When it comes to common diagnoses in the foot, plantar fasciitis is by far the celebrity of the bunch. Sure, there are a few others such as heel spurs, neuromas and stress fractures that come up frequently, but more often than not PF is the one I hear about most from athletes struggling with foot pain. It makes sense. Most everyone knows people who’ve had it in the past or who still struggle with it. The problem with diagnoses like this is that they are often overused.

Let’s look at the common symptoms for plantar fasciitis:

• Stiffness and pain with the first few steps (especially after sleeping or sitting for a period of time)… aka pain with weightbearing. Symptoms typically improve after a few steps but may persist.
• Pain that increases with activity (prolonged standing, stairs, exercise).
• Pain that improves with activity initially, but returns afterwards.

Sound familiar to what you have experienced symptom wise? Yes. Yes. And yes. Here’s the catch though. All of those symptoms can come from the intrinsic muscles of the foot as well. Here’s a visual to explain what I mean:

Each of the colored areas above are common pain locations for each of the tiny muscles in the foot. See how much overlap there is? All of these muscles are found beneath the fascia and can be injured by the very same things. Unlike the fascia which is a thick fibrous band that is stretched out with weightbearing, the intrinsics are just like every other muscle in the body. They contract and relax and play a big role in how the foot functions. They can also be overused and injured making them stiffen up and become inefficient. When that happens they stop doing their job of stabilizing the foot and leave the fascia with more and more of the workload until it essentially breaks down under the strain.

On the ATA site, we talk alot about looking at muscles and structures as chains. Everything is connected. Changes to any link in the chain will affect the rest of the chain and how it functions. Plantar fasciitis is a perfect example of this. Yes, the fascia can get injured and cause these symptoms. The bigger question is why is it getting overloaded to the point of breaking down. In that regard it’s really two injuries isn’t it? What broke down and what caused it? When it comes to overuse injuries, these two are rarely the same.

So how do I find the cause and fix it?

Typically when you google plantar fasciitis treatment, you get something like this:

• Stretch your calves.
• Wear good shoes with adequate arch support. Avoid shoes with soles that are too stiff or likewise too flexible.
• Massage the fascia (with a tennis ball, lacrosse ball, frozen water bottle, etc).
• Strengthen the intrinsic muscles by doing toe curls with a towel.
• Try a night splint or see a podiatrist to consider orthotics.
• NSAIDs
• Ice
• Rest

While those treatments may help, there’s also a good chance that you’ll find yourself staring down months and months of foot pain with no relief. So instead of focusing on those generic treatments, let’s go back to the self evaluation you just did (click here to catch up on the previous two posts on self evaluation and improving mobility on the foot ). During the evaluation we focused on three areas: 1) the forefoot (aka the toes), 2) the midfoot, and 3) the rear foot. Normal ambulation and propulsion require the coordinated use of all three.

The rearfoot

Let’s start with the rearfoot (aka the heel and how it hits the ground). This area of the foot is 100% influenced by what is going on upstream in the leg. While the foot and toes contain the small intrinsic muscles, they also contain the long tendons from the muscles located along the tibia and fibula (the lower leg). Mobility restrictions in any of these muscles will pull the tendons at their insertions in the foot.

Here’s a visual:

All of these muscles have one thing in common: they either invert or evert the foot (tilt it in or tilt it out). That means that when they are chronically tight they will pull the rearfoot with them. Once that happens, it means that with every step your foot is landing in a way that forces it to work harder and compensate. All of the tendons on the right in the picture above invert the foot. The tendon on the left, everts the foot.

To fix this, most treatment plans recommend calf stretching and night splints. This is not wrong advice! Typically the reason these long tendons/muscles get cooked in the first place is because of a tight calf (gastroc and soleus) that goes on to restrict ankle mobility. To compensate the body will typically invert or evert the foot to help make up for that loss of motion and keep us moving forward.

A better way to look at fixing the rear foot is to look at it in two parts: 1) the calf + ankle, and 2) the long muscles/tendons that invert and evert the foot. Focusing on just the calf may make big improvements but if that restriction has been going on for a long time, you can guarantee that there are restrictions in the smaller muscles as well. Ignore those and no amount of calf stretching or night splinting will make a difference as the ankle will still be limited by those long tendons and how they position the foot at heel strike.

