Pain under the foot? Plantar Fasciitis.

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Ever got out of bed, put your foot on the ground and felt like you were standing on a pin? Then after ascertaining you AREN'T actually standing on a pin, trying it again, and having to go through an excrutiating few minutes as you wander around with this horrific shooting pain right underneath your heel?

Welcome to the world of plantar fasciitis, or, policemans heel. I've been a victim of it, and have treated a good number of people for it, from footballers to people who haven't been able to get fitted for ski boots because of the pain. What the heck is it? What causes the pain? Why does it affect some people and not others and most importantly, what can be done to allieviate it?!

Under your foot is a long ligament called the Plantar Fascia. It goes from the Calcaneus (heel bone) to the toes, and it is this piece of tissue where the pain is generally focussed. The tension in this ligament is partially what helps keep longitudinal arches in your feet in place as you walk.

The reason for it becoming painful is that it has become inflammed and tender as a result of either excess pressure on the area, or because of an issue slightly further up the body - generally in the calf muscles. (in my experience, the soleus rather than the Gastrocnemius, but we'll come to that later).

As you may know if you read the post about fascia, everything in the body is connected, so no one issue in the body can be looked at in isolation to the rest of the body. This is no exception. Calf muscle complex (the triceps surii - if you want to get technical) can develop excessive tone - get too tight, which pulls up on the heel. This then transfers down through mechanical loading so that the plantar fascia is pulled toward the heel, and stretches it tighter than it should be. The ligament is stretched over the boney spur which it attaches to, and becomes painful and inflammed, and hey presto - you have a very very painful spot on the bottom of your foot.

There are a number of mechanisms of injury for this. The most obvious one being hard shoes on hard surfaces - hence the name "policemans heel". Walking on hard surfaces with shoes without sufficient shock absorbancy, or with bad mechanics is going to end up making the tissues under the heel very tender. A number of city boys walking around in very snazzy shoes end up with pain under their heels, because the biomechanics of their feet don't work with the shoes, and the ligaments end up screaming in protest. The most recent case that I've seen was a footballer playing excessive amounts of football at the end of the season, on ground that was scuffed up and rock hard from a season of games, with a pair of football boots that were best suited for soft grass. Unsurprisingly his heels were not thanking him for it, and he had to miss a couple of games because of pain in the left heel.

Some of the advice on the net is to get yourself a tennis or a squash ball, (or if you're REALLY sadistic, a golf ball), and stand on it, rolling it around the base of the foot so that you can stretch out the ligament. Now, that's a great plan, and is very useful, but, as I'm always banging on about, thats looking at the smoke - not the fire. No matter how much you waft the smoke away, the fire is going to continue to create more of it.

The actual issue is most likely coming from the Soleus. (note that this is not a definite be all and end all, just what I have seen in my experiences so far). When I tell people that the pain is coming from a tight calf muscle, there are normally exclaimations that they ALWAYS stretch their calf muscles out, and it couldn't possibly be the reason.

The Calf comples- quite complex- as you can see, the Black muscle- the Gastrocnemis- the one you see on muscley peoples legs- attaches ABOVE the knee, and is stretched when the knee is straight.

What they mean is they always (ahem, well, sometimes) stretch out the Gastrocnemius, which is the most superficial (closest to the surface) muscle. This muscle attaches to the achilles tendon at the bottom, and just above the knee at the top. Doing a normal calf stretch, with the back leg straight is fantastic for this muscle, and stretches it marvellously. However, there is another muscle which I referred to earlier - the Soleus. It is deep to the Gastrocnemius and while it attaches to the same place at the bottom - the achilles tendon, at the top, it attaches BELOW the knee. All the time you stretch out the calf with a straight leg, the Soleus doesn't get a look in, and when you start exercise, its like you're starting with a cold muscle.

As you can see- the Soleus, which is deep to the gastroc (black muscle in the last pic) attaches to the achilles tendon at the bottom, but BELOW the knee at the top. Hence it is not stretched when the knee is straight.

If you want to stretch out the soleus, or at least get some blood into it before you head off on your walk/run/cycle/bog snorkel/netball game, do what you would do to stretch out your "calf" and then bend that back knee. It'll feel odd, but thats the point. Don't stretch to failure, or to pain, stretch to a slight tension.
And do it again at the end of the exercise session as well to get the waste metaabolic products out again.

How does this affect us with painful heels?

Well, because the Soleus is never stretched out properly, it retains its shortened state, and pulls on the achilles tendon, which pulls on the fascia around the heel, which pulls on the plantar fascia, and bang, you have tight tissue right the way down the back of the leg to the heel, and PAIN on the bottom of your foot.
It is THIS that may well be the fire.

You should be able to work out the pulling relationship of the calf muscles on the heel, and hence why pain appears on the bottom of the heel from this photo.

As a massage therapist I would look at the tension in Soleus and use a variety of techniques to relax it out. It would most likely be ridiculously painful to touch, so a gentle start, moving into some slightly more robust techniques would be called for - lengthening tissues, making them more pliable and generally assisting it to be less tight and ischaemic.

In terms of self-help - by all means use the balls on the bottom of your feet - you could also use a foam roller (as discussed in the ITB post) on the calf muscles - though be aware that it might not go deep enough to affect the soleus. It may be that you need to change your footwear - are they worn out? do you perhaps need to consider looking at orthotics? One thing I would suggest not falling back on as a first resort is buying "squidgy" footbeds - designed to be like a gel under your foot - again this is blowing away smoke - you are not correcting what is wrong, you are simply trying to make what is wrong feel better - not a good plan.

If you DO want to put something in your shoes which might make it better - look at getting a pair of pre-moulded footbeds like Superfeet- they don't squidge, but they do try and make your foot more biomechanically efficient - a better option than nothing.

Right, I hope that gave you some food for thought. Stretch that soleus, stand on a golf ball, and see a massage therapist. If they don't start prodding around in the compartments around your calf, go to another one. They may even track the biomechanical inefficiencies back up to the hips, or elsewhere in the body - don't be surprised. Everything is connected to Everything else.