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.
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.
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.
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.
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.
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.