Pacific College of Oriental Medicine Alumni

To have peace in one's soul is the greatest happiness. - Oriental Wisdom

Practice Building

Continuing Ed
Pacific Symposium
Additional CEU Events
CEU Tapes

Alumni events

Alumni Profiles

Oriental Medicine News

Update Your Info

Alumni Email List

Request Records

Download Graduate Exit Interview

Alumni Minutes

Classifieds
Jobs
Opportunities
Office Space
For Sale

An Acupuncturist's Guide to the Treatment and Assessment of Plantar Fasciitis and Excessive Foot Pronation

By Matt Callison, L.Ac.

The feet play a very important role in dynamic posture and balance, although a change in the foot mechanics can predispose the foot and body to injury. Shaped like a half dome, the foot has two primary arches that provide shock-absorbing features during weight-bearing activities. A collapse of one or both of these arches puts overwhelming stress on the soft tissue and joint components of the foot, which can cause pain somewhere along the musculoskeletal chain. In this article, we will examine excessive foot pronation, its role with plantar fasciitis, and how acupuncture can effectively treat this syndrome. In addition, we will discuss rehabilitative exercises and the indications for arch support use.

First, a brief functional anatomy overview of the foot is needed in order to continue. The foot and ankle consist of 26 bones articulating with 30 synovial joints, supported by over 100 ligaments and 30 muscles.

The distal tibia and fibula meet the talus bone to form the talocrural joint, commonly known as the ankle joint. The talus bone sits between the medial and lateral malleolus in the mortise cavity, aligned directly below the tibia. With no muscle attachment to it, the talus bone acts as a pivot for the ankle joint, in which the gastrocnemius and soleus moves the joint into plantarflexion while the tibialis anterior and toe extensors perform dorsiflexion.

Distal form the ankle joint, the inferior surface of the talus articulates with the calcaneus (heel bone), making up the subtalar joint. One the medial side of the foot, the head of the talus articulates with the navicular bone. This joint can be palpated at SP 5 (Shangqiu) as the foot moves in and out of inversion. On the lateral side of the foot, approximately half way between UB 62 (Shenmai) and UB 63 (Jinmen), the calcaneus articulates with the cuboid. These joints combined (the subtalar, talonavicular and calcaneocuboid) have the primary function of absorbing the rotation of the lower extremity by producing movements of supination (inversion, plantarflexion and adduction) and pronation (eversion, dorsiflexion and abduction).

The key muscles responsible for these movements are the gastrocnemius/soleus group (triceps surae) and the anterior and posterior tibialis muscles. When these lower extremity muscles fail to adequately control the subtalar motion, hypermobility can exist. When left untreated, this may lead to the development of many foot and ankle problems.

The bones of the foot are arranged structurally to form three arches. The two main shock-absorbing arches are the medical longitudinal arch, which runs the medial length of the foot, and the anterior transverse arch that runs across the width of the distal forefoot. The third arch, the lateral longitudinal arch, runs the length of the lateral side and is more functional during weight bearing positions.

The medial longitudinal arch, traversed by the spleen and kidney channels, extends from the calcaneus through the first three metatarsals. It is the longest and highest arch, and is the most dynamic as a shock absorber during static support and movement. The navicular bone is the keystone of the medical arch and is found at the arch's high point, just above K 2 (Rangu). This point can be very tender when the navicular bone drops inferiorly as in foot hyperpronation (Fig. 4). The tendon of the tibialis posterior inserts on the navicular bone and is important in maintaining the integrity of this arch, whereas weakness of this muscle can lead to a pronated position of the foot.

The major ligamentous support with the greatest contribution for the medial arch is provided by the plantar aponeurosis.

The plantar aponeurosis, or plantar fascia, is a fibrous band that runs distally from the plantar medial aspect of the calcaneus to the metetarsalphalangeal joints.

The anterior transverse arch, or metatarsal arch, extends approximately from UB 65 (Shugu) crossing with K 1(Yongquan) to meet SP 3 (Taibai). This arch also provides shock absorption as it depresses and spreads during weight bearing.

The lateral longitudinal arch extends from the calcaneus through the last two metatarsals. It is shorter and lower than the medial arch with its keystone bone being the cuboid, located just above UB 63 (Jinmen).

