Plantar Fasciitis can be a chronically debilitating injury associated
with athletics or even the moderately active person. It involves the
inflammation of the plantar fascia most commonly at the insertion point
on the medial calcaneous. It is common in senior athletes that have
started a fitness or walking program after being sedentary for a period
of time. People with high arches (Pes Planus) are also at risk. Plantar
Fasciitis can develop in both the active population or during
activities of daily living (ADL) depending on what other pathologies or
dysfunctions of the kinetic chain are present. The key to prevention,
identification, and treatment of plantar fasciitis is assessment of the
kinetic chain and correcting dysfunctional segments with flexibility
and resistance training. The NASM-OPT� method of training can be
utilized for a systematic approach to treatment and prevention
strategies.

Pathogenesis of Heel Pain
Progression of the pathology of heel pain may be caused and exacerbated
by a number of issues both of a structural and functional nature. The
client/patient will exhibit point tenderness at the insertion of the
plantar fascia on the medial aspect of the heel or calcaneous.
Squeezing the heel may produce the pain normally felt and will be
described as a dull aching to sharp pain localized at the insertion.
The client/patient will complain that it is most painful in the morning
especially with "the first step out of bed." This pain complaint is due
to the positioning of the foot and ankle during the night. The ankle
will usually be plantar flexed relaxing the metatarsal and transverse
arches of the foot. This foot and ankle positioning causes the plantar
fascia to be in a shortened position for most of the night. When the
client/patient steps down on the foot in the morning, the foot comes
into neutral and subsequently into dorsiflexion during walking
movements. This movement causes the plantar fascia to stretch and pull
at the insertion (painful) site causing a fair amount of pain lasting
up to an hour. The client/patient will commonly state that the pain
subsides somewhat during the day and that it is at least bearable until
the following morning. While many who suffer from this pain may decide
to stop acitvity or become more sedentary to avoid the pain, upon
resuming activities or even activities of daily living, the pain may
return and this might become a never ending circle of injury or pain.

Common Conservative Treatment Methods
There are numerous common treatments considered conservative in nature
that attempt to address the pain usually at the point tender sight. The
American Orthopedic Foot and Ankle Society recommends at least six
months of conservative nonsurgical treatment of heel pain. Typical
strategies include achilles tendon stretching, rolling a frozen water
bottle, can, or golf ball the length of the medial longitudinal arch,
ice massage, or other thermo modalities. Over the counter NSAIDS, or
prescription anti-inflammatory medications are commonly used in
conjunction with traditional thermo modalities. Night splinting to
maintain a dorsiflexed or neutral position of the ankle is common and
may help with the "first step" pain. It should be noted that these
modalities and treatments often assist in the treatment of pain at the
sight of pathology, but do not address the dysfunctions in the kinetic
chain that are most likely causing the pain syndrome.

For health and fitness professionals, there are a few activities to try
with your clients to help alleviate the causes of pain:

Assessment
A bilateral assessment of the kinetic chain starting with the 1st
Metatarsal Phalangeal joint (MTP) or "big toe," and moving up to the
ankle, knee, and hip will reveal critical information about basic
dysfunction. Range of motion and goniometric assessment of these joints
as well as identifying musculature that is tight and elongated or weak
is a must and will assist the health care professional with specific
flexibility training goals. Normal goniometric range of motion for the
1st MTP is 0-70 degrees of extension. Normal dorsiflexiion of the ankle
is 0-20 degrees. In most patients with plantar fasciitis, these values
are far from normal and will assist in the progression of the pathology
by causing the hip, knee, and foot to externally rotate, subsequently
pronating the foot. It is important to note that pronation of the foot
is the primary cause of the pathology of plantar fasciitis and so the
movement dysfunctions that assist in pronation of the foot must be
addressed. These movement dysfunctions will occur during activities of
daily living as well as sport/fitness activities. Addressing the ROM
deficiencies in the 1st MTP as well as the ankle is the first step in
preventing or treating common heel pain or plantar fasciitis. Tightness
or a shortening of the peroneal (peroneus brevis, peroneous longus,
peroneus tertius ) musculature is a major contributor of pronation of
the foot. The peroneal complex can become shortened because of lack of
ROM of the 1st MTP and ankle and the subsequent relative flexibility
movement dysfunctions associated with these ROM deficiencies. Further
assessment specifically of the proximal hip musculature and its affect
on the kinetic chain components below the hip is also a strategy that
must be utilized.

The musculature of the lumbo-pelvic-hip complex (LPHC) is responsible
for maintaining alignment of the femur and stabilization of the hip and
pelvis during gait or activity. It is common to have tightness and
weakness or inhibition of the LPHC musculature. Principles of altered
reciprocal inhibition and synergistic dominance are responsible for a
breakdown of the kinetic chain in the hip, lower leg, and foot. This is
most commonly seen when the client spends a significant amount of time
sitting or activities that are primarily associate with the sagittal
plane. These activities that shorten the hip flexor complex, cause a
reciprocal inhibition of the gluteus maximus and other musculature
responsible for stabilization of LPHC and femur in the frontal plane
during movement. When this occurs, the femur will medially rotate and
adduct at the hip causing an abduction of the lower leg at the knee
joint and subsequent external rotation and abduction at the ankle and
pronation of the foot. As mentioned above, these dysfunctions may
happen during activities of daily living as well as during
fitness/sport activities.

