AddressingPlantarFasciitiswithPilates

JennaLamornaMcCabe

16December2016Wimbledon,UK,2016

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Abstract

ThispaperisabouttheuseofPilatestoaddressplantarfasciitis.Statisticsshow

thatbetween4%and7%ofpeopleintheworldhaveheelpainatanygiventime

andabout80%ofthesecasesareduetoplantarfasciitis1.Inflammationand

painfromthisconditioncanbesosevereitinhibitsday-to-dayactivityduetothe

inabilitytowalknormally.Thiscasestudylooksata50year-old,activeandfit

womanwhohasrecentlystartedsufferingwithplantarfasciitisinherleftheel.

Asaresult,herbodyhasasevereleft/rightimbalanceandhasstartedto

compensateforthepainwithnewmusclepatterns.Sheis12sessionsintoa20

sessionPilatesplan,advisedbyherdoctor.Withthecorrectfocus,Pilatescan

helphersignificantly.

1Beeson,P.“PlantarFasciopathy:revisitingtheriskfactors.”FootandAnkleSurgery.September2014.20:160-5

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Tableofcontents

AnatomicalDescription 4

Introduction:SufferingPlantarFasciitis 8

CaseStudy:TheClient 9

ConditioningProgramme 11

Conclusion 13

Bibliography 14

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AnatomicalDescription

PlantarFasciitisisinflammationoffascia–athick,white,fibrousbandoftissue,

fascia(orapneurosis),whichoriginatesatthemedialtubercleofthecalcaneus

(heel)andrunsforwardtoinsertintothedeep,shorttransverseligamentsofthe

metatarsalheads,dividinginto5digitalbandsatthemetatarsophalangeal

joints2.Thesebandseachextenddownthefivedistalphalanges,straddlingthe

flexortendons.

Theplantarfasciastretchesalongthesoleofthefoot,supportingthearchand

protectingthesolefrominjury3.Onthebottomofthefoottherearetwomajor

ligaments:thelongplantarligamentandshortplantarligament.Theligament

generallyreferredtoasthe‘plantarfascia’or‘fascia’isthelongplantar.When

theplantarfasciaisoverlystretched,tinytearscanoccuronthesurfaceofthe

muscle,causinginflammationandpain,whichisoftenfeltintheheeland/orthe

soleofthefoot4.Ahealthyplantarfascialigamentisstrongandsupportsthearch

withenoughelasticitytobeartheimpactofthespringinyourwalk.

2 Williams,P.L.,Warwick,R.Gray’sAnatomy.Philadelphia:WBSaunder;1980.36:612-6133“PlantarFasciaAnatomy.”DocPods.DocpodsPtyLtd,Web.Copyright2016.http://www.docpods.com/plantar-fascia-anatomy4Beeson,P.“PlantarFasciopathy:revisitingtheriskfactors.”FootandAnkleSurgery.September2014.20:160-5

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Thesuperficiallayerofplantarfasciaembedsintotheskinfoldbetweensoleand

thetoes5.Thedeeperlayerextendstoembracethedigitalflexortendonsoneach

proximalphalanx.Plantarfasciacanbedividedlaterallyintothreedistinctparts:

themedialpart,thecentralpartandthelateralpart.Thecentralpartisthe

thickestandthelargestpartrunningbetweentherelativelythinnerandless

prominentmedialandlateralparts.

Duringwalking,theplantarfasciafunctionsmainlywhentoespassivelydorsi-

flexduring"heelrise"to"toeoff"6.Itstabilizesthearchofthefootandallows

flexionofthefirstmetatarsal,enablingthefirstmetatarsaltocarrythemajority

ofthebodyweight.Italsoprovidesshockabsorptionwhenthefoothitsthe

ground.

