Plantar fascitis

REFERENCES
Calliet R 1981 Foot and Ankle Pain. FA
Davis Company, Philadelphia
Chaitow L 1996 Muscle Energy Techniques.
Churchill Livingstone, Edinburgh
Clemente C 1984 Anatomy: A Regional Atlas
of the Human Body. Urban and
Schwarzenberg, Baltimore-Munich
Dowd I 1996 Taking Root to Fly. Contact
Collaborations, Inc., New York

Kapandji IA 1974 Physiology of the Joints

Volume 2. Churchill Livingstone, New
York
Lewit K 1992 Manipulation in rehabilitation
of the motor system. Butterworth,
London
Rolf I 1977 Rolfing. Healing Arts Press,
Rochester
Travell, Simons 1983 Myofascial Pain and
Dysfunction: The Trigger Point Manual,

Volume 1 and Volume 2. Williams and

Wilkins, Baltimore
Warfel J 1981 Extremities. Lea & Febiger,
Philadelphia
Warwick and Williams 1974 Grays
Anatomy. WB Saunders Company,
Philadelphia. PA
Witt P 1999 Institute of Structural and
Integrative Somatics class lecture.

Physical therapy perspective

Janet Potts

Introduction
Traditionally, in physical therapy,
plantar fascitis is treated at the site
of the symptoms with use of
ultrasound, ice, exercise, soft tissue
mobilization, etc. Practitioners have
also focused attention on foot
mechanics, especially subtalar joint
pronation, and its involvement in
plantar fascitis as well as other
symptoms. Again, the treatment
area focused on with this approach
is at the foot with orthotic
fabrication and use. This author
wishes to present an approach,
which, rather than focusing on
a symptomatic model of care,
introduces the possibility that
attention to distant influences might
offer alternative therapeutic choices.

Janet Potts PT
4218 Idldale Drive
Fort Collins, CO 80526, USA

The questions she wishes to ask

include:
. Could plantar fascitis result from
a pelvic soft tissue and/or joint
imbalance?
. Furthermore, in the example of
our case study client, could
cranial restrictions influence a
pelvic imbalance and contribute
to symptoms of plantar fascitis?
The focus of this article is
threefold. The first aspect considers
cranial influences on the pelvis and
therefore on gait. The second section
considers a theoretical model of how
a pelvic imbalance, could result in
plantar fascitis. Lastly, clinical
findings, treatment approaches, and
the outcome of the care of the case
study patient will be presented as it
relates to this approach.

Functional anatomy
of the cranium, core link
and sacrum

Correspondence to: J. Potts

Tel.: +1 970 229 1617
Received August 2000
Revised September 2000
Accepted October 2000
...........................................
Journal of Bodywork and Movement Therapies (2001)
5(1), 45^49
# 2001 Harcourt Publishers Ltd
doi: 10.1054/jbmt.2000.0205, available online at
http://www.idealibrary.com on

The meninges of the brain and

spinal cord are the dura mater,
arachnoid and pia mater. Intracranially, the dura mater is fused to
the periosteum on the inner surface
of the skull with the strongest
attachments along the venous

sinuses and at the base of the skull

and circumferentially at the foramen
magnum. The dura mater has sheet
like projections that subdivide the
cranial cavity and are the falx
cerebri, the tentorium cerebelli, the
falx cerebelli, and the diaphragm
sellae (Fig. 1). Extracranially, the
dura attaches to the posterior
vertebral bodies of C1, C2 and
sometimes C3. It then continues as a
free sack until its firm attachment at
the second segment of the sacrum
anteriorly. It is here where the three
membranes blend and extend
through the sacral hiatus and
anchor at the tailbone (Hollinshead
1974).
According to craniosacral
concepts theorized in a
biomechanical model, each of the
cranial bones has a characteristic
motion that is considered normal
physiologic motion. During the
flexion phase of cranial motion, the
midline bones of the cranium
(sphenoid, occiput, ethmoid, and
vomer) are said to rotate anteriorly
or posteriorly about a transverse
axis into flexion. Simultaneously,
the paired peripheral bones (frontal,
parietal, temporals, maxillae,
palatines, zygomae) are said to
rotate externally around their
varied, specific axes (Fig. 2).