Midfoot

From the rearfoot, let’s move onto the midfoot. As you weightbear at heel strike and come forward over the foot, the foot intrinsics spring into action. Not only do they help evenly distribute the impact, but they also stabilize the foot to create a solid platform which we then push off of. This is done by reinforcing the arches and positioning the toes. As the literal middle man, a lot can go wrong to ruin this. There can be restrictions in big toe mobility that prevent a normal pushoff and shorten the stride. Likewise, the rear foot can hit the ground out of position and the midfoot is left trying to make up for it. This doesn’t give the foot intrinsics enough time to stabilize the foot and again push off is affected.

To fix this, most treatment plans focus on foot wear and toe curls. Arch supports and orthotics are designed to help the midfoot out by reinforcing the arch for the instrinsics. In an overused foot that is beat up and stiff from the workload, this is a good thing. Don’t view it as a permanent fix, but as a way to give the midfoot some rest while you get to work loosening up the restrictions that are causing that overuse. Over the counter inserts or kinesiology tape are both cheap options to accomplish this.

The toe curls that are typically recommended are prescribed to “reinforce the arch”. Again, this is not wrong! Those intrinsics will need to be built up to restore their normal function, however, all the toe curls in the world won’t make up for muscles that have lost mobility and function.

A better way to look at fixing the midfoot is to focus on mobility first and loosening up each of those little intrinsic muscles. These muscles do far more than simply flex and extend the toes. They pull the toes together and spread them apart to provide a bigger base of support. They also work in conjuction with the long tendons above the ankle (sometimes even attaching to said tendons). Once mobility is restored, strength work will be much more effective instead of simply overworking already tired muscles even more.

Forefoot

Last but not least, let’s talk about the forefoot and the importance of getting to that big toe. In a foot that lands evenly and correctly stabilizes the midfoot, the big toe is able to push off of a stable platform and propel us forward to the next step. For this to work, the other two areas need to work properly. If they don’t, the big toe does less and less, becoming tighter and tighter from disuse. This tightness can be made worse over time as the body tries to compensate around it by either rotating the lower leg or pronating/supinating the foot.

To fix this, treatment plans typically recommend massaging the bottom of the foot and stretching the toes back. Just like the other two areas, that advice is not wrong. It’s just limited to working on one plane of movement. The toes don’t work that way. Yes, they do curl (flex) and extend, but they also abduct and adduct (move towards and away from each other). While straight massage will help elongate and stretch the fascia, it will only work some of the intrinsics. In the presence of advanced compensation, loosening up all the of the intrinsics will require a bit more work to get everything moving again.

Likewise, stretching the toes back will stretch the muscles that move them. However, to ensure that you are actually stretching the intrinsics and not just the long tendons, attention needs to be given to which joints you are stretching in the toes. Remember, there are three joints in each little toe and two joints in the big toe. Moving all of the joints at once will only get the long tendon.

Bottom line?

Don’t underestimate the role of the intrinsics in your foot pain. Mobility restrictions in these muscles are commonly misdiagnosed as plantar fasciitis, nerve entrapments/neuromas, and stress fractures. In the next post we’re going to go one by one through the intrinsics (each of the colored circles in the first picture). We’ll talk about where each one produces pain and what it’s commonly mistaken for. We’ll also talk about how to stretch/massage them.

In this post we are going to talk about ways to improve foot mobility and function based on what you found during your self evaluation. Here’s a quick preview of what the routine will look like:

• Warm up with foam roller.
• Joint mobilizations using resistance tubing or a pull up assist band.
• Stretching
• Muscle re-education + strengthening

All said and done, this is a 15 minute routine that you can do while watching tv at night. Sound good? Let’s get to it then.

1. Warm up

What you’ll need: Foam roller. The size of the roller is up to you and what you have at home. In the video, I use a smaller roller circumferance wise, but you can use a larger roller as well. If using a big roller, grab a tennis ball to work the foot and shin areas.

This part of the routine is all about warming up the muscles and increasing blood flow to the area. We’re not looking to dig deep at this point or break things up. We’re just looking to get some slack in the superficial muscles and take a quick inventory of what’s sore/tender and what’s not.

Areas to focus on: calf (gastroc + soleus), posterior tib, peroneals/shin, and bottom of foot

How long: 30 seconds – 1 minute each area. Set the timer!

2) Joint mobilizations

What you’ll need: Resistance band or pull up assist band.

In this part of the routine, we’re working on those sections of the foot we learned about in the self evaluation (forefoot, midfoot, rearfoot). Joint mobilizations are a great way to make sure that the joints in each of those areas are moving the way that they should.