5“PlantarFasciaAnatomy.”DocPods.DocpodsPtyLtd,Web.Copyright2016.http://www.docpods.com/plantar-fascia-anatomy6“BodyMaps–PlantarApneurosis.”Healthline.HealthlineMedia,Web.Copyright2016.http://www.healthline.com/human-body-maps/plantar-aponeurosis

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Asyoucanseeintheimageabove,theplantarfasciaisenclosedbetweena

numberofkeymuscles,whichactontheankleandfoot.Thetibialisposterior

(whichconnectsthelowerleg–andspecificallytheperoneuslongusand

peroneusbrevis-tothearchandundersideofthefoot)andtibialisanterior

(whichrunsacrossthetibia,fibulaandankletothemedialarchofthefoot)are

theclosesttwomajormusclesneighbouringtheplantarfasciawhichenable

dorsiflexion,plantarflexionandinversionofthefoot.

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Otherimportantmusclesthatwillimpact,orbeaffectedbythemovementofthe

plantarfasciainclude:

- Theextensordigitoriumlongus,whichrunsdownthefibulaandattaches

tothetopofthefourouterdistalphalanges.

- Thegastrocnemius(prominentcalfmuscle),whichconnectsfromthe

lowerfemurtothecalcaneus(heel)viatheAchillestendon.

- Thesoleus,whichrunsdownthebackofthetibiabelowthe

gastrocnemiusintothecalcaneusviatheAchillestendon.

- Thepernoealslongusandbrevisasmentionedabove,whichoriginateat

thefibulaandinsertviathetibialisposteriorintotheundersideofthe

foot.

Itisimportanttobeawareofhowthesemusclesareconnectedandfunctionin

relationtotheplantarfasciawhenaddressinganissue/injuryandtheresulting

compensationsofthistoo.

Movementsofankle-footjointandtheprimarymusclesthatproducethese

movements7:

Joint Movement PrimaryMover

Ankle-foot Dorsiflexion Tibialisanterior,extensordigitoriumlongus

Ankle-foot Plantarflexion Gastrocnemius,soleus

Ankle-foot Inversion Tibialisanterior,tibialisposterior

Ankle-foot Eversion Peroneuslongus,peroneusbrevis

7Isacowitz,Rael.StudyGuide:ComprehensiveCourse.CostaMesa,California:BodyArtsandScienceInternational,2013.

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Introduction:SufferingPlantarFasciitis

Statisticsshowthatbetween4%and7%ofpeopleintheworldhaveheelpainat

anygiventimeandabout80%ofthesecasesareduetoplantarfasciitis8.It

becomesmorecommonwithageanditisunclearifonesexismoreaffectedthan

theother.

Thosesufferingwithplantarfasciitiswilloftenfeelthemostseverepainduring

thefirststepsoftheday,orafterthefoothasbeenrested.Bendingthefootand

toesupwards,puttingweightontheheelandexposingthesole/heeltoimpact

canintensifypain.Irritantsofplantarfasciitisarecitedaslongperiodsof

standing,supinationofthefootduetomisalignment,increasedorintensified

impactexercise,orobesity.

Symptomsofplantarfasciitisarecitedas:inflammation,tightcalves,the

shortenedplantarfasciaprotrudingthesolewhenyoustretchit(i.e.during

dorsiflexion)duetotension,anatomicalfoot-anklealignmentproblemsdueto

compensation,alackofstrengthinsupporting/neighboringmusclesanda

‘handedness’imbalance,whichfavoursthedominantsideofthebody.

Adoctor,orthopedicfootspecialist,podiatristorchiropodistmustclearclients

toundertakePilatesbeforestartingacourseofsessions.

8Beeson,P.“PlantarFasciopathy:revisitingtheriskfactors.”FootandAnkleSurgery.September2014.20:160-5

