plantar fasciitis

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

 

DIY Friday: Plantar Fasciitis

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*Do it yourself! Every Friday we do a roundup of great posts, videos, or other resources around a theme that help people to turn their bodies from cranky to happy.*

A recent chat with the Facebook tribe started to go down the plantar fasciitis rabbit hole, so here I am dedicating a DIY Friday to it! I also have an interview coming up next week with Jae Gruenke, founder of Balanced Runner, and since so many runners struggle with plantar fasciitis it seemed like a theme was emerging.

First, what the heck is plantar fasciitis? The short version is that the plantar fascia (fascial sheet on the bottom of your foot) begins to pull away from it's attachement on the calcaneus (heel bone) and you wind up with some pretty gnarly burning heel and foot pain. In the book Born to Run* author Christopher MacDougall describes it as the runner's version of a vampire bite, because, as runner legend has it, once you're "bitten" with plantar fasciitis many feel you are never the same again. Well breathe deep because I'm here to tell you that plantar fasciitis is one of those things that I actually have in the "easy" category in my brain simply because I see it resolve so often and so readily. Which isn't to say it doesn't take some doing, but here's how:

  • Erik Dalton is a brilliant manual therapist and teacher, and this video is the clearest description I have found of what is actually going on in plantar fasciitis. The article that precedes the video also does a fanstasic job of explaining how it's not just your foot. It's never just one thing. Never, ever. But it's always helpful to be educated on the more global view of any condition, which is what this article handily does! If you are a manual therapist, there is also great content here on how you can treat it in your clients. If you are not a manual therapist, please don't go grabbing your friend's leg and shoving and shaking stuff around! It actually takes a good bit of learning in order to effectively contact fascia and to know how to appropriately work joints like he does in the video, so just mashing on your buddies is likely to cause more harm than good. The article is here, and the video is at the end of it.

 

  • Speaking of taking a global view, as Dalton mentions in his article, "Plantar fasciitis often results from lack of individuality of motion in the calf muscles due to adhesions." That is very true, and taking it a bit further, it is an issue with the whole posterior chain of fascia. Otherwise known as the "superficial back line" as defined by Tom Myers Anatomy Trains work. Here is a great image of that line. So, if you want to resolve your plantar fasciitis, give due attention to everything here along the chain as well.

superficial_back_line_copy

  • Oh look! Here's recently interviewed Sue Hitzmann of the MELT Method preaching it like she teaches it, and is also talking about plantar fasciitis as a global issue:

  • Oh wait! What do we have here!? It's Katy Bowman of Restorative Exercise talking about plantar fasciitis as a global issue (in particular those persnickity hamstrings with some data that talks about why). Hmmm, maybe it's not just about the foot...

Ok, ok, taking all this good input about how it's not just your foot and moving forward with a healing plan for yourself here's what I actually like, a lot, for treating plantar fasciitis:

Smart fascial manual therapy from either a practitioner, or you can MELT at home.

Softness! Learning how to soften your foot is a game of coaxing it to let go, not of yanking it around. I like hamstring stretches that have a fully dorsiflexed ankle (bring toes toward shin) so that you're not missing tight bits in your calves. This would look like lying on your back with a strap around the ball of your foot, and flexing at your hip to bring the foot closer to the ceiling. Though stop when you hit your own end range with the flexed ankle (rather than pointing the toe to get farther). You can also stretch standing on a slant board like this one, again, I like a soft surface to a slant board, and it is also very helpful to think about really letting all the musculature of your foot soften into is as you stretch. Think of your plantar fascia as warm, gooey silly putty that is just oozing onto the slant board. Do not hyperextend at the knee or shove your pelvis forward ofyour ankles while standing on a slant board.

Alexander Technique. Speaking of letting the musculature go, I find so many people micro grip in their feet as a result of stress, or strain and pain patterns elsewhere in the body. I love Alexander Technique as a way to learn about your own micro grips and how to find a way to let them go. I recommend working with a teacher, rather than doing this alone at home, as you will need trained eyes to point out things you have become totally blind to in your own body. Most people are amazed at how much they are subconsciously clawing at the floor with their toes. No really.