The mobilizations to work on:

1. Ankle joint
   1. With the band pulling the lower leg back
      1. knee straight
      2. knee bent
   2. With the band pulling the lower leg forward
      1. knee straight
      2. knee bent
2. Midfoot
   1. tennis ball on arch under big toe
   2. tennis ball on arch uder little toe
   3. standing leg swing
3. Big Toe
   1. same set up as the ankle (knee straight) but with something to prop the big toe up. Use a broom handle or textbook (something an inch or so high). If your big toe is limited, look here for ways to modify this based on your mobility.

How many? Mobilizations are slow, controlled movements. Shoot for 3-5 reps for each area (NOT each technique listed above). For example, start with 5 reps with the band at the ankle and the knee straight, followed by 5 standing leg swings for the mid foot, and 5 reps working on the big toe. Total for any workout = 15 reps. Remember, you want these sessions to be repeatable, not to make you sore for five days.

3) Stretching

What you’ll need: a belt or strap.

Think of stretching as your way to build on what you started with the roller and joint mobilizations. When working on the foot you’ll want to focus not only on the toes and foot itself, but also above the ankle where the muscles are.

Here’s the goal:

• Toes. Once through each toe as shown in the video.
• Top of foot/shin
• gastroc + soleus
• peroneal + post tib with a strap/belt

Goal- pull to you feel a stretch and hold. 5-10 seconds for the toes. 20 seconds for the top of the foot + larger muscles.

 

4) Muscle Re-Education/Balance/Strength

If you found mobility limitations during your self evaluation, chances are those limitations have been there for a LONG time. That means your body has gotten really good at compensating. To truly make changes, mobility is only a part of the solution. You then need to teach yourself to get back to using the ball of your foot evenly and pushing off of it. It’s not as simple as loosening things up and then voila! Everything goes back to normal.

In the progression below (and in the video), we’re working on restoring movement patterns so you weightbear normally through the foot to get to that strong push off. Think of it as levels. Master one, and then you can move to the next. In terms of sessions? Shoot for 5 minutes at whatever level you’re at.

1. Arch reinforce. Practice being able to pull up arch without using your toes. Once the foot is ready, add in tightening up your core and glutes to stand up tall.
2. Add in forward lean at ankles to increase weightbearing on ball of foot. Only lean forward as far as you can hold your feet in position.
3. Controlled move up onto toes with even weightbearing along ball of foot. Remember each level builds on the last. Start with pulling the arch up and getting your posture set, then lean forward onto ball of foot and then move up onto toes in slow, controlled move.
4. Single foot on toes.
5. Marching in place (alternating between single stance on toes). Knees should be straight but not locked out. Start slow and build speed.
6. Jump rope/jumping jacks. Focus on building time. You want to have even pressure along ball of foot. Jump. Land and immediately push back up with knees straight.

Bonus round:

For some of you, the above techniques won’t be enough (especially if things have been stuck in those tight positions for a long time). If that’s the case, you’re still going to want to start out with the layout above. It’s a good jumping off point to start getting some slack in those muscles.

Here’s what you can add in to go after those muscles on a deeper level:

1. Cross friction
   1. foot
   2. shin
   3. calf
2. Tennis ball mobilizations
   1. foot
   2. shin
   3. calf (gastroc + soleus)
   4. post tib

Alright! That’s it for now. If have questions about your foot and what you’re finding? Drop me an email or comment below.

Let’s face it. As endurance athletes, our injuries are rarely traumatic. They gradually and slowly build over time. Sure they may “sneak up” on us when they do strike, but the bad mechanics and mobility restrictions that led to them have been long time training partners by then. The whole goal of these next few posts is to give you a reason to actually stop and look at your body, joint by joint. I think many of you will be surprised just how much wear and tear the endurance lifestyle truly puts on our bodies.

