If the Feet Aren’t Happy, Nobody’s Happy

ath-feetAnyone who has experienced plantar fascitis or Achilles tendonitis can attest that the above title is true. In more severe cases, either of these problems or any other tendonitis problem can bring your activity participation to a full halt. In the more common cases, one can continue to be active, but have your performance limited by a recurring tendonitis or fascitis. Plantar Fascitis is an inflammation of the thick connective tissue that covers the bottom of the foot from the heel to the ball of the foot. Achilles tendonitis is an inflammation of the connection of the calf muscles onto the back of the heel. The first line of treatment and prevention should be properly fitted footwear that is chosen with the assistance of someone who can evaluate how much support your foot needs and where it needs it. Fortunately for us, there are now many specialized shoe stores who have well trained staff to do this. Sometimes this is all that is needed and sometimes more steps are required.

In order to resolve and prevent these and other similar conditions, it is helpful to have an understanding of the healing process and the role of eccentric strengthening in promoting the healing of connective tissues. An eccentric activation of muscle is one that occurs while a muscle is being lengthened. The lowering of the weight phase of a biceps curl is a simple example of an eccentric activation, whereas the lifting of the weight to the shoulder is the concentric phase of the exercise. The muscle and tendon is still actively controlling the load and under tension as it lengthens during the eccentric contraction phase. Due to the nature of muscle and tendon, it is possible for these structures to tolerate greater loads (tensile forces) during eccentric activation than they can produce during concentric activation. This information can be applied to help resolve nagging injuries such as plantar fascitis or Achilles tendonitis.

The common difficulty with these “-itis” injuries is that the tissues form scar tissue to heal microscopic structural tears when we are at rest, but with activity and tensile loading of the tissues, the structural tears recur. This is why you often feel the pain first thing in the morning, but after you have been walking for a little while you feel better. As you rest, the tissues heal in a shortened and weakened position, then when you walk, you tear apart the healing that occurred during the nights rest. In order to heal fully, you have to balance stretching and strengthening through a full range of motion with controlling for not overloading the structure and perpetuating the injury. It is easy to tell when overload occurs; you will feel the return of your pain. Of course, simply doing nothing may keep you out of pain, but it will not rebuild the strength and flexibility needed in the tissues to return to full activity.

The Three mechanical components for healing are inflammation control, restoration of tissue flexibility and restoration of tensile loading strength. Ice and anti-inflammatory medications are standbys for the first component. For flexibility, gentle prolonged progressive stretching in a pain free range is required. For weight bearing structures such as the feet, this can be accomplished by holding a weight bearing stretch for 3 minute plus intervals. Restoration of tensile load strength without damaging overload can be accomplished by focusing on eccentric exercises. It is important that the exercise be performed through the full range of motion available. In the case of the plantar fascia and Achilles tendon, this means doing strength work such as calf raises (plantar flexion) from a position of fully up on the ball of the foot and lowering till the heel is lower than the ball of the foot and the limit of flexibility is reached. Obviously to accomplish this the weight must be on the ball of the foot with the heel hanging off the edge of whatever you are standing on. Initially start with lifting up using both legs and holding on for balance, then shifting more weight to the painful side and lowering with an emphasis on that leg. One should do repetitions to fatigue, but never load the leg with so much weight that you provoke your pain. In this case, stretching before the strength work and icing afterwards to control for inflammation are critical.

These same concepts can be applied to other tendon or connective tissue injuries in the body. If these steps do not help to fully resolve problems, then seek out a therapist, podiatrist or other professional that can perform a detailed biomechanical assessment of your whole body and evaluate if other options such as orthotics may help. If you work on the feet diligently and the feet don’t get better, it is probably not the fault of the feet. Everything is connected and the whole system must function smoothly for it to remain pain free.

Brian Beatty, PT, CSCS rides when he can and complains of not riding enough when he can’t. He also talks incessantly to anyone who will listen about biomechanics, physics and experiential learning. When not riding he can be found from too early in the morning till too late at night hanging around Balanced Physical Therapy and Balanced Movement Studio in Carrboro and Durham.