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: Too Tight and Too Loose Ankles

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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.*

People are frequently plagued by seemingly disparate, but often intertwined, problems with their ankles. More specifically the curse of the too tight ankle, and the curse of the too loose ankle.

Too tight ankles are a pain in the butt for things like doing squats, and for walking and running in ways that won't agitate your spine (because you need ankle mobility for normal biomechanical movement of the spine- true story!).

Too loose ankles are known by their partner in crime: the constantly repeating ankle sprain and the nagging sense that you can't trust bearing weight to the all important weight bearing ankle.

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So whether you're a tight-ankled person or a chronic sprainer- or a combo platter of both as your ankle tries to stabilize and find a happy home base- here are some excellent resources for your self care needs:

  • Did that leave you hungry for more!? Did you totally fall in love with that Wheelies in the Park move!? I thought so. Here Katy talks shop re: ankles with more precision, and also includes the inspiration for the wheelies move, a video by the brilliant Jill Miller. (Seriously the Wheelies in the Park is one of my new favorite things and has my neighbors worried, yet again, about my sanity as I play with them in my yard).
  • Lastly, Jill makes another ankle-relevant cameo, but this time with Kelly Starrett on MobilityWOD. He talks about the important piece of the fibular head being able to "get out of the way" so the ankle can move. I see this particular stuck-ness a lot in my practice. And Jill, the chocolate to his peanut butter, comes to the rescue with a therapy ball move to mobilize that. Do not do this with anything harder than a therapy ball. Please and thank you.

Go forth and have happy ankles.

photo by Generation X-Ray 

Let Freedom Ring: A Knee Recovery Story

christine_head_shot4aWe're kicking off a new series here at The FFF; The Let Freedom Ring series! I'll be talking to people who have healed from a wide variety of injuries and chronic pain conditions to better spread the hope around (you can get better!!) In this first interview of the series I talk with Yoga Tune Up® teacher Christine Jablonski about her nasty knee injury, the repercussions that it had 15 years after the injury, and how she's managed to not only keep all her own parts (knee replacements are unpleasant people), but to become even more functional and mobile over time. Check out the video to hear her story, and stay tuned to this week's DIY Friday as Christine will be back with some videos on how you can work on your own knee rehabilitation! Below the video is a timeline of what we talk about when.

:59 Christine talks about how her knees were pre-injury and that she was very athletic

1:10 The skiing accident that took her knee out

1:27 What the injury actually did to her knee and the structures that were injured

2:00 The surgery that required a lot more than she or her surgeons originally thought.

2:09 Her rehabilitation regimen as strictly a "strengthen and tighten" protocol in an attempt to keep the knee stable.

2:28 Her surgeons doom and glood proclamation about the future of her knee.

2:50 When the proclamation started to come true.

3:09 The search to get her knee healthy again, and 3 different surgeons opinions.

3:38 Her frustration that none of the surgeons were able to give her any tools to figure out a path to healing (other than surgery)

3:48 Christine’s big breakthrough question: “Why after the accident did I have cartilage and now 15 yrs later I don’t?” and where the answer led her.

3:59 How a purely strengthening and tightening rehabilitation program all those years ago was her downfall many years later.

4:09 Give the joint space to breathe!

4:34 The ignored adductors

4:39 The beginning of finding her own healing journey and what that looked like.

5:00 She’s been able to keep all her own parts! No knee replacement required!

5:19 How she actually has MORE strength and mobility in it now. It’s not just holding steady

5:56 And her back came along for the party too!

6:20 The other therapies besides yoga and Yoga Tune Up that helped her to heal

7:02 Why it takes a village to get better

7:20 The fear that gets wrapped up in pain and the importance of managing that

7:38 What she’s playing with and experimenting with now (Krav Maga, Crossfit, other kinds of movement) in order to move away from the knee fear and making the knee “special”. How those movement experiences have integrated things.

The end!

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P.S. You can find Christine at Quiet Corner Body Studio

P.P.S Do you have an amazing story of healing!? I would love to hear it. You can email me at brooke [at] fasciafreedomfighters[dot]com

DIY Friday: Lengthen those itty bitty hamstrings!

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5483358664_22080e5e98_bI have been a card carrying member of the short hamstrings club my whole life. As a result of a birth injury I had, among other things, profoundly limited range of motion in my posterior chain (think back body/postural musculature). So while every other little girl in ballet class was effortlessly falling into a full split, I was busy trying desperately to touch my toes, which at that time resulted in merely touching my knees. Yep you guessed it, ballet classes didn't last long for me (and ended in tears...). I honestly had recurring dreams as a child about doing an exquisite forward fold and being able to press my nose to my knees.

While I still struggle to some extent with mobility restrictions in my posterior chain (the nose to knees dream has yet to be realized for example) I have come a long, long way from the days of feeling like the gimpy girl in ballet class. I still smile every time my hands touch the floor in a forward fold, and I doubt that will ever go away! So for those of you who are looking at the floor with yearning as your fingertips dangle far above the floor, this DIY Friday is for you.

The first 3 videos are re-posts from my private practice blog, Soma Happy, which was the inspiration for FFF (it became FFF because I wanted it to be more than just my voice). So you can watch my three favorite insta-hamstring lengtheners in action! They are all taken from Yoga Tune Up®, which I teach, and if you want to get the magical therapy balls for yourself, you can find them here. And once you get past all of my videos, there is a link to a super useful post from Gray Cook which offers another perspective.

First up, how to use the therapy balls to safely roll out the hamstrings directly without agitating the sciatic nerve:

Secondly, this one is a sneaky little side door entrance to longer hamstrings! You'll find that by simply rolling out your feet, that your entire posterior chain is lengthened courtesy of the magic of fascia (connective tissue). Test it out for yourself by doing an initial forward fold/toe touch, then rolling out one foot, and doing another toe touch before moving on to the other side. Are your hamstrings much longer on the side that got the foot rolling? Boy howdy they are!

Lastly, this is a stretch called Asymmetrical Forward Fold which will really get you and your toes closer to one another. Try the same test/retest as in the last video by doing before and after forward folds, checking the difference between sides when you have only worked one leg.

Ok that's just about enough of me. All of my approaches here are myo-fascial release oriented. For another perspective from a great mind in functional movement, this is an excellent article from Gray Cook, one of the co-founders of Functional Movement Systems, which addresses the neural factors at play, and the why behind short hamstrings. Hint: many of us are using them as stabilizers, so if you want to lengthen them, you had also better pay close attention to upping the ante on stability and motor control as well. Bonus! It also has phenomenal instruction on deadlifting (with video) if you stick around to the end. Check it out here: What's In a Toe Touch? 

 

Photo by kevinalle