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Potts

The extension phase of cranial

motion is said to result in the
opposite motions as the cranial
bones return to their neutral/start
position. In addition, during the
flexion phase there is thought to be a
cephalad pull of the spinal dura due
to the attachment of the membranes
around the foramen magnum being
elevated. The motion at the sacrum,
which is thought to result, involves
the apex moving anteriorly and the
base moving posteriorly. The motion
of the sacrum occurs around a
transverse axis at the level of S2
the location of the dural attachment.
This motion, called respiratory
motion of the sacrum, is an
involuntary motion and differs from
the voluntary biomechanical motion
of the sacrum. It should be
understood however, that this
respiratory motion of the sacrum
often corresponds with pulmonary
respiration synchronistically; yet, the
two are distinct, separate entities
(Magoun 1976; Fig. 3).
As a result of the dural
attachments and the dural
membrane connections there is
thought to be a direct duplicating
motion of the occiput and
sacrococcygeal complex.
Sutherland, the father of cranial
osteopathy, described this
connection as the core link between
the pelvic bowl and the cranial bowl
(Magoun 1976). One can now
conceptualize how abnormal,
asymmetrical tensions placed on the
meningeal membranes by sacralcoccygeal dysfunctional motion
could be transmitted to the other
bones to which these membranes
attach (cranium and/or upper
cervicals). This situation could
theoretically result in abnormal
cranial motion. Conversely,
abnormal, asymmetrical intracranial
tensions or motion restrictions could
theoretically be transmitted to the
sacrum. For example, clinical
findings by this author show a high
correlation between left torsions of

Fig. 1 Dural membranes. As published in Cranial Manipulation, L. Chaitow, Churchill

Livingstone.

the sphenoid and left sacral torsions

and that right spheno-frontal
restrictions correlate highly with
upward shears of the right ilium.
Moreover, treatment of the
intracranial restrictions seems to be
able to promote direct correction of
sacral and illial lesion. Restricted
motion at either end of the core link
seems to be able to prevent
permanent correction of a lesion at
the other end of the link.
It has been said that the cranial
mechanism is the most cogent
manifestation of life itself (Magoun
1976). By definition, it has the power
to compel or constrain (MerriamWebster 1979). The physiological
functions of the body are said to be
controlled within its environment
(fourth ventricle). Therefore
restrictions of motion or cessation of
the entire pumping mechanism are
thought to be able to result in many,
varied and distant manifestations.

The eect of a
concentrically shortened
iliopsoas on foot
mechanics/plantar
fascitis: A theoretical
model
Plantar fascitis correlates highly
with prolonged or excessive

Fig. 2 Proposed motion of the cranium with

flexion phase of motion.

pronation of the foot. If the foot has

not returned to a supinated position
at push-off, then the foot is forced to
push off, not in a rigid bony lever,
but through increased tension in the
plantar fascia. Foot pronation may
be due to local problems or from
more proximal dysfunctions. A
common finding seen by this author,
in plantar fascitis, is a decreased
push-off in the gait cycle and
a concentrically contracted,
hypertonic iliopsoas.
In considering the effect of muscle
imbalance on gait, we must
recognize the functional
environment of the body, i.e. closed
chain functional kinetics versus

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Plantar fascitis

Fig. 3 The core link. As published in Palpation Skills, L. Chaitow, Churchill Livingstone.