Foot pronation is often referred to as something that is dysfunctional or abnormal. On the contrary, foot pronation is part of normal foot motion during gait. Pronation acts as a shock absorber mechanism for the forces applied onto the foot, especially when the foot comes into full contact with the ground. It is when the medial longitudinal arch begins to fall, or has fallen, that the foot hyperpronates. The patient's foot may have the appearance of a normal arch when in a non-weight-bearing position such as laying down or sitting, but when standing up, bearing weight on the foot, the medial arch falls, creating excessive pronation (Fig. 3 and 4). Excessive pronation stretches the soft tissue that supports the arch, forcing the muscles to work harder in order to control the hyperpronation from this stretched position. The puts overwhelming stress on the soft tissue and joint components of the foot, causing pain somewhere along the musculoskeletal chain. The result may be plantar fasciitis, morton's nroma, shin splints, knee problems and more. Many people have overly pronated feet without any musculoskeletal complaints, although in a clinical study of 50 people with musculoskeletal pain, 84% of the patients had excessive foot pronation.

Signs of excessive foot pronation:

Helbing's sign, a medial bowing of the Achilles tendon

Foot flare when standing or during gait.
Internal knee rotation, the center of the patella angles inwards. The wet foot test. Have the patient wet his feet and walk on a smooth, dry surface to view the body's weight distribution as evidenced by the footprint.

A protruding medial malleolus and a low medial arch. This can be measured with the following techniques:

From a standing position, a measurement can be taken between K2 (Rangu) and the floor for each foot, comparing them for fallen arches. If there is a difference between the feet greater than 3-4mm then there is a moderate to high risk of injury.

A measurement taken on one foot at a time, from a non-weight bearing position and compared with a weight bearing position, is significant in assessing the medical arch. If there is a difference in the arch from weight bearing to non-weight bearing greater than 5-7mm then there is a moderate to high risk of injury. The measurement is taken from K2 (Rangu) to the floor in both positions. The patient can place the body weight on the back leg for the non-weight bearing measurement.

A weak foot may develop into a hyperpronated foot for various reasons:

Inactivity during childhood and adolescence may fail to develop the strength of muscles and ligaments needed to support the body weight.
Constant walking on hard, flat surfaces such as cement sidewalks without proper foot support.
An imbalance between the posterior and anterior leg muscles. A shortened gastrocnemius/soleus group (triceps surae) tends to flatten the medical arch and stretch and weaken the small muscles and ligaments of the foot.
Weakening of the small plantar muscles, ligaments and plantar fascia allows the larger muscles to become imbalanced in an attempt to allay the strain upon the ligaments.
Weakening of the tibialis posterior and shortening of the peroneus group.

The health of the spleen and kidney organs/meridians needs to be assessed due to the influence of these organs and meridians on the bony structure and soft tissue. The kidney meridian from K1 (Yaoquan), K6 (Zhaohai) and spleen meridian from SP 2 (Dadu) to SP 5 (Shangqiu) traverse along supportive medical arch anatomy, thus an excessively pronated foot can most certainly create stagnation of qi in this area. Needling motor points, selective ah-shi points and acupuncture points to clear stagnation benefits these conditions. However, once the arch has collapsed from a functional deformity into a structural one, there is a limitation on what can be done with needle stimulation and exercises. Once the longitudinal arch has flattened, it cannot be elevated by exercising the muscles of the foot, as it is impossible for them to exert a tension great enough to raise a fallen arch.

While using orthotic shoe inserts can be very effective for supporting the medical arch, an effort to strengthen the supporting soft tissue for arch stabilization should be considered first. Adding integrity to the foot/ankle complex with acupuncture treatment and rehabilitative exercises may be effective in eliminating the patient's complaints.

Rehabilitative Exercises

These exercises have three mean objectives: to improve the local circulation, to stabilize the foot in the correct position in relation to the leg and to improve the range of motion of the individual joints.

Towel exercises

Exercise #1

Have the patient sit on a chair and place a towel on a smooth surface floor. Place the foot flat on the edge of the towel so that most of the towel is forward, away from the foot.

The patient scrunches the towel under the foot, which moves the far end of the towel towards the foot. Make sure the foot stays on floor as flexing the toes and forefoot creates the movement. Add a weight to the end of the towel to provide resistance.

Exercise #2

Have the patient sit on a chair and place a towel on a smooth surface floor. Place the foot flat on the edge of the towel so that most of the towel is lateral from the foot

The patient scrunches the towel under the foot, which moves the far end of the towel towards the foot. Make sure the foot stays on floor, flexing the toes and inverting the foot to create the movement. Add a weight to the end of the towel to provide resistance.

