Load Your Feet to Improve Plantar Fasciitis

Last month, I wrote about dissonance that occurs, when I perceive discord among yoga teachers and other movement thinkers, whose work I follow. As a yoga teacher, former research librarian, soon to be Restorative Exercise Specialist™, and someone with rebellious tendencies, I am wired to ask a lot of questions about what is being taught in yoga – and why – and whether cues were informed by research or lineage. Often this results in mental compromises (and annoyed teachers & colleagues) as I try to reconcile such teachings with each other and with what I experience in my body or with my students and clients. There comes a time when a clarifying convergence of ideas emerges that confirms I am on the right path and following teachings from which I am meant to learn. This is one of those occasions. 

In previous posts (listed below), I discussed plantar fasciitis (aka plantar fasciosis) and biomechanical and environmental factors that can be addressed conservatively through yogasana, plantar fascia-specific stretching, alignment, and conditioning.

Previous posts on plantar fasciitis and exercises that can help:

https://footloveyoga.com/2015/01/05/plantar-fasciitis-what-we-know-what-we-can-do-about-it-january-5-2015/

https://footloveyoga.com/2015/01/08/what-does-plantar-fasciitis-your-down-comforter-and-your-sleep-position-have-in-common/

https://footloveyoga.com/2015/01/17/simulating-the-toe-off-event-in-walking-to-stretch-your-plantar-fascia/

https://footloveyoga.com/2015/01/13/strong-yoga-foot/

https://footloveyoga.com/2015/03/16/the-strong-yoga-foot-and-your-flat-feet-in-research/

Upon returning yesterday from what has come to be known as the Jules Mitchell Portland Tour, I found the September 1, 2015 issue of my partner’s American Family Physician peer-reviewed journal sitting on my desk with a section circled. The article was titled “Top 20 Research Studies of 2014 for Primary Care Physicians.” Basically, a group of clinicians with expertise in evidenced-based medicine performed monthly surveillance on 110 clinical research journals in 2014 (the 20th year they have been doing such surveillance). They identified 255 studies that had potential to change how family physicians practice, and narrowed that group down to 20 studies with relevance to primary care practice, validity, and likelihood that they could change practice. The section circled for my benefit was from one of these 20 studies titled “High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up,” which addressed the question of whether strength training is more effective than stretching for patients with plantar fasciitis. The bottom line answer was YES. “A regimen of strength training improves pain and function in patients with plantar fasciitis faster than a typical stretching regimen. Over time, though, patients who stretch will continue to improve and have similar improvement.” My take home, after reading the full study, is that high-load strength training, at 3 months out, resulted in quicker reduction in pain and improvement in function, when compared to stretching alone. However, 3 months was the magic time period. Before three months and at 6  and 12 months, strength training was not superior to stretching.

So, how does this research study on plantar fasciitis converge with the Jules Mitchell Portland Tour? Jules is one of the teachers in my dissonance piece. She is a biomechanist and yogi, who wrote her masters thesis on the science of stretching and turned the world of yoga on its head. One of her workshops that I attended this weekend was an impressive attempt to distill  3 years of research on the biomechanics and neuromechanisms of stretching into 8 hours of yoga workshop. The piece that is relevant here, further distilled from 3 years of research to 8 hours of workshop to two minutes of interpretive writing, is that loading connective tissues, which happens in active static stretching and isometric and eccentric training, is how we get stronger, healthier connective tissues. It is all about the load. You must input load. It is so much more complicated and nuanced than that…I challenge you to learn more by reading Jules’ seminal post on tissue mechanics, which begins her blogging journey of her thesis work.

In explaining results of the plantar fascia study, the authors confirm Jules’ findings that large tensile forces (loads) are associated with improvements in symptoms in conditions involving degenerative changes, like plantar fasciosis. Since the plantar fascia is composed of type 1 collagen fibers, it responds to high loads by laying down more collagen, which may help improve the condition. An additional benefit of high-load strength training is increased ankle dorsiflexion strength, as decreased ankle dorsiflexion strength has previously been identified in those with plantar fasciosis.

Applied exercises in your home yoga practice

With a little creativity, you can use yoga props to combine ankle dorsiflexion and controlled loading of the plantar fascia. This exercise can be used by those with or without plantar fasciosis, as it trains active mobility and improves strength at end ranges of motion in your feet and ankles, which is good for everyone. We know that strong, flexible feet are healthy, happy, and mobile.

