Plantar Fasciitis From Leg Length Discrepancy

167794107_e8a7b59b0d_zI admit it, I've spent a long time being overconfident about my ability to easily and quickly resolve plantar fasciitis (a painful condition of the foot caused by the plantarfascia pulling away from the heel bone). Because I work in a fascial field as a Rolfer® I've had a lot of people contact me for help with plantar fasciitis over the years and most of the time I have been able to easily help them. I've written about that approach here, and, in fact, when plantar fasciitis results from a short or gluey posterior chain of tissue (i.e. the calves, hamstrings, gluteals, and low back and spinal muscles), it does in fact respond very readily to to this approach. Tight fascia = loosen that fascia. Easy, right?

Fortunately there seems to be some divine order that says when a person (in this case, me) gets too assured of something (in this case via a formulaic way of thinking about the body), some wonderful opportunity to see the body freshly as the complex unified organism that it is presents itself.

The first time I had a plantar fasciitis client fail to respond was, as these things go, with a dear friend. And while I would love to pretend that I'm an enlightened being, when a friend in pain comes to me I now have my normal desire to help out layered with an egoic desire to be the one who "fixes" them. Ha ha ha! Silly mortal! You cannot fix people! Yes, this whole "be the one who fixes people" drive is usually a set up for a fall.

This was also the first time I had encountered plantar fasciitis as a result of a leg length discrepancy. Or at least it was the first time I became aware of that courtesy of the conversations that she and I, and the wonderful physical therapist who I had referred her to, had as things resolved. Since that time I have met with a handful of other people who were dealing with the same thing and so I wanted to write about it here to save some people the months and years of trying to get better to no avail.

Here's the important detail: if someone is struggling with plantar fasciitis chronically and they are not responding to normal treatment (i.e. smart manual therapy and movement that addresses the fascial and functional movement problems), there is a good chance that they are dealing with a leg length problem, and until that gets resolved the pain is going exactly no where. 

So first let's talk leg length discrepancies. They vary quite a lot from incredibly subtle to quite obvious. I write this because most people assume that if they have one longer leg that it would be glaringly obvious and they would be aware of it. However if it is the subtle variety (which also happens to be the most common variety) it usually goes unnoticed. Even teeny discrepancies can cause people a lot of grief.

Leg length discrepancies come in two flavors- either a bone length (structural) difference or an alignment and soft tissue (functional) difference. Because everything in our bodies works in sync with one another, sometimes differentiating between the two types can feel like splitting hairs. In fact, the bone length version is traditionally called a "structural" difference, and the soft tissue version is traditionally called the "functional" difference, but I can't really bring myself to continue differentiating them that way here since, well, whether it is bone or soft tissue ultimately you are dealing with a structural and a functional issue no matter what. Everything has its structural and functional components and I don't know why "structural" should refer to just the hardest bits, i.e. the bones. Then again I'm biased. I write a blog with the word fascia in the title. I digress...

Semanitcs aside, here is why it is important to know if you are dealing with primarily a bone length difference or primarily an alignment/soft tissue issue* because depending on which flavor you have, your treatment will be quite different.

A bone length difference happens when either your femur or your tibia is literally shorter on one side than another. This is the more rare scenario and will happen most commonly if you've had a break in one of those bones (particularly if that break happened when you were still growing), or if you've had a joint replacement since that requires actually removing and replacing part of both of those bones in the case of a knee replacement, and just the femur in the case of a hip replacement.

This is important to know because you cannot make your bones longer now. So while I'm not typically an orthotics kind of girl, if you have one leg that is longer than another due to a bone length discrepancy you are going to have to work with someone who can make a very thoughtful lift for you to wear. This will even out your leg length problem and start you on the road to healing.

I say "very thoughtful" because you can't just go to the pharmacy and pick up something Dr. Scholl's produced for the masses. It needs to remedy the situation with precision and not be the cause of new trouble. Think of when you get dental work; If your dentist filled a cavity and left one tooth significantly longer than the other teeth- youch! It will hurt a lot when you try to bite down. And if one tooth is left shorter than the other teeth, your jaw strains to make your bite meet causing a different kind of discomfort that is more joint-centric (TMJ) and less tooth-centric. Your feet become how you "bite down" on the ground as you walk and stand, and a mismatched pair of legs will have repercussions into your ankles, knees, hips, pelvis, spine, and head. Not to mention that persnickety plantar fasciitis.

Even if it is determined that you have a bone length difference, you have still spent a lot of years (usually) walking around on an uneven foundation, so you'll still need some thoughtful bodywork, but sadly thoughtful bodywork in the absence of a lift is not going to stick with you and the pain will return. So in the case of a bone length difference: lift first, bodywork next. And you may need to tweak the lift as your soft tissue compensations resolve.

An alignment issue happens when you have movement patterns, accidents, injuries, or surgeries that cause your soft tissue to become misaligned. This can take many forms and so is less easy to give a bullet point list. It is also more common however, so here are a few examples to give you an idea of what I mean (note the bullet points even though I said I couldn't do that. Maddening, right?):

  • You spent years competing in high jump and so always jumped off one leg, causing one psoas and quadratus lumborum to hike up. 
  • You spent years carrying everything (kids, groceries, big purse, etc) on one side, causing one psoas and quadratus lumborum to hike up.
  • You had an abdominal surgery which caused some scar tissue internally causing one psoas and quadratus lumborum to hike up.
  • You have scoliosis which causes one psoas and quadratus lumborum to hike up.

Ok now I'm just being annoying. I have a rally cry here and in my practice which is, "It's never just one thing!" and that is true. And it is also never just two things like I oh so tidily made it in the bullet points above. It is always the synergy of how everything comes together and what compensatory patterns  emerge to try and help you out. However, if you are dealing with a leg length discrepancy you can be sure that the psoas and quadratus lumborum are a big part of that dance. When they shorten on one side they have the effect not only of creating pelvic rotations and imbalances, but also of making the leg seem to tuck itself up into the pelvis more.

So if you have plantar fasciitis that has not resolved with manual therapy and you also have sacroiliac pain, low back pain, tight IT bands, piriformis syndrome, lateral knee pain, or gait problems (i.e. limping, or a strongly externally rotated leg), you may very well be dealing with an underlying leg length discrepancy which needs to be addressed in order for the pain to resolve. However, if the main "buddies" that come with your plantar fasciitis are tight hamstrings, calves, and gluteals, and you just plain have a tendency to overexert the hell out of yourself (hellooooo ultra marathoners!) you will likely do quite well with and get some long term resolution with manual and movement therapy alone.

And if you think you might fit this description and are wondering which side you are longer on- the pain usually starts on the longer leg.

* Yes, I got all uppity and italicized with the "primarily" because if you have a bone length difference you can be sure that you will also have an alignment issue. Also "Soft Tissue Issue" is a great name for a band and someone should steal that. 

Research references: http://www.japmaonline.org/content/100/6/452.abstract

photo by Iacovos Constantino