Make sure the knee stays pointing forward. The patient may start to recruit the hip muscles when fatigue of the lower leg and foot muscles occur.

Exercise #3

Have the patient sit on a chair and place a towel on a smooth surface floor. Place the foot flat on the edge of the towel so that most of the towel medial from the foot.

The patient scrunches the towel under the foot, which moves the far end of the towel toward the foot. Make sure the foot stays on floor, flexing the toes and everting the foot to create the movement. Add a weight to the end of the towel to provide resistance.

Make sure the knee stays pointing forward. The patient may start to recruit the hip muscles when fatigue of the lower leg and foot muscles occur.

Tubing Exercises

There are many types of exercise bands and tubing available from sporting good stores or medical rehabilitation supply sources.

Tibial internal rotation exercise

Have the patient sit on a chair and place the tubing around the foot. Anchor the other end laterally away from the body so resistance is felt by moving the foot medially.

Keep the foot flat on the ground and make sure the knee stays pointing forward. The patient may start to recruit the hip muscles when fatigue of the lower leg and foot muscles occur.

Move the tibia from an internal rotation starting position to external rotation, moving the foot outward. The tubing should be taut in the starting position.

Ankle/Calf Stretch

Have the patient place the anterior transverse arch, K 1 (Yongquan) area against the wall with the heel flat against the floor

Keeping the knee straight, move the entire body close to the wall, stretching the calf.

From this stretching position, bend the knee, moving it close to the wall as the body sinks into the stretch.

When to Use Arch Supports

Using arch supports can be very effective when foot over-pronation signs are evident and acupuncture treatment plus the prescribed exercises fails to eliminate the patient's pain completely. Arch supports can be purchased at many sporting good stores, foot accessory stores, or custom made.

The following are possible case scenarios to indicate arch support use:

Recurrent ankle sprains may have permanent ligament damage, scar tissue adhesions and instability; arch supports may provide enough stability.
History of lower extremity problems such as shin splints caused by inadequate mechanical pull of lower leg muscles. Stress fractures or knee pain caused from an internally rotated tibia.
Back problems that intensify with walking, standing or running. Foot overpronation can create an unlevel pelvis thus putting the lumbar vertebrae and supporting musculature at risk of injury.

Plantar Fasciitis and Hell Spurs

The plantar fascia is a strong fibrous plantar aponeurosis tissue that supports the medial longitudinal arch. It connects the medical tuberosity of the calcaneus and flares outward as it extends distally to the five metatarsal heads. The plantar fascia can be irritated as a result of extreme ranges of motion of the foot. During gait, the arch is flattened in dorsiflexion and increased in plantarflexion, placing a wide range of tensions on the plantar fascial attachments. With excessive foot pronation, stress is increased to the plantar aponeurosis with resultant microtearing at its attachment on the calcaneal tuberosity. Over time, the bone may grow, creating a bony outcropping or spur usually from the anterior medial aspect of the calcaneus. The developing heel spur is the body's way of reinforcing a weakened area with a harder tissue that is strong enough to combat the long-term stress. Studies have shown that the heel pain of plantar fasciitis is not necessarily coming from irritation of the bone spur, but the inflammation of the tendinous attachment. Over 50 percent of patients who had heel spurs surgically removed continued to have pain afterward.

Assessment

Heel pain at the medial attachment on the calcaneus. Worse with walking and may refer between the spleen and kidney channels of the foot.
Increased pain with the first steps out of bed in the morning
Pain upon palpation of the medial process of the calcaneus.
Pain is increased with walking on the tiptoes.
X-ray may show if heel spur is present.

Treatment with Rehabilitative Exercises

The aforementioned strengthening and stretching exercises are good to include with the following plantar fascia stretches.

Stretch #1

With one leg crossed over the opposite knee, grasp the ankle with one hand and the underside of the toes and the metatarsalphalangeal joint (ball of the foot) with the other hand.

Pull the toes and ball of the foot towards the shin as the other hand pulls the calcaneus (heel bone) in the opposite direction.

Stretch #2

Standing two to three steps away from a wall, bend the forward leg and keep the back leg straight with the back foot flat against the floor.

Raise you rear heel off the floor and shift your weight onto the ball of your foot. Apply the appropriate amount of weight by pressing downward to feel a stretch of the underside of the foot.

Stretch #3

Kneel on all fours with your toes underneath the body. Lower the pelvis backwards and downwards as pressure is kept on the balls of the feet.