when it needs to be
like precooked bacon. Try to picture the
difference and relate it to living tissue to get an
understanding what adhesions look like.
An adhesion is a small nodule that forms in the
fascial plane when stress is placed on the tissue
over and over again. The more stress, the more the
adhesions form. The adhesions form in the fascia
hindering free movement. Fascia is connective
tissue that wraps around the outside of bone and
muscle. Fascia has its own nerve supply making it
sensitive. Adhesions restrict motion.
The small nodules prevent the muscles from
moving freely without friction. I want you to
imagine two plastic baggies filled with hamburger
meat. Rub the two bags together. They should glide
against each
other nice and smooth. There is no friction and it
seems effortless. This is how different muscle
groups should move when in close proximity to
each other.
Now when the fascia becomes dysfunctional,
more adhesions form. Little tiny nodules that
cause friction form in the surface of the fascial
plane. There is much pain as the number of
adhesions increase. Blood flow becomes
diminished and the tissue becomes stagnant . The
shape of the covering of the muscle changes as
more stress is placed on the dysfunctional tissue.
The muscle stops working efficiently.
If you have ever seen someone's arm after a
cast has been removed you will notice changes in
the muscle versus the healthy arm. Fascial
restriction will do the same thing but is not as
obvious to the naked eye.
The more dysfunctional the muscle becomes the
more painful it gets. The adhesions then act as a
choking point preventing normal muscle function.
Preventing the removal of toxins with normal
venous return and is some cases even restrict
lymphatics. This causes the muscle to become
engorged with lactic acid and muscle waste products
which further restricts healthy muscle movement.
More pain ensues.
Picture the plastic baggy becoming more like
bubble wrap. As the bubble wrap drags across
more bubble wrap there is increased surface
friction. More friction equals more pain. More
adhesions then form.
My immediate job is to identify these adhesions
and start removing then using Graston. This is not
a fun procedure, but it is highly effective.
Since your foot is where the pain is, this is the
most logical place to start. The adhesions are easy to
find because your patient will become very
apprehensive and
pull away as soon as you land on a painful
adhesion. Their eyes will also tell you a lot about
how much pain they are in. Usually the patient's
eyes will widen when you get near a bad spot
loaded with adhesions.
The worst pain is often found past the heel in
the arch of the foot. This tissue is called the
Plantar Aponeurosis and it covers many muscles,
particularly Flex or Digitorum Breves, Flexor
Hallicus Longus and Abductor Hallicus. These are
all hotbeds for adhesions.
The dysfuncion starts higher in the kinetic
chain. So we must examine the whole chain to
really understand and fix this problem of Plantar
fasciitis.
Here is where I need to get radical and turn this
on its head. From here you need to understand
that muscles in your torso affect your leg and foot.
They are connected. Any exam that leaves out part
of the whole kinetic chain will result in partial
outcomes. You want results right?
The Abdomen
The trunk Flexor Iliopsoas and
iliacus are in your abdomen. They
help flex the trunk at the hip. So if
you were to do a crunch you
would be activating these muscles. The Psoas is a
powerful muscle that flexes the thigh, bringing the
knee up and forward. Lie on your back and make
cycling movements and you will understand what
the psoas does.
It has been my experience that the trunk flexors
are often inhibited on the side of P.F. Almost to
say that the body recognizes an imbalance and
tightens down one side of the trunk to add
stability where it is lacking. Think of it as a
protective mechanism that prevents you from
doing further damage to yourself. This does result
in less movement. The examiner must consider the
trunk flexor muscles when trying to understand
P.F.
The Upper Thigh front portion.
The Tensor Fascia Lata (TFL) is a
muscle that inserts into the strong
band of connective tissue that runs
down the side of the leg called
Iliotibal band. Notice a connection
from the iliopsoas a muscle that
inserts onto the ilium and the
ilioitibial band which has its origin
on the ilium and inserts onto the fibula below the
knee. It is thick and very deep. The TFL is a hot
bed for painful adhesions that go unnoticed until
you deeply palpate the tissue.