open chain kinetics. Muscle function

during closed chain kinetics
involves an eccentric stabilizing,
decelerating, or accelerating muscle
contraction. Therefore, muscle
function, including that of the
iliopoas, during the weightbearing
portion of the gait cycle primarily
involves eccentric stabilizing,
decelerating, or accelerating muscle
contraction. (This is often the
opposite of the classic, concentric
action definition of the muscle).
EMG studies by Basmajian have
shown that during ambulation, the
iliacus muscle acts continuously
and peaks at two points in the gait
cycle. One peak is during the swing
phase and the other is at midstance.
The psoas peaks at these times, as
well as, a third peak at 50% of the
cycle during push-off (Basmajain
1985). Other research has shown
that accelerating muscle contraction
is most important during the swing
phase when the iliopsoas and
quadriceps femoris bring the limb
forward. This momentum
progression is then controlled and
stabilized by most muscles during
weightbearing and is of a
decelerating nature on the limb and
stabilizing type at the joints (Dykyj
1988). For example, the findings of
Simon et al. describe the role of the
posterior calf muscles in normal gait
as restraining the bodys own
forward momentum and not used to
propel it further (Simon 1978).
Therefore, the role of the iliopsoas
during the swing phase is
acceleration of motion and the

probable role during the

weightbearing phase is of
stabilization/deceleration. In
accordance with the nature of
closed-kinetic chain muscle
function this weightbearing
contraction would normally be
eccentric.
Research by Janda has shown
that muscle dysfunction is not a
random occurrence but that muscles
respond in characteristic patterns.
Postural-tonic muscles respond to
dysfunction by facilitation,
hypertonicity and shortening.
Dynamic-phasic muscles respond
to dysfunction by inhibition,
hypotonicity and inhibitory
weakness (Janda 1983). Therefore,
the iliopsoas responds to
dysfunction by becoming short and
hypertonic. This author proposes
that a dysfunctional, concentrically
shortened iliopsoas reduces push-off
in the gait cycle because it is acting
concentrically during a closed chain
weightbearing activity. When a
concentrically shortened iliopsoas
influence is unilateral or
asymmetrical a rotational
movement dysfunction is produced
in the pelvis and lumbar spine. For
example, a hypertonic right iliacus
will produce a left torsion of the
sacrum (anterior prominence of the
sacrum on the right/posterior
prominence on the left) due to its
anterior attachments to the sacrum.
(This finding also corresponds to the
action of a hypertonic left
piriformis). A hypertonic right psoas
assists in producing a left lumbar

rotation (transverse processes

prominent on the left).
As discussed above, sphenoid
torsions seem to correlate with
sacral torsions, and spheno-frontal
restrictions seem to correlate with
illial dysfunctions. Could sacral
torsions and illial dysfunctions
therefore be shown to influence gait
mechanics? Further study of this
dysfunctional gait pattern as it
relates to concentric versus eccentric
function of the iliopsoas; how
iliopsoas dysfunction relates to
pelvic obliquity, and how pelvic
obliquity relates to dysfunctional
gait patterns might demonstrate a
clear link between these factors and
the development of plantar fascitis.
Consideration has so far been
given to the influence of an iliopsoas
muscle imbalance on the push-off
phase to the gait cycle. Discussion
has also shown the possibility of a
dysfunctional iliopsoas contributing
to pelvic obliquity and functional
roto-scoliosis. The possibility has
been discussed that specific cranial
restrictions could contribute to this
pattern of dysfunction. What
follows is a presentation of the
findings, treatment and outcome for
the case-study patient, as it relates to
this approach.

Case study ndings,

treatment and outcome
The most significant, clinical findings
at the time of the physical therapy
initial evaluation of the case study
patient (Pamela) were as follows:
Subjective
The patients primary complaint was
frontal headaches occurring every
weak lasting for 15 days (pain scale
of 610/10) beginning 3 years
earlier. Her secondary complaint
was of daily foot pain on the left
greater than on the right (pain scale
of 05/10) occurring with more
weightbearing that began while

