At my clinic, IFAST Physical Therapy, here in Indianapolis, I see many patients complaining about issues such as plantar fasciitis, heel pain, Achilles tendinitis, bunions, and many other foot-related pain syndromes. Oftentimes, my patients have been seen by several physicians or physical therapists with little or no relief from their painful symptoms.
They still have pain in their heel when they first get out of bed in the morning. They still have pain when climbing the stairs. It feels like they have a rock in their shoe digging into their foot when they stand or walk for any length of time. Even when they do their foot and calf muscle stretches that they were instructed to do by well-meaning health professionals or that their latest Google search recommends, they still have the same pain.
Perhaps they’ve been told that they have one leg that is longer than another resulting in a leg length discrepancy that is the cause for their pain (this is almost NEVER the case!). So they wear the heel lift in their shoe to make their leg length equal, but they still have the same pain.
Why does their pain persist?
Because their foot problem isn’t a foot problem.
Understanding Human Asymmetry and Your Foot Pain
With two eyes, two ears, two arms, and two legs, we humans all appear to be symmetrical beings on the outside. On the inside, however, we are quite asymmetrical. The most important asymmetry we have is in our diaphragm muscle with the right diaphragm being larger and stronger than the left diaphragm.
This is partially due to our internal anatomy. We have a large liver on the right side of our abdomen that sits under the right diaphragm and gives it a larger, dome shape that provides it with a better position to be strong. On the left side, our heart sits on top of the diaphragm resulting in flattened shape that limits its position to be as strong as the right side.
The diaphragm is most commonly known as our breathing muscle, but it serves several additional important functions including how we control the position of our trunk and pelvis. The diaphragm provides this control function along with our abdominal and back muscles.
Because of the asymmetry in position, shape, and strength of the diaphragm, there is a difference in the way we stabilize our trunk on each side. We tend to favor our right side. We standing on our right leg more than our left, and we lean more to our right than our left. It is entirely normal and all humans will tend to shift to the right at times of mental or physical stress. This allows us to take advantage of our larger right diaphragm and to fulfill or primary need to get valuable oxygen to our brains and bodies.
This tendency to shift to our right promotes a corresponding shift in our pelvis with the left side of the pelvis coming forward and the right side shifting backward. The resulting position looks like this:
From this pelvic position, all the joint relationships are adjusted from the hip to the knee to the foot downward toward the floor. The result will be a change in the orientation of the as it rests on the floor. The typical way to address the appearance of the foot is to look at the arch along the inside of the foot. When the arch is low to the floor, a.k.a., a flat foot or fallen arches, the foot is said to be pronated. When the arch is high, the foot is said to be supinated.
When the left side of the pelvis is forward and right side backward, the most common presentation of foot type that we see is a supinated foot on the right and a pronated foot on the left to varying degrees.
If you do a quick Google search, you easily find thousand of articles (it’s actually 50,000 for supination and 276,000 for pronation) blaming either foot position as THE cause of plantar fasciitis or heel pain. The reality is that you may present with plantar fasciitis or heel pain in either case.
In looking at the muscles and plantar fascia on the bottom of the foot, you’ll see that most of these tissues attach directly to the heel bone called the calcaneus. Regardless of foot pronation or supination, there will be active or passive tension in these tissues. While this does not always result in a patient experiencing pain, it certainly may be causal or contribute to a mechanical influence that results in a painful experience.
The key point to understand is that while you may be experiencing pain in the foot or heel, the mechanical relationship that may be driving your foot pain can be all the way up in the pelvis.
PLANTAR FASCIITIS Q & A
- I was told that my heel pain was inflammation of the plantar fascia, is that true?
Maybe. If your foot or heel symptoms are acute and occurred over the last few day, it may be inflamed. In most cases this is the result of direct trauma or injury to your foot like a hard landing, stepping on a rock in bare feet, etc. This type of pain is caused by our natural immune and inflammatory processes that promote normal healing of tissues. If your pain has lasted more than a couple of weeks, it’s doubtful that it is an inflammatory process and requires a more extensive evaluation for a mechanical or neurological influence.
- My therapist told me that I have a twist in my pelvis and one of my legs is longer than the other (called leg length discrepancy) and that is causing my plantar fasciitis, can that be the cause because I’ve never had foot pain before?
A true leg length discrepancy rare exists and requires that the bones of your legs be measured for length via an x-ray. If your leg length was determined by a therapist feeling (called palpating) the bony areas of your pelvis and ankles or by visually comparing your leg length or measuring with a tape measure while lying down, then the assessment is most likely inaccurate. Tests like these have been shown in the research to be terribly inaccurate. IFAST Physical Therapy uses a reliable, evidence-based evaluation approach that includes a battery of tests to determine if there is a mechanical component influencing your pain.
- Will orthotics help my plantar fasciitis?
Maybe. Over time, tissues in your ankles and feet may have adapted by getting longer or shorter. If this is the case, then an orthotic or simply a better shoe may be helpful in addition to exercises and activities to improve the mechanical component that may be driven from the rest of the body down to the foot. Rarely are orthotics the total solution to foot or heel pain. IFAST Physical Therapy works with one of the top podiatrists in the country and uses PRI orthotics when necessary in combination with our total body approach to improve the mechanical influences to your pain.
- I was shown that I have a bone spur on my heel, is that the cause of my pain?
Doubtful. Bone spurs sound terrible and because they are near your area of pain, they often get blamed as the source of your complaints. Truth be told, bone spurs are a very mild area of thinly calcified tissue. There is currently no support in the research to indicate that these can be a cause of pain. Many people are found to have bone spurs incidentally and have no pain at all. Unfortunately, many patients undergo surgery to have them removed and continue to suffer from foot and heel pain.
- Can’t I just stretch my calves and my plantar fascia and make it better?
Plantar fasciitis is often blamed on tight calves, tight plantar fascia, or some other tight structure. The medical field can’t even agree on what “tight” actually means, so it is often misleading to tell patients that stretching is a fix of any kind. Quite often during our IFAST Physical Therapy exam we find neurologic and mechanical influences that may facilitate or cause muscles to increase tension unnecessarily that may lead to mechanically derived pain. It often results in immediate reductions in tension of the muscles making stretching unnecessary.
- How do I schedule my IFAST Physical Therapy evaluation?
Indiana residents now have direct access to IFAST Physical Therapy services and don’t need your physician’s referral to start physical therapy. Just call IFAST Physical Therapy at 317-578-0998 or email us at [email protected] to set up your IFAST Physical Therapy evaluation.