Plantar fasciitis and foot pain are two of the most common and problematic impairments people suffer from. This can be a challenging thing to fix for a number of reasons, however, there is one reason in particular that inhibits complete recovery – inflammation of the periosteum at the tibialis posterior tendon attachments in the foot. Remember, these attachments are the deepest attachments in the arch of the foot and are basically impossible to properly treat without needles. If the periostitis is not addressed, foot pathology and pain will likely never go away completely. Lucky for us, using needles makes treating the periosteum super easy. Implementing needles into your treatments will lead to faster, more complete and longer lasting results.

Check out my previous blog on plantar fasciitis.

Plantar fasciitis and foot pain are common impairments that inhibit and hinder millions of people from performing their activities of daily living (ADL’s). This should not surprise anyone, especially here in the USA. Decreasing the massive obesity problem in our country would significantly reduce basically all medical problems, including foot pain. There is not a single medical issue that is not exacerbated by autonomic nervous system (ANS) dysregulation and conversely, there is not a medical impairment that I am aware of that is not helped by ANS homeostasis.

For every 1 pound of body weight you lose, the force going through your knee joint, every time you take a step, is decreased by about 4 pounds.

It works the other way around also. This ratio is even more severe in the ankle and foot because the joints are smaller. So, let’s say you lose 20 pounds and you try to take 2,000 steps a day. That’s 80 pounds less force going through each knee, every step. 80 x 2,000 = 160,000 pounds. That’s 160,000 less pounds of force going through each knee every day. Again, amplify that effect in the ankle and foot. Think that makes any difference in how much your feet hurt?

Tibialis Posterior

The tibialis posterior is the most problematic muscle in the arch of the foot, when it comes to plantar fasciitis, and foot pain in general. Remember, this is the deepest muscle in the calf and it starts just below the knee. The tibialis posterior tendon wraps around the medial malleolus and attaches at the base of metatarsals (2-4, typically) and holds our arch in whatever position is normal for you. If you have any arch at all, and you cut the tibialis posterior tendon, your arch will collapse with weight bearing. So, if cutting the tendon makes the arch flat, what happens if you shorten the tendon? No, the foot doesn’t fall off, hopefully… If it does, call me… The arch gets bigger, taller.

The overall length of muscles gets shorter when knots (trigger points) are present. This is just like tying a knot in a rope. The more knots in the rope, the shorter it gets. The shorter the tibialis posterior gets, the higher the arch gets. The higher the arch gets, the more stress and force is displaced into the bottom of the foot while walking. This is one of the ways, the most common way, I think, that the plantar fascia and other structures on the bottom of the foot become inflamed and painful.

One of the reasons plantar fasciitis is such a chronic problem for a lot of people, even after years of treatment, is that treating the primary cause of the pain, the tibialis posterior, is basically impossible to treat. Unless you dry needle. Then its super easy to treat. Without needles, you cannot directly touch and treat the tibialis posterior. This is the case for everything but skin all over the body. The easiest location to access the tib posterior muscle is the distal, medial portion of the calf. It can be accessed anywhere behind the tibia by inserting a needle through the calf complex, although, this may be uncomfortable. The tendon can be needled anywhere from the medial high ankle to the attachments in the foot. The easiest place to needle the tendon, which works awesome, is directly adjacent to the medial malleolus. Remember, with a large, long muscle (lever arm) using a bony fulcrum and a short tendon past the fulcrum (force arm), the tibialis posterior muscle belly directs powerful forces through its tendon, into the foot. When any tendon starts pulling extra hard on the bony, periosteal attachment, periostitis ensues. Bone inflammation leads to further muscle shortening, tissue hypoxia, chemically induced pain, more muscle shortening, more pain, and the negative feedback loop of nastiness continues.

Another problematic thing a short tibialis posterior does is cause joint displacement.

All short muscles, for that matter, cause joint displacement. This displacement starts in the foot, at the bottom of the kinetic chain. This can lead to joint displacement anywhere else in the entire body, depending on the individual persons particular compensatory patterns. It is not uncommon for foot pain and joint problems to lead to cervical pain and joint problems, which can, in turn, cause arm pain, dizziness, increased compensatory gait patterns, and worse foot pain.

This is why it is vital to treat the whole body when you are working with your patients. If you just address the painful area, you are not addressing the entire problem. You may not be addressing the cause of the problem at all. Just because someone complains of pain in a certain area, that does not necessarily mean the painful area is the reason for the pain. The calf complex has amazing effects on shoulder ROM, cerebral blood flow, balance, etc. There was a recent study I read that showed correlation between chronic calf tightness and early onset dementia.