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Potts

running cross country 6 months

earlier. She also reported bilateral
anterior thigh pain that only
occurs with an increased activity level
(and reached a pain level of 10/10)
when she was running on the crosscountry team. (It is interesting to note
that anterior thigh pain is a referred
pain pattern of the iliopsoas
according to Simons and Travell
1992).
Gait
. Shuffling gait with minimal pushoff.
. Hard heel strike on the right
with circumduction of the right
foot.
Structural
. Valgus rearfoot position.
. equal leg lengths.
. Pelvic obliquity (right upward
shear of ilium; left sacral torsion
and sidebending).
. Functional rotoscoliosis (L5T6
concave right; T5T3 concave
left) with multiple segmental
motion restrictions.
Mobility
. Gross active and passive range
of motion was within normal
limits including passive
dorsiflexion.
Strength
. Plantar flexion was slightly weak
on the right side.
. Bilateral hip adductor weakness
with substitution including
dropping of contralateral
shoulder.
Soft tissue
. Left greater than right psoas
hypertonicity.

. Swelling on the posterior medial

arches of both feet.

Cranial dysfunction (dened by

direction of ease of motion)
. Spheno-basilar junction: left
torsion, superior vertical strain,
and right lateral strain.
. Left temporal and parietal
external rotation.
. Right temporal and parietal
internal rotation.
. Bilateral spheno-frontal
restrictions.
Treatment
From the evaluation, it was
determined that primary motion
restrictions were present in
Pamelas cranium and treatment
was initiated there. Her gait pattern
was observed after each stage of
treatment.
Pamelas gait pattern, following
treatment of her cranium,
demonstrated a more integrated, less
disruptive gait with less soupiness.
This improvement was notable but
not dramatic. However, it was
impressive to find that all of the
segmental functional scoliosis
components had normalized except
for the upward iliac shear.
This finding was then treated by
releasing of her left and right
illiopsoas muscle hypertonicity
(Box 1) until her iliac crests were of
equal heights. The sacrum was in
neutral after treatment of the
cranium. It was felt that the illiopsoas
hypertonicity imbalance was
influencing the structural inequality
rather than the sacroiliac joint itself.
After treatment of Pamelas
illiopsoas her gait was observed
again and found to be of a more
dramatically improved nature.
There was more equal weight
shifting on a more upright vertical
axis with markedly improved
equilibrium and fluidity.

Pamelas second visit was

approximately 10 days later and
included re-assessment of the
original findings. The functional
rotoscoliosis had maintained
correction and the cranial
restrictions were at a minimum.
A core-strengthening program
was then initiated with Pilatesbased exercises that emphasized
eccentric control of the psoas,
oblique and transverse abdominal
muscles, hip adductors, and the deep
external hip rotators. The Pilatesbased exercises neuro-muscularly
reprogram these muscles and
effectively lift the trunk off the feet,
decompressing the arch of the foot.
On the third visit Pamela was
reporting relief from her headaches.
Objective findings were as on the
second visit. Pilates-based footwork
exercises were initiated and her gait
was re-assessed afterward. There
was a dramatic decrease in the
shuffling gait pattern and Pamela
commented my knees are moving,
lifting.
Pamelas fourth visit revealed that
her improved gait pattern observed
after her last visit had been
maintained. She reported that this

Box 1

The patient lies supine with knees

bent and feet flat on the table. The
therapist palpates to find the psoas in
the lower abdominal area superior
and medial to the ASIS (resisting hip
flexion may be used to confirm the
location). Having made digital
contact via an oblique pressure
(towards the spine) the patient is
asked to rock the pelvis backward
into a posterior pelvic tilt and
forward into an anterior pelvic tilt,
but not to the extremes of the
motion. This motion is performed
gently, until a release is noted by the
palpating fingers. Usually there is a
significant decrease in tenderness to
palpation with this technique.