Think of it as a cycle:

• Overworked muscles stiffen up. This can happen for a variety of reasons. Assuming all is normal in terms of mobility, strength and technique, it could just be overuse without sufficient recovery. Poor mobility? Strength? Technique? All of those things will simply expedite the process. When a muscle is overworked, it stiffens up to try and protect itself, plain and simple. Things like dehydration, nutrition, work position can all affect this even more.
• Chronically tight muscles lead to tight joints. Mobility restrictions left unchecked will eventually get stuck that way. Stuck muscles lose their ability to contract fully and move the joint they support. This will carryover until that joint gets stuck too as it’s not moving through it’s full motion either.
• Mobility restrictions (whether muscle, joint, or both) = impaired strength + function. All the strengthening in the world won’t make a difference to a muscle or joint that doesn’t move like it should. When dealing with aches or outright injuries, look at what moves the way it should and more importantly what does not. Fixing that will be the true fix, not focusing on what hurts and nothing else. The legs are chains. Is it more likely that link broke because it was faulty or because the rest of the chain was overloading it instead of sharing the work.
• In the face of mobility restrictions, the body will compensate until it finds a way to continue moving forward. This is where the trouble really starts as the smaller muscles get more work than they can handle and finally break down. If you’ve ever been slapped with an injury that wouldn’t go away or injury after injury, it’s likely because you’re compensating. To truly heal, not only do you need to fix the injury but you need to reverse the compensation and relearn movement patterns to shift the workload back where it belongs.

For those of you bringing old injuries and past surgeries to the table? This is even more true. Most of us are in such a rush to get back that we only get most of the way there and then take off with training again. Sound familiar? I know I’ve been guilty of it myself in the past and while I lucked out initially, it did come back to bite me.

So how do you break that cycle?

The first step is knowing what normal looks like. To do that, we’re going to go joint by joint and show you how to self evaluate your own mobility. After that, we’ll go through a little treatment routine to help you work on that joint. Sound good? Okay then. Kick those shoes and socks off because we’re starting today with the feet.

Self Evaluation

Have you ever googled “foot anatomy”? If you have, you were probably hit with a million pictures each containing no less than a hundred arrows to bones, muscles and ligaments. Let’s simplify that into something a little more manageable.

• The lower leg bones are the tibia and fibula. Think of them like a big wrench in shape. The outside part (the fibula) is slightly longer than the inside part (the tibia).

• The “wrench” sits on top of a ball- the talus. When people mention things like subtalar joint? This is what they’re talking to. It’s not actually a “ball” in shape, but it does have multiple bony attachments and plays a big role in how the midfoot and rearfoot interact with each other.
• The ball then attaches to the tarsal bones (the midfoot) and the heel bone (calcaneous and rearfoot).
• The midfoot attaches to the long bones that go to each toe (the metatarsals).
• The long toe bones attach to the little toe bones that bend and straighten each toe (the phalanges).
• The metatarsals and the phalanges make up the forefoot.

The structures responsible for moving all of those bones come in two forms:

1) Long tendons coming from muscles up above the ankle. This includes the posterior tibialis, FHL (flexor hallicus longus), FDL (flexor digitorum longus), the long peroneal muscle on the outside of the lower leg, and on top of the foot the anterior tibialis and extensor digitorum longus.

2) Small muscles in the foot itself like these (note, these are only a few. There are actually four layers of little muscles.

3) Also of note in the bottom of the foot is the plantar fascia.If you’re looking for the sesamoid bones, those are in the tendons right under the 1st MTP joint.

When we look at all of these structures, let’s focus on three parts.

1. The heel bone/calcaneous (rearfoot)
2. The midfoot
3. The toes/forefoot.

During normal locomotion, impact is absorbed by the rearfoot first and then transmitted through the mid and forefoot. This is achieved by the midfoot progressively loading the arch and tarsal bones to create a stable platform at the ball of the foot for the big toe to push off and propel you forward. In other words, it’s a team effort so as we move through this self evaluation, let’s focus on the three areas and what might throw things out of whack.

The Rear Foot

An easy way to eyeball what’s going on is to have someone look at your feet from behind. Start with the achilles tendon and see what direction it’s moving in. To set up, start with your feet hip width apart and march in place for a moment before stopping. Then have someone take a picture of both feet so you can see for yourself.

Does it go straight up and down like the first picture on the left? Or is it moving up in an angled direction like the second two pictures? To help with the visual, use the outside of the foot as a parallel line. As you can see with how I’m standing when I move into those positions I’m either all the way on the outer edge of my foot, or I’m all the way in on my inside arch like the picture furthest to the right. Both of these positions make it impossible for the midfoot to succeed in creating that stable platform to get to the big toe.

The Mid Foot

Once you’ve established the alignment of the rearfoot, the next step is seeing what the midfoot is doing in response. It’s either doing the same thing, or it’s trying to compensate.