Vasoconstriction Exacerbates Plantar Fasciitis & Foot Pain

Tibialis posterior hypertrophy, thickening, happens when the muscle gets angry. Remember, the tibial nerve, artery and vein typically run between the tibialis posterior and the soleus. With a thick, grumpy tibialis posterior, the tibial vein gets smushed between it and the soleus. Tight muscles have a hard time slowing down arterial blood flow, as arteries have a smooth muscle lining and thick walls to hold against blood pressure. Veinous blood flow, however, is easily restricted by tight muscles. So, if you have normal or increased blood flowing down to an inflamed foot, and the return tubes, the veins, are smushed and narrower than usual, a blood traffic jam and swelling begins. This leads to stagnant blood laden with pain amplifying chemicals hanging out in the foot.

Remember, one of the ways blood returns to the heart is via “milking” of the veins by muscle contraction. Veins have valves that allow blood to go towards the heart, but not backwards. So, when a muscle contracts around a vein, it squeezes the vein and the blood can only go one direction, towards the heart. The reason varicose veins are so visible is because their valves are broken, which decreases their stability and allows blood to get pulled backwards by gravity. Thick, hypertrophied, shortened, angry muscles with knots in them do not contract uniformly or strongly. Knots are hypercontracted groups of sarcomeres (building blocks of muscles) that can shut off just about all the blood flowing through that hypercontracted tissue. This leads to hypoxia, more shortening, more chemical, more pain. All of these factors significantly impede the veinous milking necessary for normal blood flow through the foot.

Secondary to the anatomy of the tibialis posterior tendon attachment in the foot, any muscular or tendinous shortening will, in turn, compress the mid-foot and rear-foot joints. Joint compression leads to joint capsule hypomobility and cartilage degradation. Remember, the inside of joint capsules contain synovial tissue that produces synovial fluid. Capsule movement stimulates the synovial tissue to produce synovial fluid. Think of this as the oil for our joints. Without normal capsular ROM, synovial fluid production inside the capsule is diminished. When this happens, it’s like driving a car with really old, thick, nasty oil in the engine. This is not good for our joints and leads to acceleration of joint degradation, pain and impairment.

Dry Needling to Treat Plantar Fasciitis

Dry needling is the best way we currently have to decrease joint compression. Like, the best way that currently exists on planet earth. Not to mention the homeostatic effects of needling on the autonomic nervous system. Once the muscles and other tissues are normalized, joint manipulation becomes more effective, as the tissues that caused the joint deviation are now in a more anatomic position. This allows a more thorough, comfortable and lasting manipulation of the joint. If you regulate muscles and do not regulate joints, the muscles will return to a pathologic state. If you regulate joints only, the whole reason the joints get deviated in the first place, the muscles, are not addressed, the muscles. This is why combining dry needling and manipulation is such a huge advantage, as opposed to using one, but not the other. Taking advantage of their synergy amplifies their efficacy exponentially.

Don’t forget to treat bilateral and connect the spinal level to whatever nerve innervation you are treating. Doing this really adds another layer of efficacy to the treatment, I think through increased neural plasticity and ANS homeostasis. If you pay attention, sometimes you notice a histamine response in the exact area you are needling, but on the opposite side. Other times, patients will mention a pain response to a needle, but in the opposite side of the body from where the needles are. Sorcery, aliens, or the little elf that steals my socks out of the dryer… how else would this wonderful weirdness happen? I don’t treat as heavily on the non-affected side, but pick a few pieces of pathologic tissue to connect low frequency (1-5 Hz) stim to. The neurophysiologic mechanism of action by which treating bilaterally functions is poorly understood, as is most medical stuff. The important thing is that it works, we will figure it out more completely at some point. Keep an eye out for new breakthroughs in quantum biology.

I like to needle down to the periosteum of the L4-S4 spinal nerves when treating the tibialis posterior and the foot, since these nerves innervate those structures. Although L4 does not innervate the foot, crossing junctional zones of the spine and ANS divisions adds another layer of efficacy to the treatment. Remember, the ANS goes from primarily sympathetic in the lumbar spine to parasympathetic at S2-S4. Again, exactly why crossing these zones works is poorly understood, but it works. Treating the S2-S4 spinal segments will also treat the pelvic floor musculature. These muscles are often completely disregarded, but are of vital importance to treat to regulate the ANS toward homeostasis. The pelvic floor muscles, when tight, also cause pelvic joint deviation, which, in turn, can cause just about any joint or muscle problem out there, including plantar fasciitis.

References

Foot Pathology

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Autonomic Nervous System

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