Friday Q&A: Plantar Fascitis

Q: I have a question about flat feet and Morton's toe. I'm a 57 YO man who walks a lot and I have both. I always have difficulty balancing on one foot—tree, eagle pose, etc., and have recently had a bout with Plantar Fasciitis showing up in my left heel. No fun. I was at a yoga class yesterday and some poses felt good, others hurt. When I left the class, I literally limped home and iced it for 1/2 hr. then heat, then rest. I had acupuncture at Quan Yin this morning for it and bought new, sturdy shoes and heel pads. It feels a little better today. Can you suggest any asana or other treatment I can do at home that may help speed the healing process and prevent future trouble?

A: If you can remember way back to three weeks ago to our question of the week, (above) our reader had shared that he had a triple whammy going on in his feet: flat feet (see Flat Feet), Morton’s neuroma (see Morton's Neuroma) AND Plantar Fascitis! We have addressed the first two topics already, and now we now ready to look at what is commonly referred to as heel spurs. This is a bit of a misnomer, as only sometimes does an X-ray of the feet show spurring off the calcaneus bone, a bony deposit of calcium growing forward along the plantar fascia. We’ll come back to this and clarify what these things are in just a moment.

The plantar fascia is a sheet of connective tissue that stretches from the heel bone, the calcaneus, forward along the sole of the foot to the base of the toes. It assists the ligaments and the muscles of the foot in maintaining tension across the bottom of the foot to help maintain the arches of the feet. As connective tissue, it has strength, but does not stretch much before running the risk of tearing or becoming inflamed. And, unlike muscles, it does not contract and create active movement in the foot.

Plantar fascitis (PF) is inflammation of this thick tissue on the bottom of the foot. It almost always occurs where the tissue arises from the heel bone. There are many possible factors that contribute to its development but basically it occurs when the thick band of tissue on the bottom of the foot is overstretched or overused. This can be painful and make walking more difficult. In fact, no one goes to the doctor with this condition unless their foot is giving them pain! According to the NIH, you are more likely to get plantar fascitis if you have (or do) any of the following:

• foot arch problems, either flat feet (ding, ding) or high arches
• long-distance running, especially running downhill or on uneven surfaces (I have four students with PF and all of them are runners)
• sudden weight gain or obesity
• tight Achilles tendon (the tendon connecting the calf muscles to the heel)
• shoes with poor arch support or soft soles

Plantar fascitis occurs in both men and women. However, it most often affects active men ages 40 - 70. It is one of the most common orthopedic complaints relating to the foot. Interestingly, in my practice recently, I have seen more women coming in with complaints of PF than men. As far as diagnosing plantar fascitis, as I mentioned above, PF is commonly thought of as being caused by a heel spur, but research has found that this is not the case. On X-ray, heel spurs are seen in people with and without PF.  So how does the doctor or podiatrist figure out if you have this particular foot malady? 

The diagnosis of PF is usually made based on your history and physical exam. There is usually a complaint of stiffness and pain on the sole of the foot near the heel. It is usually dull or sharp, worse on the first few steps in the morning, better with continued movement if is not super flared, and recurs if you have been sitting for a while and get up and walk again. It can also occur if you are standing for a while or climbing stairs, or after intense activity. One of my students whose PF is improving, notices some lingering pain when the affected foot is the back foot in Warrior 1 pose. We are modifying it for now by using a wedge under that heel in that pose to eliminate the pain. The pain associated with PF can develop slowly over time, or suddenly after intense activities. During your physical exam, the doctor will press on the sole of the foot, especially near the heel bone, and if this elicits pain, this is another piece of evidence pointing to PF. They will also note if you have flat feet or high arches, if there is any redness or swelling near the heel bone, or if any stiffness or tightness can be appreciated on the arch at the bottom of the foot. X-rays could be ordered, too. 

One of the reasons students will sometimes come to me for yoga or acupuncture treatments is the long course of recovery or resolution of the symptoms of PF.  It can take from two months to two years for this condition to resolve! The average is nine months, which in this day and age can feel like an eternity. And on rare occasions, the pain could persist beyond two years, and some folks opt for more invasive (can you say “surgery”?) treatment at that point. Here in the US, a typical treatment plan by your doc could include, ice, resting by not doing aggravating activities, anti-inflammatory meds, wearing an immobilizing splint at night and physical therapy stretches for the Achilles tendon and feet. Commons sense recommendations include wearing shoes that fit properly and have good arch support. In addition, heel cups for your shoes or other more sophisticated arch supports might be recommended. If things don’t improve, steroid shots and more invasive treatments might be added.

How might yoga help out?  Well, in addition to what we have discussed in the last two weeks, resting poses, such as Legs up the Wall pose (Viparita Karani) and all the inversions that involve having your feet in the air could assist in resting the plantar fascia. Many of our modern poses could also assist in stretching the Achilles tendon and the feet, if done with mindfulness, so as to avoid aggravating your foot symptoms. Almost all of the standing poses could have possible benefits in this regard, and Malasana, Garland pose, which is a deep squat, could do double duty. 

The opposite case could be made if the poses are aggravating the foot, in that you may need to do some creative propping to permit your practice to continue without worsening your symptoms. Doubling up your sticky matt for more cushioning can help, as can using a wedge under the ball of the front foot or heel of the back foot to minimize stretch during flared times. An example of a pose that puts a lot of pressure onto the front foot heel is Parsvottanasana (Pyramid pose).  Here I would use the wedge under the ball or the front foot. As always, if you want yoga to be in the mix of your healing plan, work with a teacher with experience around PF for the greatest chance of success. We’ll leave the feet behind for now, and I look forward to your upcoming questions!  Don’t be shy, ask this guy!

—Baxter