I use a block, half round, and yoga mat. You can use a stair step or low stool in place of a yoga block and a rolled up towel or yoga mat for the half round/mat combo in the images below.

The first two pictures show my naked set-up, but I actually cover the whole contraption with a yoga mat because the half-round slides on the block without the mat, when I start doing the exercise. You probably won’t get slippage if you are using a towel instead of a half-round.

plantar fasciosis load1 plantarfasciosisload2 plantarfasciosisload3

  1. Place the toes of your right foot on the mat-wrapped half-round (towel), so that they are maximally dorsal flexed, meaning your toes extend back towards you.
  2. Place the ball of your foot on the block (stool or step).
  3. Hold onto a chair/rail for balance and slowly, over a period of 3 seconds, lift your right heel, so that you rise up onto the ball of your foot (concentric phase).
  4. Remain in the raised position for 2 seconds (isometric phase).
  5. Slowly lower your heel, over a period of 3 seconds, to slightly below the level of the block (eccentric phase). The rise, hold, & lower is one rep.
  6. Repeat up to 12 times (reps) for up to 3 sets.
  7. Once you can do 3 sets of 12 reps, play around with increasing the load by wearing a loaded backpack. You might decrease the number of reps at this new load, but increase the number of sets. The idea here is to progressively load the tissues as you get stronger.
  8. Perform this exercise every other day.
  9. If you find you are not strong enough to do unilateral heel raises, try using both feet at the same time until you are stronger.
  10. This protocol is just a suggestion. Modify the load, reps, sets, and props, customizing it to suit your strength, flexibility, and movement history.

plantarfasciosis load5 plantarfasciosis load4

P.S. Look at how in the first picture, both ankles are dorsal flexed; and in the second both are plantar flexed. Not intentional. Just a neural pathway, I guess.

Consider adding this exercise to your foot health protocol of stretching, strengthening, and mobilizing your feet.

Namaste, Michele

Foot Cramp Fetish or How I Learned to Love the Marble Bridge and Relieve My Plantar Fasciitis

If you like foot cramps, then this is the exercise for you! Seriously, if FootLove Yoga has inspired you to move your feet more and in a variety of new ways, you may have discovered that some exercises cause your feet and lower legs to cramp. This is not surprising as cramps can be the result of:

  • muscle fatigue – the intrinsic muscles of your feet are weak
  • limited range of motion – your muscles are not at their optimal lengths and your joints are not accustomed to exploring new ranges of motion
  • poor circulation – muscles that don’t move don’t get much blood into the smallest blood vessels
  • increase in activity – your muscles are not prepared for the loads you are now asking of them

Good news is that if you continue to exercise your feet, spend more time barefoot, and make better shoe choices (thin, flat flexible sole with a wide toe box) your feet will get stronger and more flexible and the cramping will diminish and disappear for good.

I first learned of an exercise I call Marble Bridge from an article by Robin Rothenberg in the trade magazine Yoga Therapy Today. Robin learned of it from her colleague John Childers. I lean on their language to describe how and why it works.

Marble Bridge

    1. Lie on your back with your knees bent and your feet standing on the floor, pelvic width apart
    2. Place a yoga block or stack of books under your sacrum (this is the lowest part of your spine. Make sure the block is not under your lumbar curve.)
    3. Hold a marble or large bead with the toes of your right foot, curling your toes around it as you would if you were making a fist with your hand. If you don’t have a marble, you can pretend to hold one, but it doesn’t work as well.
    4. Extend your right knee, keeping your knees even with each other. This is equivalent to eka pada salamba setu bandha sarvangasana or one legged supported bridge pose in yoga
    5. Cramp Point your foot (plantar flex); hold for 5 seconds
    6. Cramp Flex your foot (dorsiflex); hold for 5 seconds
    7. Alternate cramping pointing and cramping flexing your foot for as long as you can stand it…
    8. If you cramp, release the marble, rest and begin again. You may need to lesson the amount of time in each foot position
    9. You can make this posture easier by removing the block
    10. You can make this exercise more challenging by doing a full, unsupported bridge

marblebridge4

What is happening?

The action of grasping the marble strongly contracts the flexor muscles on the bottom of your foot; while the action of pointing your foot strongly causes a contraction through the Achilles tendon all the way up into your calf; at the same time you are deeply actively stretching the extensors on the top of your foot and front of your lower leg. This is a perfect storm of eccentric contraction that strengthens your muscles, increases the range of motion in your feet, and improves circulation and waste removal to your lower legs & feet, especially the heels that receive little blood flow and are ground zero for plantar fasciitis.