To measure the midfoot, let’s use the pressure under the ball of the foot. It should be even throughout (shown by the parallel purple line in the first picture on the left). In the middle picture, there is more pressure through the big toe and in the last picture on the right there is more under the little toe (compare the purple lines to the horizontal white line). As a visual alternative, look down at your feet while you’re standing there. Is there a space between all of your toes or are they bunched up on one side? Can you easily raise up onto your toes with even pressure through the ball of your foot or do you instantly deviate to one side? Both are signs that the midfoot is moving too much/too little.

If your calcaneous was inverted or everted what did you find? Was the midfoot moving in the same direction? For example if everted/pronated, was your arch flat (same direction) or did it still have a space (opposite direction)? If inverted/supinated, was the arch off the ground (same direction) or was your big toe flat on the floor? (opposite direction)

(Note** In the event that you’re finding that things may be off but you aren’t sure or you want a professional to take a look (especially if you’ve been battling foot problems)… DO IT. Get on google and find out who in your area does gait analysis/biomechanic evaluations. It may be a local coaching group/gym or it may be a local medical professional (ortho, PT, Chiro, etc).  Everyone specializes a little differently and these days everyone has a website. If you can’t tell, pick up the phone and start calling places! )

Forefoot

Self Evaluation- what did you find?

Here is a video explaining some of the things you may have noticed during your self eval and a little explanation behind why I look at these things when evaluating my patients.

Key points

• Look at the foot as three moving parts: 1) the heel 2) the midfoot and 3) the big toe. Each of those parts will play a huge role in how the foot absorbs and transmits impact to the rest of the body.
• If one of those parts isn’t moving the way that it should, don’t stop there. How is the rest of the foot compensating?
• Pay attention to callus patterns! Are they bigger than they should be or in a strange spot?

Find something unexpected? Or have no idea what to make of something?

Take pictures and email them to me! Or post a comment below.

This series is all about teaching you what your mobility looks like but also how to make improvements if you find that things aren’t moving the way that they should. In the next installment we tackle the latter.

Click here to continue on to our next post “How Improve Foot Mobility”

Of all the hard to reach/get to areas in the legs, I think the inner hamstring/adductor junction is one of the hardest. With a roller, you have to contort into all kinds of weird positions or use the very edge of it which is tough to do depending on your roller firmness. With the various sticks, it’s easy to reach but hard to get even pressure. Those are just the superficial techniques. Deeper work like cross friction or trigger point release is all but impossible. That’s why the R8 wins big points in my book as this area is such a common problem spot for endurance athletes.

When you look at the legs, the muscles are small down in the feet and ankles and get bigger as you move up the leg to the thighs and hips. That design makes for an efficient transfer of the workload up the leg. The problem is that when something stops that workload from getting to the biggest muscle of all (the glutes!), smaller muscles are left to try and pick up the slack. When hip extension is limited, propulsion coming from the glutes is diminished and even nonexistent. One of the bodies common ways to make up for this is to recruit the inner hamstrings + adductors to act as hip extensors. They’re already engaged as you’re body moves forward over the stance leg after all. The problem with this is that they aren’t meant to work that hard and they can get overworked easily.

Over time, if that compensation pattern continues, the entire femur can rotate in to try to help those struggling muscles out. Now you’re looking at full leg involvement as the lower leg will also have to compensate. If you’re someone who has chronic outer quad pain or problems with pain at the pes anserine. This is an area you need to work on!

When you look at the R8, you have up to 8 wheels to use (4 on each side). In the video below you’ll see that I use those wheels in three varieties.

#1- All four wheels, even pressure on both sides. I think of this is as my warm up to flush the area out and start narrowing down where the sorest and tightest spots are. Use both sides evenly! If you have problems in that inner hamstring area, you can bet your outer quads will be sore too. That’s one of the great things about the R8. It makes it impossible to forget to work the OPPOSITE side as well as the painful side.

#2 Two wheels, one side only. For this technique, I anchor down one hand and then use the middle two wheels to walk a small problem area. There won’t be much movement here and that’s okay. You don’t want that movement. You just want the ability to add tension and get to the deeper layers of the muscle. With this handhold you can work in two directions: 1) in the same direction as the muscles and 2) perpendicular to them in more of a cross friction technique.

#3 One wheel. You can use them on both sides, or anchor one side down like above. This is for specific sore spots. Same rules as above in terms of which directions you can work in. For this kind of release, relax the muscles and let those wheels sink before adding more tension. This will make for a much deeper release!

Here’s a video demo to walk you through palpation tips and the techniques themselves:

 

Thanks and fire away with any questions in the comments sections!