* Footnote: If you haven't read Born to Run I highly recommend it. And if you are a runner, I practicaly require it (if I could do such a thing). It has a lot of  fascinating information, particulary when it comes to the evolution of highly engineered running sneakers paralleling the evolution of highly unpleasant runner injuries, and is also a beautifully written and engaging story.

DIY Friday: Bye Bye Foot Pain!

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*Do it yourself! Every Friday we do a roundup of great posts, videos, or other resources around a theme that help people to turn their bodies from cranky to happy.*

bowman footThis DIY Friday is a review of Katy Bowman's book, Every Woman's Guide to Foot Pain Relief: The New Science of Healthy Feet. So first off, dudes, you know I love you so stop your grumbling. This still thoroughly applies to you. I believe Bowman wrote her book to the ladies mainly because we tend to make much, much poorer footwear choices for ourselves. Men are not expected to wear 3 inch heels to the office, for example. Well, depending on the office? That would be an interesting office. Sorry, I got off track, my point is, if you are a man who is struggling with foot pain, don't cheat yourself out of getting this amazing resource just because the word "woman" is front and center. Just hide it on your Kindle or something, ok? You'll have to read a few bits on the plague of high heels, but the rest is super juicy and relevant for men as well as women. And the exercises given in the book are distinctly gender neutral and fan-freaking-tastic.

But on to the book review: I frequently find in the movement and alignment world that many resources skew either too woo woo, are overly filled with academic jargon, or are just plain misinformed rookies trying to make a buck in the chronic pain field. Well Katy Bowman is not going to tell you that you can resolve your foot pain by imagining all of your chakras simultaneously blooming into daisies, nor is she going to make you read endless lists of ligaments of the feet (try saying anterior inferior tibial fibular ligament 3 times fast!), and as a scientist with a Masters in biomechanics, she's certainly no rookie. Her book hits that perfect sweet spot of being both profoundly useful, and accessible to a wide population. It also happens to answer many of the most common questions that I hear in my Rolfing® practice related to the feet. Scratch that, make that related to everything.

Yes, this book will help you with foot-specific issues like bunions, hammer toes, plantar fasciitis, corns, neuromas, etc, but it is also an enormously useful resource to help people with knee, hip, and back pain, as well as addressing  posture and I would argue a seriously important read for anyone concerned with maintaining health while aging. As Bowman writes in her book, "The function of the foot goes way beyond the scrunching of the toes and the stabilizing of the ankle. The foot is the platform for your entire body. The muscles have to be strong enough to keep your entire body moving as smoothly as possible. If I haven't clearly stated it before, the current state of your feet is a future projection of how well you will be able to move as you get older. "

Don't believe the divine Ms. Bowman and I on this one? Then try this little experiment at home: pretend your feet have suddenly turned into rigid bricks and take a walk on your pretend ultra-rigid feet. Did you just instantaneously turn into Frankenstein in your living room? Yep, that's because the mobility of your feet determines to a huge degree the mobility of all of you. You cannot move with the supple spine of a Brazilian samba dancer with Frankenstein's feet downstream from that spine. To put it into more anatomical/ less monster movie terms; joints are where we move musculoskeletally in our bodies. Imagine yourself navigating a day without movement at your knees and elbows and you get a sense for the joints=movement equation. In our feet we have thirty-three joints. In my elbow I have 3, and in my knee I have 2, but my feet have thirty-three. Those dogs were built for mobility, and that is in large part for the benefit of how that mobility translates up to the rest of you.

But enough of my yammering. If you're still reading this review it's because you want happier, healthier feet, or you want to play with how improving your foot health might impact the rest of you. Well good news! Nearly half of Katy Bowman's book is dedicated to "The Foot Gym" with exercises to help you get your feet into tip top shape. They are all very easy to do at home and can be dripped into your life in a totally sane way. You don't need to suddenly dedicate an hour a day to working on your feet to see benefit, and it doesn't require investing in ridiculous new equipment. You can find the book and give the exercises a shot here.  Needless to say, I highly recommend it.