Many times, pain in the bottom of the foot or heel can be pushed into a blanket diagnosis of “you have plantar fasciitis”. But is it plantar fasciitis? Could it be another condition like tibialis posterior tendonitis, stress fracture in the heel, radiating pain from the low back? While getting a blanket diagnosis of plantar fasciitis based on zero exam with some basic rehab and soft tissue techniques thrown at it may work, there is a good chance it probably will not. You must know what you are aiming at. And in the same boat, what is causing the plantar fasciitis? Just because there is pain and inflammation in the plantar fascia does not mean that the CAUSE of the pain is coming from that area as well. In fact, it rarely does. This is why seeking out help from sports chiropractor or physical therapist is important to get a proper diagnosis and most importantly find out the main cause of the pain.
For the purposes of this blog, we will assume that we have ruled out all red flags, low back, and other conditions near the foot. We will focus on differentiating between plantar fasciitis and tibialis posterior tendonitis. We will go through anatomy and function, classic signs of each condition, and patient history things to consider. In the next blog we will go through treatment and rehab considerations for each condition.
The plantar fascia is a dense, fibrous connective tissue that is attached to the heal, toes, and many surrounding muscles and structures of the bottom of the foot. The plantar fascia is designed to be a passive (meaning non contracting) transmitter of forces that are put on the foot. It is also a supporter of the medial longitudinal and transverse arches.
The tibialis posterior is the deepest and most central muscle of the lower leg with fibers originating on both shin bones. It wraps around and inserts into the calcaneus, navicular, cuboid, cuneiforms, and the second through fourth toes. With it location, multiple attachment points, and powerful tendon, it is the most important stabilizer of the foot helping to create the medial arch. When injured or weakened, stabilization of the foot can be compromised. The tibialis posterior also helps to flex the ankle down and turn in.
A big misconception we hear is that a patient’s pain is due pronation or their “flat fleet”. The reality is people with high arches can get plantar fasciitis and people with “flat feet” are not doomed to come down with it. It is more about the rate at which you can control pronation and how long you remain in it that it the problem. People who overpronate or cannot control the rate of it, will elongate the fascia like wringing out a dish rag that will cause increased strain on the fascia. This foot is too mobile.
People that cannot move properly through the foot limit their shock absorption and cannot dissipate forces, so the fascia takes a beating. This foot is too rigid.
Stayed tuned as we will cover how treatment for people that cannot control pronation vs people that cannot move properly throught the foot can be different, as well as general treatment and rehab considerations for each condition in the next blog!
References: Gilroy, A. M., MacPherson, B. R., & Ross, L. M. (2008). Atlas of anatomy. Stuttgart: Thieme.
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