When Plantar Fasciitis Treatment Fails…

The characteristic pain of plantar fasciitis hits when you first get up. Foot down on the floor and ouch! you know about it. The pain tends to ease as you get going and the tissue warms up. It is a pain that is easy to define because it hurts so much in one place – just in front of the heel on the underside of your foot. A change in exercise or training habits can trigger it, as can a change in footwear or standing for prolonged amounts of time.

Plantar Fasciitis can be a difficult condition to treat because its stubborn and oftentimes it isn’t even plantar fasciitis at all but something else causing the pain on the underside of your foot or heel. Tight muscles on the lower leg can refer pain onto the heel and underside of the foot, nerves can get trapped as they make their way under the foot and poor circulation can all create issues similar to plantar fasciitis. Some of these potential causes are explored below:

Calf Muscles

The calf muscles (soleus and gastrocnemius) run down the lower part of the leg and insert into the heel via a common tendon – the achilles tendon. Tightness in either the gastrocnemius or soleus can refer pain into the heel. This is likely a problem if you stretch your calf and feel pulling in the back of the leg, especially if it refers lower down to the heel.
Pain is often worse in the morning. Overnight, most people sleep with feet slightly pointed – putting the calf muscles in a contracted position. As you get up and stand on the foot the calf muscles stretch triggering the pain after a night of rest.

Flexor Hallucis Longus

A long name for the muscle that pushes (flexes) the big toe down. This is the movement just before your foot leaves the ground when running or walking– the toes pushes down to help propel you forwards.
If flexing your toe against resistance (place finger under big toe whilst pushing it away from you) replicates your pain this is likely your culprit. The pain is typically felt running underneath the foot on the big toe side.

Its a common pain for ballerinas who have to regularly push up on to point (tip toes). Also if you over-pronate as a runner you end up putting excessive force through the big toe as it takes the brunt of the force as you push off to propel forwards.

Tibialis Posterior

This muscle runs up the inside of the leg and helps to invert the foot – pulling the inside of the foot up. This muscle is strongly stressed when running – particularly with over pronation as the muscle is stretched. In the acute phase (first few weeks) the muscle becomes inflamed. Left untreated and the original stressor still present, chronic cases lead to degeneration of the muscle or tendon. Pain can be felt on the inside of the ankle running under the inside of the foot (where the muscle inserts) in the instep.

Tarsal Tunnel Syndrome

There’s a thick ligament on the inside of the ankle – running between the ankle and the achilles tendon on the back of your ankle/ foot. Tendons, the tibial artery and posterior tibial nerve all run under this ligament. The area under this ligament can become congested, sometimes from scar tissue from repeated injury. This can compress the nerve and refer pain into the arch/ instep of the foot.
This needs treating quickly. Leaving any nerve compression for a long period of time may lead to permanent nerve damage, resulting in chronic weakness, numbness or pain.

Medial Calcaneal Nerve

The nerve which detects sensation in your heel and bottom of foot in the area where plantar fascitis is found is the medial calcaneal nerve. By modulating this with acupuncture we can reduce intensity of plantar fasciitis.

Heel spurs & Plantar Fasciitis

Plantar fascia runs on the underside of the foot, connecting the toes to the inside aspect of the underside of the heel. It’s fibrous and acts like a spring when pushing upwards off the foot. Damage to this fascia is typically caused by overuse.

Repeated over time the continual trauma near the heel causes the body to create a bony protrusion, known as a heel spur. This is the bodies way of trying to protect an over-stressed area.
Its tempting to think that the heel pain is coming from the heel spur, but according to some studies over 50% of patients who have heel spurs removed still suffer the pain (Surgical Treatment of Calcaneal Spurs – A Three Year Study, J AM Pod Med Assc, 1991:81:68-72)– because the pain originated in the damaged plantar fascia. The heel spur was a symptom of the plantar fascia, rather than the cause of the pain.

In longstanding cases of plantar fasciitis there is a high prevalance of necrosis of the tissue around the heel, due to poor blood flow from the medial plantar artery. This artery can be impinged by the muscle which moves the big toe outwards and downwards (abductor hallucis longus). Excess strain can be placed on this muscle when the big toe points inwards excessively (as can occur with bunions), or with excessive pronation of the foot (which stresses the big toe through excessive flexion forces).

How Can Acupuncture Help?

Given the multiple presentations of what can apparently be just plantar fasciitis, a thorough assessment is necessary prior to treatment, where I asses range of movement, strength and get a full history. Treatment times can vary from as little as 3 treatments for recent onset in a fit and healthy patient to 10-12 treatments for patients who have long standing pain and are in relatively poor health.