Both Rothenberg & Childers use this exercise to treat clients with plantar fasciitis. Rothenberg explains that the plantar fascia is often “locked long” or, put another way, chronically tensed in extension. The fix for tissues in this state is to strengthen them, since chronic tension makes them weak, and simultaneously use strong contractions to counter the state of chronic extension. She combines undulating stretching with strong contractions. She cured her life long plantar fasciitis this way.

You can watch a video of this exercise on FootLove Yoga Facebook page.

Namaste, Michele

Simulating the Toe Off Event in Walking to Stretch Your Plantar Fascia

You learned in my first post on Plantar Fasciitis that stretching the plantar aponeurosis aka fascia is associated with better outcomes than other conservative, conventional treatments including anti-inflammatory medications, corticosteroid injections, and both custom and over the counter orthotics. In addition to stretching the tissues statically, you can functionally stretch the plantar fascia by simulating the tensioning of the plantar fascia that occurs during the propulsion phase of gait (walking). Three variations of the static stretch are provided in order of intensity, followed by a link to a video of the dynamic, functional stretch.

Plantar Fascia Stretch – Static

Plantar fascia stretch

Plantar fascia stretch

Plantar fascia stretch from my behind

Plantar fascia stretch from my behind

Level 1

  1. Stand up on your knees with the dorsal (top) sides of your feet and toes touching the floor.
  2. Extend the toes of your right foot forward, so that the bottoms of your toes are touching the floor
  3. Hold for 1 minute and repeat on left foot
Kneeling plantar fascia stretch

Kneeling plantar fascia stretch

Level 2

  1. Be on your hands and knees with the dorsal (top) sides of your feet and toes touching the floor.
  2. Extend the toes of your right foot forward, so that the bottoms of your toes are touching the floor
  3. Pressing your hips back towards your heels will increase the stretch
  4. Hold for 1 minute and repeat on left foot
Semi hands & knees plantar fascia stretch

Semi hands & knees plantar fascia stretch

Level 3

  1. Begin in either Level 1 or Level 2 starting position
  2. Extend the toes of your right foot forward, so that the bottoms of your toes are touching the floor
  3. Sit back on your heels (vajrasana) with your spine upright and neutral
  4. Hold for 1 minute and repeat on the left side

007

Plantar Fascia Stretch – Dynamic

  1. Be on your hands and knees with the dorsal (top) sides of your feet and toes touching the floor
  2. Bring your right foot forward until the sole is on the ground and your butt is on your left heel
  3. Rock forward from heel to toe on your right foot
  4. See the video of this on FootLove Yoga Facebook Page

Note in the photo above that I did not get my pinky toe extended forward. I should have reached around to coax that lil puddin into extension.

In any of the variations, try to reach back to your foot and massage the fascial tissue in a crosswise direction, providing an additional myofascial release of these sticky tissues.

Namaste, Michele

Back Up Your Hips to Cure Your Feet

Alignment Habits

In an earlier post, I suggested that you have three habits that are critical for the health of your feet. And you have control over the outcomes of each habit. Total control!

  1. The shoes you (choose to) wear
  2. How you move your feet
  3. How you align yourself

Every time I consider this list, I am tempted to declare that one is more important than the others. But, I never do, because they are equally culpable in impacting the tissues of your feet. An entangled lot they are.

Take alignment. Last week, I wrote about how to position your feet, when standing and walking, with the outside edges in a straight line. Feet that do not point straight ahead, but instead point out laterally or diagonally are one of the most effective alignment habits you can have for building a bunion. But there is another alignment habit that is just as prevalent and injurious. Standing with your pelvis shifted anterior of your body’s center of mass. Huh?

The mass of your pelvis is your center of gravity. If you draw a vertical line from heaven to hell, it should go through the exact center of your pelvis. You really could be the center of the universe. “Should” is key here. Wherever the center or mass of your pelvis is, that is where the bulk of your weight will be. If your pelvis is is vertically stacked over your knees, ankles and heels and vertically stacked under your shoulders & ears, then the bulk of your weight will be over the center of your heels, which is structurally the strongest part of your foot and the only place 100% of your weight should be. When your pelvis is shifted or thrust forward of your ankles/heels, your center of gravity, mass of your pelvis, bulk of your weight loads your forefoot, the weakest part of your foot. The tiny bones, muscles, and other tissues of your forefoot are intended for intrinsic movements and supporting the arches of your feet. Bearing weight on the front of your feet can contribute to plantar fasciitis, bunions, bone spurs, hammertoes, flat feet, metatarsalgia (pain at the base of the toes), and neuropathy.