The Sartorius muscle starts at the Ilium
laterally and goes across the the front thigh
to below the knee on the inside of the leg. I
have found a number of adhesions in the
area closest to the inside of the knee on my P.F.
patients.
We need to release the the overall tension in
the kinetic chain where it originates. To locate this
on yourself feel the inside of your knee and press.
This muscle is more superficial so you should be
right on it when palpating the area. If it hurts you
may have adhesions here that can cause P.F. all
the way down the foot.
Let's go down to the front part of the lower leg.
You will find more muscles with adhesions when
you start looking deeper. By now you should be
adept at locating adhesions.
Press hard and feel for pain. If
you reach down the outside of
your leg below the knee there
are long muscles called the
Peroneus longus and brevis that go down the
outside of the leg into the sole or Plantar surface
of the foot. These are big hotbeds for adhesions.
It also can shed some light on why the foot can
hurt so bad from a muscle in a different location.
The adhesions will be found higher up
closer to the knee and they really add complexity
to P.F.
I feel that addressing these areas outside the
box are a major reason I am able to deliver solid
results for my patients. It really is not crucial for
you to remember the names of these muscles. Just
make sure that the doctor examining you checks
for them.
We are still on the front of the leg. The next
big muscle to pay close attention to is the tibialias
Anterior. This muscle can be
found closer to the front of the
tibia, which is the larger lower
leg bone towards the inside of
the leg. Its job is to invert the
foot bringing the heel down
and toes up. Quite often I find
a nest of painful adhesions here. Fortunately
Graston does a wonderful job of fixing them.
The next spot on the lower front leg to pay
attention to is the Extensor Digitorum Longus.
This muscle attaches to the four outer toes. If you
palpate closer to the middle of the leg between the
Tibialis Anterior and the Peroneus you will find the
Extensor Digitorum.
The Tibialis and Extensor Digitorum are in the
front of the leg and insert on the
top of the foot. This action allows
the foot to dorsiflex, an
important action in the ankle. The
more important the activity of the
muscle the more likely it will be to
have adhesions present.
Let's turn you over and examine the calf
muscles. The calf muscles are real close to the
perceived problem point.
These muscles are the more obvious ones
related to P.F. since they are so close to the heel.
Almost always there is also involvement of the
Achilles due to its insertion point on the superior
aspect of the calcaneus at the calcaneal tuberosity.
Many professional athletes have Achilles problems
that sideline them for extended periods. It would
be in their best interests to go up the kinetic chain
for answers as to why their Achilles are involved.
The first muscle of the lower posterior leg to
consider is the Gastrocnemius. This is very big and
close to the surface of the calf. It has two heads
that join to form the Achilles tendon. If you look
you will almost always find adhesions all over the
gastrocnemius on both sides. When I first got into
treating p.f. area I concentrated on the most
was the Gastrocnemius. I got really good results
back then. I am now amazed that I keep finding
more areas to examine the more I
study this fascinating topic. Lucky
for me the results keep getting
better as well.
The Soleus muscle goes under
the Gastrocnemius. It is a powerful muscle that
aids in balance while standing. What is
important here is because it is nerve rich, you
have more potential pain. It can be found close to
the ankle on both sides. Find these adhesions and
reduce them with Graston.
The bottom of the foot will hold many tender
painful adhesions needing work. Let's look at the
major muscle groups that offer the fastest
response when working with the plantar surface of
the foot.
Flexor Digitorum Brevis flexes the
lateral four toes and can be quite
painful especially when applying the
Graston technique. Next to this
hotspot is the Flexor hallucis longus
that goes to the big toe. Overlying
these muscle groups is a layer of
fascia called the Plantar
Aponeurosis. It is thick and loaded
with adhesions.
While I have not pointed out every single muscle
that affects P.F. I have certainly told you about the
muscles most often involved. An exam should
involve these at a minimum. Do not be afraid to
ask your physician about them. You could be
doing them a favor by educating them about P.F.
Let's move on how we treat these painful
adhesions. First we apply a local cleansing agent
with anti-bacterial properties. Starting with the
area furthest away that you have determined has
adhesions you will apply a topical lubricant of your
own choosing. A thin layer will do. Take a Graston
tool that best suits the affected muscle and apply a
scraping motion in several different directions.