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CaseStudy:TheClient

Aliceisa50year-old‘stayathome’mumoffourchildrenwhoseagesnowrange

between17and26.Shepracticesyogaandisakeenrunner.Althoughshehas

alwaysbeenactivewiththechildrenandwalkingherdog,shehasrecently

startedrunninganincreasedamounttotrainforamarathon.Shehassuffered

withpatellainjuries/irritationonherlefthandsideinpreviousyearsonafew

occasions,buthasalwaysmanagedthisseeingaphysiotherapist.Around4

monthsago,theonsetofplantarfasciitisinherleftfootforcedhertoseek

medicalhelpasthepainbecamesoseverethatshecouldnolongerwalkaround

withoutextremediscomfort.Shewasclearedandadvisedtostartundertaking

PilatesinlateSeptemberwhenshewasreferredtothestudio.Wearenow12

sessionsinandshehasmadehugeprogressintermsofre-balancingherbody.Of

herlowerlimbs,herleftsideisstrong(andclearlytakesthebruntofimpact

whenrunningandwalking)whilstherrightsideisveryweakthroughthefoot-

ankle,kneeandevenhip.Shehasaslightanteriorpelvictiltandishavingto

consciouslyworkonherpelvicengagementtore-alignthis.Hertransverse

abdominusrequiressomeextraattention,butotherwisehertrunkstabilization

andoblique/rectusabdominusstrengthisgood.Shecarriesverylittleexcess

weight;sheisgenerallyflexibleandisincrediblyfitasidefromhercurrent

plantarfasciitisissue.Herlumbarspinearticulationislimitedbutshehasno

lowerbackpain.Therestofherspinearticulateswellandherupperbodyis

strong.Intermsofherlowerextremity,heradductorsareweakandneedtobe

trainedtoengage(forexampleduringpelviccurlsandanyexerciseswithlegson

tabletop).Hercalvesareverytightonbothlegs,butmoresotheleft.Herleft

footalsohasquiteaseveresupinationduringmovement.Shecurrentlydirects

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moreweightthanusualintotheballofherleftfoottocompensateforthepainin

herheel,whichhasstartedtoslightlyliftherlefthipupwards,andthisneedsto

beobservedcloselyduringsessionstoensureincorrectmusclepatternsarenot

adapted.

AconditioningprogrammeusingtheBASIBlockSystemisbeingusedtowork

withAlice’sbodyholistically.ThetenBASIprinciplesofawareness,balance,

breath,concentration,centre,control,efficiency,flow,precision

andharmonyarebeingutilizedandAliceisparticularlyreceptiveto

concentration,control,breathandflow.Shedoes,however,understandan

increasedneedforprecisionandbalance(inparticular)tocorrectherissue.

HercurrentsessionsfollowtheBASIblocksystemandfocusonexerciseswithin

eachblockthatwillalsotargetherissueareasof:

- Foot-anklealignment(leftsupination),strengthandstretching

- Encouragementofperonealengagementontheleft

- Encouragementofadductorengagementonbothlegs

- Calf,archoffootandAchillesstretching

- Rebalancingoflowerextremities(leftdominant)

- Realignmentofslightlefthipcompensation

- Correctionofanteriortiltandencouragementofpelvicengagement

- Transverseabdominusstrengthening

- Increasinglumbarspinearticulation

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ConditioningProgramme

Note:repsshouldbeslow,controlledandchoreographedwithbreathing

BASIBlock Apparatus Exercise(s) NotesWarm-up Mat/

Cadillacbed

Pelviccurl,Spinetwistsupine,Chestlift,Chestliftwithrotation6repseach

Checkpressingequallythroughthefeet,watchkneesdon’textend

outwards,kneesandanklestogetherandlevelinSpinesupine

twist

Footwork Reformer3red

Parallelheels,paralleltoes,V-positiontoes,OpenV-position

heels,OpenV-position

toes,Calfraises,Prances,

Prehensile(ifcomfortable),Singlelegheels,Singlelegtoes6-8repseach

Watchfootalignment(especiallyleftsupination)andweight

placement,ensurecorrectflexionineachposition,checkfoot-ankle-

knee-hipalignment,engageadductorsandhipadductors

whenkneesexternallyrotated,incalfraises,usethefullrangeof

anklemotionthroughthesubtalarjoint,inprehensilewrapthefeetandreachtheheelsunderthebar,

insinglelegmaintainpelvicstabilityandcorrectfoot-ankle-knee-hipalignment-especiallyon