There are other reasons for vertical stacking of your joints, all of which I will write about in more detail another time.

  • minimizes the forces that cause joint degeneration
  • signals your pelvis and femurs (your “hips”) to build more bone density, making them stronger and less susceptible to fractures

Getting Your Hips Back

My yoga students attest to the broken recordness of my cuing. “Hips back, hips back, hips back.” “Get your hips back over your heels.” “Your hips should be stacked over you knees, which should be stacked over your ankles.” “Keep your pelvis from shifting forward.” “Hips back, hips back, hips, back.” I never tire of saying it.

What and where are your hips anyway? Your hip is not a bone. Your hip is actually a joint made from your pelvis and femurs. Basically, the top of your femur (greater trochanter) fits into the socket or acetabulum at the side of your pelvis. When you place your hands on you “hips,” you are actually placing them on the top of your pelvis.

Here is how to get your hips back:

  1. Stand with your feet aligned – outer edges are straight. See building a bunion.
  2. Shift your weight back, all of it, into the center of your heels.
  3. Press the balls of your feet (not your toes) into the mat, without bringing your weight forward.
  4. With your hands on your hips, the top of your pelvis, gently guide your pelvis back** until your hip joint (about where the side seam of your jeans lies) is stacked directly above the side of your knee, which is stacked directly above your the side of your ankle at the maleolus bone, which is directly over the center of your heel.

**It is critical that you don’t rotate your pelvis back (tuck your tail) or forward (Beyonce your butt), but merely shift it back.

When you back your hips up, it may fee like your butt is sticking out behind you. That’s good. That’s where it should be, behind you. It’s why we call it your rear.

The images below will give you a visual of what it looks like to have your hips thrust forward (losing) or properly backed up (winning). This is from one of my favorite books from my favorite biomechanists Katy Bowman. Her book Every Woman’s Guide to Foot Pain Relief: The New Science of Health Feet is my go-to source for most things feet and is absolutely relevant for men too. In fact, I wish she had named it “Every Human’s Guide…” because other than a few strictly female bits, it is applicable regardless of gender.

Pelvis forward of center of gravit

Pelvis forward of center of gravity

In the image above, The stance on the left shows Katy’s center of gravity, her pelvis, is where it belongs. In contrast, she is definitely not vertically stacked in the stance on the right.

hipsback10002

In the image above, Katy’s pelvis is clearly shifted forward until the bulk of her weight is over her forefoot, which, overtime, could have disastrous consequences for her feet. On the right, her hips are backed up and her pelvis is over her knee, ankles, and heels.

hipsback10003

In the image on the left, Katy’s alignment is signaling the bone cells in her hips to build more bone density because the weight of her torso is stacked vertically. Her stance on the  right, overtime, will prove degenerative to her joints.

I’ll leave you with one final thought. Backing up your hips is a practice. It takes intention, practice, and time to instill this new alignment habit. Start today.

Namaste, Michele

What does Plantar Fasciitis, your down comforter, and your sleep position have in common?

Biomechanist Katy Bowman introduced me to the concept of casting. When you cast something, you immobilize it and its ingredients adapt to the shape of the cast. It happens in metals, clays, and body tissues. If you’ve ever broken a bone and worn a cast, you know that when you finally remove the cast, your tissues – bone, muscles, tendons, ligaments, fascia, even skin – have adapted to the position they have been held or casted in. We cast our bodies in many ways and with many apparati.

Take feet, for example. Most human feet are casted into the shapes of their shoes for many hours a day and have been that way for almost as many years as their operators have been alive. If your shoes have a tight toe box, are thick and rigidly soled, and have positive heels (any amount of heel elevation relative to the toe) then you have been casting your feet into a tight, weak, motor and sensory deprived mess. Maybe its what brought you to this blog.

Another way we cast our feet, which is particularly problematic for plantar fasciitis (PF), is by keeping them in plantar flexion aka “pointer” flexion, pointing our toes like a ballerina, when we sleep. This position is known to aggravate PF. Try this. Get in bed, lie on your back, pull on your heavy winter covers and notice what position your feet are in. They will be pointing. Now, pull the covers off of your feet and notice how they come into a more neutral position, not quite dorsiflexed (aka flexing your foot or ankle – opposite of pointing), but less plantar flexed. Podiatrists will sometimes prescribe an orthotic called a night splint that you wear to keep your foot in dorsiflexion. But a less extreme and more comfortable alternative that you might try if night splints are not for you is simply donning soft, warm socks (sadly, also a cast, but less problematic than plantar flexing) and sleep with your feet out of the covers.