Stay on the muscle for about five minutes per area.
You must do this up to the tolerance of your
patient. Some patients will be more sensitive than
others. Try to understand that the tissue is nerve
rich and that this treatment can and will be very
painful. If you hurt them too much they may not
return and they will not get the help that this
treatment can deliver.
Go down the leg, repeating the cleansing process
and application of topical lubricant until you get
to the sole of the foot. This should take about half an
hour.
I have found it helpful to then apply Class IV
Cold Laser Therapy to the affected areas. The cold
laser acts to start the cellular healing process.
Light is energy. Laser light
provides packets of photon
light energy to ramp up the
tissue healing after the
traumatic Graston procedure
to rid the muscle of the
dysmorphic adhesions.
The Class IV Laser is a highly effective way
to stimulate cellular regrowth. I recommend that it
be used every time a Graston procedure is
performed. It speeds up the healing time and does
a more efficient job than just doing Graston alone.
The laser light acts like photosynthesis allowing
the tissue to grow back normally.
I want to add a final piece to the P.F. puzzle.
The affected leg in most cases has a bone
component that needs explaining from a
chiropractic vantage point.
The P.F. foot is associated with what we call the
long leg syndrome. What happens in this
case is that the leg moves inferior from the hip
joint. Therefore that leg hits the ground harder
because it is closer to the ground when upright.
While lying face down it is clearly evident if one
leg is shorter then the other. Most of the cases
I have treated have this on the side of P.F.
I would strongly urge you to get checked out by a
chiropractor on a regular basis. If you
leave this piece of the puzzle out I think P.F. Can
come raging back in a few years. Because your
foundation is not solid and the muscles in the
chain will have to work harder to accommodate the
imbalance.
The A.S.I.S. is the attachment site for the Psoas
and iliacus muscles as well as the origin of the
sartorius and tensor fascia lata so there is a big tie
in. In the absence of chiropractic care a self
remedy would be to lie face down on the floor and
to place a sneaker under the P.F. side facing
towards the opposite hip. This will ease the pelvis
back into a more anatomical efficient position
lessening the length of the Longer p.f. leg.
Let's Review. If you think you have P.F. you
should try an over-the- counter hard orthotic. I
suggest Superfeet which can be purchased at
running stores, athletic departments or online.
Custom made orthotics should come from a
podiatrist. I can fit people for orthotics but prefer
to get the Podiatrist's opinion. It is really their
specialty and I feel they do a more thorough job
when fitting them properly.
Reasons for orthotics are many. As we age the
arch breaks down. If you want to stay active
you will need arch support at some time or
another. Getting it before you really need it will
keep you upright longer and with less pain.
Your footwear should be supportive most of the
time. Sandals and high heels are okay once in a
while. When purchasing shoes seek a good store
that has knowledgeable salespeople who can guide
you. You would be better served by purchasing
one good pair than several inexpensive pairs.
Invest in yourself. You will save money over time
with less doctors visits. Then when you do make it
to the golden years you will be running circles
around your peers.
I always feel like a chiropractic heretic when I
harp on shoes and supports but they help form a
foundation. The more solid your foundation is the
less you will need my care. So this advice is not
self-serving, it is just good advice.
It is hard to Graston on yourself. You might be
able to get the front of the legs and the top and
side of the thighs but it just is not the same. I will
give my email address and I would be happy to
recommend a practitioner close to you.
Your body is mechanical and needs work as we
age and stay active. Do you stop changing your
car's oil when the odometer hits 85,000 miles? A
common sense approach to staying in the game
should include some ongoing chiropractic care
with your exercise program. I really do not see too
many people with P.F. who are not active. It is a curse
you will have to deal with but your life will be
longer and fuller with exercise and activity.
I would like to thank you for reading this ebook.
I hope you have learned from my experience and
that it helps you find relief from Plantar Fasciitis.
Dr.Brian McKay
Darien, CT
Give the night splint the boot !
The End
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