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Plantar fascitis

change in her gait felt more second

nature to her and that she was no
longer having foot pain.
Treatments were continued with
emphasis on improving her core and
adductor strength. After six total
treatments Pamela had walked 1/4
mile and ran 100 yards without
return of her symptoms. Her
headaches and daily foot pain had
not returned.
It is interesting to note that during
the course of her treatment she had
one significant exacerbation that
was a result of emotional stress. Her
shuffling gait pattern returned as
well as significant cranial
restrictions. To her credit, Pamela
was able to rebound after one
cranial treatment and her own
processing that this author believes
was a result of the tools she had
been given by and work she had
done with the body-mind therapist.
Outcome
Pamelas headaches and foot pain
was relieved after four treatment
sessions with a sedentary activity
level. Her symptoms have not

returned with the progressive return

to a running, walking and swimming
program. At the time of this writing,
one month since her last visit, Pamela
is able to run one mile without
exacerbation of her symptoms.

consider the whole body as well as

holistic influences including the
structural, biochemical, and mental/
emotional factors, so that we can
effectively enhance the self-corrective
nature of that individuals body.

Conclusion

REFERENCES

Foot or ankle dysfunction may

obviously precipitate disturbances
in the knee, hip, pelvis, low back.
Conversely, low back, hip, knee,
even cranial dysfunction can be
shown to have the potential to
precipitate disturbances in the gait.
From a clinical standpoint, either
structural/kinematic possibility
could be an etiological factor. In
addition, there exist a variety of
complimentary treatment
approaches of a particular condition
such as plantar fascitis, that produce
similar, beneficial, results.
The structural and kinematic
relationships that occur during gait
are complex and each client presents
with their individual set of
symptoms and dysfunctions. It is
our job as clinicians to openly

Basmajian JV, DeLuca CJ 1985 Muscles

Alive. Their Functions Revealed by
Electromyography. Williams and
Wilkins, Baltimore
Dykyj D 1988 Anatomy of Motion. Clinical
Podiatric Medicine and Surgery. July 5
477490 (Abstract)
Hollinshead WH 1974 Textbook of Anatomy.
Harper and Row, Hagerstown
Janda V 1983 Muscle Function Testing.
Butterworths, London
Magoun HI 1976 Osteopathy in the
Cranial Field. Sutherland Cranial
Teaching Foundation. Fort Worth,
Texas.
Websters New Collegiate Dictionary 1979
G&C Merriam Company, Springfield
Simon SR, Mann RA, Hagy JL, Larsen LJ
1978 Role of the Posterior Calf Muscles
in Normal Gait. Journal of Bone and
Joint Surgery; 60 465472 (Abstract)
Simons DG, Travell JG 1992 Myofascial Pain
and Dysfunction. The Trigger Point
Manual. Volume 2. Williams and
Wilkins, Baltimore

A chiropractic perspective
Terry Hambrick
This article contains parallel threads
of clinical information based both
Terry Hambrick DC
116 West Havard Street
Suite 2,
Fort Collins, CO 80525, USA
Correspondence to: T. Hambrick
Tel: +1 970 282 1173; Fax: +1970 2821175
E-mail: hambrick@peakpeak.com
Received August 2000
Revised September 2000
Accepted October 2000
...........................................
Journal of Bodywork and Movement Therapies (2001)
5(1), 49^55
# 2001 Harcourt Publishers Ltd
doi: 10.1054/jbmt.2000.0203, available online at
http://www.idealibrary.com on

on the general collective impressions

of the practitioners and the actual
impressions gleaned from evaluating
and treating (or recommending
treatment for) the same patient who
has served as a model for the project.
Fascia, both superficial and deep,
originates from mesenchymal tissue
and differentiates into forms suited
to their location and function in the
body. The fascia on the plantar
surface of the foot would be
considered a deep fascial sheet of
fibrous tissue that aids in supporting
the longitudinal arch. On the
calcaneus, the plantar fascia
attaches to the anterior margin
of the medial and lateral processes

and it (the fascia) extends into

a band that attaches at the base of
the metatarsals (Hamilton 1976).
It is of value in assessing the
plantar fascia to consider the
muscles that originate on the
calcaneus and assist in supporting
the longitudinal arch. The abductor
hallucis, flexor digitorum brevis and
the abductor digitus minimus all have
such attachments and provide
support, with the abductor digitus
minimus supporting the lateral
portion of the arch while the other
two form part of the medial arch
(Hamilton 1976).
Often, shortening of the
gastrocnemius and soleus is viewed

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