If you turn over onto your belly, regardless of whether your feet are covered, your feet will automatically be in plantar flexion – again, bad for PF. If you are a belly sleeper and have PF, try to cultivate the habit of sleeping on your back or side. Start out your sleep this way and move onto your back/side whenever you naturally wake up during the night.

Namaste, Michele

Plantar Fasciitis: What we know; what we can do about it – January 5, 2015

Plantar fasciitis (PF) is one of the most common causes of heel pain. It affects both sedentary and athletic people. Classic symptoms include severe pain upon getting out of bed in the morning or after prolonged periods of rest. Pain usually improves with movement, but can get worse with long periods of standing.

soleoffoot1

What’s in a name? The plantar fascia is a thick fibrous band of tendons (technically not fascia) called aponeurosis that attaches at the inner heel, run along the bottom of the foot, and attaches at the base of the toes. While long thought to be a condition of acute inflammation, current thinking suggests that it is a chronic disease with evidence of tissue degeneration. Thus the term “plantar fasciosis” has been introduced. It is difficult to treat because of limited understanding of the mechanism by which the body heals chronic degeneration.

Anatomical risk factors include obesity, flat feet, high arches, and a shortened achilles tendon. Biomechanical risk factors are overpronation (inward roll of foot), limited ankle dorsiflexion (“flexing toes to shin), weak intrinsic muscles of the foot, weak plantar flexor muscles, and poor biomechanics & alignment. Environmental factors put us at risk too, such as deconditioning (being on bedrest or sedentary), hard surfaces, walking barefoot, prolonged weight bearing, inadequate stretching, and poor footwear.

I’ll focus on those biomechanical and environmental factors that can be addressed conservatively through yogasana, plantar fascia-specific stretching, alignment, and conditioning, aka FootLove Yoga.

FootLove Yoga and January’s Happy New Feet posts can help with:

  • Overpronation of the foot – may be improved by the Strong Yoga Foot (upcoming blog post)
  • Limited ankle dorsiflexion – may be improved by calf stretching (upcoming post)
  • Weak intrinsic muscles of the foot and weak plantar flexor muscles – can be strengthened by many of the exercises I’ll be sharing in the coming weeks.
  • Poor biomechanics (how you move) and alignment are two of three habits that have the most significant impact on the tissues & health of your feet – I will convey to you some fundamental changes you can make in how your move and align yourself that, overtime, could make a significant difference in your experience of PF.
  • Poor footwear or, rather, poor shoe selection is the third of the three habits that impact your feet – Get ready for a post on this sensitive subject. I AM NOT THE SHOE POLICE. Well, kinda I am. I DO NOT HATE SHOES. Not that much really.
  • Deconditioning of the foot, which may or may not be associated with overall deconditioning – everything we do in January will be with the aim of conditioning the feet.
  • Hard surfaces & walking barefoot will be explicitly addressed as part of conditioning the feet.
  • Prolonged weight bearing (which is a reality for many jobs) will be addressed with alignment. If you have to stand for long periods of time, there are ways to align and move yourself that will help.
  • Inadequate stretching – many of the FootLove exercises will stretch intrinsic & extrinsic foot muscles, calves, and hamstrings.

Since plantar fascia-specific stretching has the best statistically significant long-term results as compared to other treatments like anti-inflammatories,  corticosteroid injections, and most orthotics, let’s start with one of these evidence supported stretches.

Manual plantar fascia stretch with massage. Extend (stretch back) your toes with your hand and massage the plantar fascia crosswise. Stretch and massage your foot for a few minutes before taking your first steps after sleep or prolonged rest.

PF manual stretch with massage across the PF

PF manual stretch with massage

PF manual stretch with dog assist

PF manual stretch with dog assist

Some of the research I looked at.

Plantar Fasciitis: A Concise Review
Schwartz EN, Su J
Perm J. 2014 Winter;18(1):e105-7.

Plantar Fasciitis
Cutts S, Obi N, Pasapula C, Chan W.
Ann R Coll Surg Engl. Nov 2012; 94(8): 539–542.

Namaste, Michele