weakerleg

Abdominalwork

Reformer1red+1blue

Hundred,Co-ordination8repseach

Pelvic-lumbarstabilisation,usedeepabdominalstoliftheadandchest,neckinlinewithspine–notension,imprintlowerback,adductorsactivated,kneesandanklesgluedtogetheruntilstrongandpreciseopen-closeinco-

ordination

Hipwork Cadillac2yellow

Frog,Hipcircles(down,up),

Walking,Bicycle10repseach

Encourageequalandlevelmovementthroughbothhipsandlegs–watchingdominantvsweak

side,watchlefthipraising,lengthenthroughleftside,ensurepelvisremainsstableandsacrum

onthebed

Spinalarticulation

Cadillac1red

Monkey,Tower

prep/Tower6-8repseach

Watchfootalignmentindorsi/plantarflexionthroughout,

controlwithtransverseabdominals

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Stretching Reformer1red

Standinglunge6-8repseach

side

Guidepelvicmovementalonghorizontallinefromposteriortoanterior,hipslevel,knees/anklesalignedwithhip,dorsiflexfootonsupportinglegwheninhamstringstretch-watchingsupination,

long,flatspine

FullBodyIntegration

Reformer1red+1blue

Stomachmassageround

back10-12reps

Ccurvespine&neck,shouldersabovehips,watchfootalignmentindorsi/plantarflexionatstraight

leg

Armwork Wundachair

1/2or2/2triceps

3/2or3/3backwardfacingdips

Tricepsseated,Backwardfacing

dips2xsetsof8-10

each

Longspine,trunkengagementandstabilisation,engagelegsandankles-feet,kneestogether,wideandstablescapuli,elbowparallel

Legwork Wundachair0/2

Legpressstanding12-15reps

Strongplantarflexion,pressthroughallmetatarsalsequally,ensurefoot-ankle-knee-hip

alignment,pullupthroughcore

Lateralflexion&rotation

Wundachair

0/2or0/1

Sideover8-10repseach

side

Legsandpelvisstable,anchorfootofthestraightlegonthefloor,lengthenequallythroughhiponeachside,workincoronalplane

only

Backextension

Wundachair

2/2or1/2

Basicswan Trunkstabilisation,abdominalengagement,legsengagedandparalleltofloor,kneesandfeet

gluedtogether,feetstrongplantarflexion,pressintopedaltowiden

shouldersaslift

Conclusion

ThisprogramshouldsignificantlyimprovethestrengthandalignmentofAlice’s

lowerextremities–especiallythefoot-anklearea-throughaspecificfocuson

recruitmentofthemajorlegmuscles(quadriceps,hamstringsand

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gastrocnemius)aswellasspecificsmallermusclesinandaroundthesubtalar

joint.Itisalwaysimportanttoworktowardsbalancedmovementacrossthe

wholebody,despitespecificareaissuesandinadditiontothis,breathingand

mind/bodyawarenessshouldbeencouraged.Tailoredsessionswillensure

optimalimprovementinAlice’sconditionandthiswillalsobeverymuch

dependentonstrongobservationandattentiontodetailbytheinstructorwithin

thesessions.

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Bibliography

Beeson,P.“PlantarFasciopathy:revisitingtheriskfactors.”FootandAnkleSurgery.September2014.20:160-5

“BodyMaps–PlantarApneurosis.”Healthline.HealthlineMedia,Web.Copyright

2016.http://www.healthline.com/human-body-maps/plantar-aponeurosis

Isacowitz,Rael.Pilates:SecondEdition.USA:HumanKinetics,2014.

Isacowitz,Rael.StudyGuide:ComprehensiveCourse.CostaMesa,California:BodyArtsandScienceInternational,2013.

“PlantarFasciaAnatomy.”DocPods.DocpodsPtyLtd,Web.Copyright2016.

http://www.docpods.com/plantar-fascia-anatomy

Patterson,J.TeachingPilatesforPosturalInjuriesandFaults:APracticalGuide.Oxford,UK:Butterworth-Heinemann,2010.

Williams,P.L.,Warwick,R.Gray’sAnatomy.Philadelphia:WBSaunder;1980.

36:612-613