Utilizing the overhead squat and single leg squat movement assessments
will identify a significant amount of information regarding the kinetic
chain. The assessor should be looking at dysfunctions and compensations
starting at the 1st MTP, ankle, knee, and hip. These are easy tests to
perform and gross deficiencies are readily identified. Experience in
assessment will reveal more and more to the assessor that may be
classified as minimal compensations. Without question, gross movement
dysfunction can be addressed easily and through utilization of the OPT
method of training, a relatively quick and long lasting effect can be
attained. [place video of OH Squat and SLS assessment techniques here]

Corrective and Prevention Strategies
Corrective and prevention strategies must include a series of ROM work
for the 1st MTP, ankle, and hip musculature as well as core, balance,
and resistance training. The OPT method of training allows a systematic
progression for accomplishing these goals. It is important to complete
a detailed assessment of the client to identify individual needs. It is
inappropriate to prescribe exercise modalities in blanket fashion for
every client/patient. All clients will exhibit different dysfunctions.
Some will be consistent and common, but all will have nuances that will
be specific to their sport or activity. It is these nuances in movement
dysfunction that the health/fitness professional should address in
training.

Progression for training should include a warm up of 5-10 minutes on a
bike, climber, or walking/jogging at a pace that will not exacerbate
the heel pain. Foam rolling of the peroneals, lateral gastrocnemius,
iliotibial band, and hamstrings is an appropriate pre-workout strategy.
Flexibility exercises to increase extension of the 1st MTP,
dorsiflextion of the ankle, and extension of the hip flexor complex
should follow. These modalities are critical and will prepare the
client/patient for core and balance training. Two of the most important
exercise modalities for prevention and treatment of plantar fasciitis
is core and balance exercises. Core strengthening/stabilization
exercise can be built into a balance training program and are primary
considerations especially in the beginning phases of training.

Balance training has been incorporated as a form of "functional
training" asking clients to stand on modalities such as half foam
rolls, BOSU balls, Airex pads, dyna discs, etc. While the intention is
commendable, first we need to gain a better idea of what is "functional
training." NASM defines functional training as a method of program
design that increases function. The NASM-OPT model, allows for a
systematic progression of program design and exercise selection to
create a training environment that will meet the needs of every client.
Balance training involves understanding proper functional anatomy, a
keen awareness and acuity for seeing movement compensations and proper
knowledge about progression of balance training exercises. Not every
client will be ready for dynamic modalities such as a dyna disc and
professionals have to understand proprioceptive tools are designed to
increase spatial and segmental awareness � not just to increase the fun
of a training program. Simply understood, this means that every
individual needs to be trained in the most unstable environment they
can safely control.

Balance training incorporates nearly every muscle of the lower body and
core, making exercises extremely rewarding for those who are looking to
lose weight, as well as seniors who need better balance, and athletes
who need reflexive joint stabilization at the ankle, knee, and hip.
While each population in the health clubs may move to a different level
of balance training, each population should begin at the same point �
learning balance stabilization. With balance stabilization, there is no
movement at the ankle, knee, or hip � teaching the body how to control
the leg by contracting the right muscle, at the right time, in the
right plane of motion.

Examples of this type of balance training would include single-leg
balance exercises. Start with a simple single-leg balance exercise on a
hard floor helping your client to maintain their posture, draw-in their
abdominals, and maintain proper alignment of their foot, ankle, knee,
and hips. If our client cannot balance on one foot initially, use an
external support to allow them to hold on to. This will help them learn
how to maintain posture, fire the gluteus maximus and control the leg
while teaching balance. Once your client has mastered the single-leg
balance, begin to challenge their stability by incorporating movement
of the upper and/or lower extremities using an exercise such as a
single-leg balance with leg reach.

Within balance stabilization training, there are numerous modalities
that can be incorporated. Begin with an exercise modality that slightly
increases the challenge such as a beam placed on the ground that
decreases the surface area that your client has to balance. Move from
there to an exercise tool that challenges your client in one plane of
motion only such as a half foam roll placed parallel or perpendicular
to the body. The next progression adds in more than one plane of
motion, utilizing a core board or a thick Airex pad. With these
modalities, there is a challenge in all planes of motion; however, the
modality still provides some stability in the challenge. The last
progression would incorporate a dyna disc � which creates a
multi-planar challenge on a very unstable platform creating the utmost
challenge for the user. Remember, place your client in the most
unstable environment they can safely control. If your client is not
ready to balance on a modality � then do not place them on one. The
sensory information you send up to the brain dictates the motor
behavior that is sent out and if your client cannot control their
ankle, knee, foot, and core while balancing on a modality, you could be
furthering compensation patterns that may lead to injury in the future.

Plantar fasciitis can be a debilitating, chronic injury process that
cannot only keep an individual from being active, but can also cause
pain and discomfort during activities of daily living. The good news is
that through proper and thorough assessment, the OPT trained health
care professional can prescribe and implement appropriate flexibility
and exercise modalities that can prevent as well as have a significant
impact on the treatment of the common heel pain associated with plantar
fasciitis.
As with all exercise selections, proper progression can make or break
the efficiency and effectiveness of the exercise and program. When
choosing exercises, make sure the degree of difficulty matches the
ability of the client. Place your client in the most unstable
environment they can safely control � keeping your client far from
injury and your program design unparalleled when it comes to amazing
results!


Glossary of Terms
Pes Planus � High Longitudinal Arch of the Foot
ADL � Activities of Daily Living
NSAID � Non-Steroidal Anti-inflammatory Drug, i.e., Advil or Aleve
LPHC � Lumbo Pelvic Hip Complex