The First Ray – Controlling the Structural Integrity of the Foot

The medial longitudinal arch (inside arch) is the main shock absorbing structure in the foot. The ability of the arch to shock absorb is dependent on the amount of movement from the bones that make up the first ray.

What is the first ray?


The first ray is the segment of the first metatarsal bone, first cuneiform bone and the joint between them.

Function of the First Ray

As the weight of the body transfers forward in walking, the calcaneus (heel) and the heads of the metatarsals (ball of the foot) are pressed to the ground which creates lengthening and flattening of the arch. This motion causes the first ray to drop. In perfect or text book gait, as we continue to step forward the body’s momentum and muscle contractions function to pull the arch up, re-stabilizing the first ray.

However, the majority of patients we see present with first ray dysfunction, where there is an opposing force and undesired motion that cause the first ray to remain in a dropped position. This reduces motion and load through the joints. Here’s the kicker, the motion and load must occur somewhere – and more often than not, improper load occurs through joints that cannot tolerate it.

There are many muscles that support and affect function on the first ray. Therefore, dysfunction to first ray mechanics can cause and affect new and pre-existing injuries or can be as a result of them.

Common injuries or presentations where dysfunction of the 1st ray is present

  • Bunions
  • Hallux Valgus
  • Arthritis
  • Hallux Limitus
  • Sesamoid injury
  • Plantar Fasciitis
  • Knee pain
  • Hip Pain

How can you improve first ray function?

Plantar Fascia Pain Explained

As Pedorthists, this condition represents a major portion of our daily schedule. We are here to tell you that your condition (although experienced by many) is unique, just like you and should be treated as such!

When you experience heel pain what is the first thing you do? Well if you are reading this page you either consulted “Dr. Google” or “Dr. Word-of-mouth”. Since there is so much information about Plantar Fasciitis we wanted to give you a resource that can help answer questions you are likely to have. In this article we will define, describe and outline symptoms and treatment options you may not know.

What is it?
Who does it affect?
How long does it last?
How do I treat this?
Will it come back?

Without further adieu, here are your answers:

Plantar Fasciitis is the term used to describe heel pain caused by the inflammation of the plantar fascia. The plantar fascia is the fibrous band that runs along the bottom of your foot and connects your heel bone to your toes.

The condition is most prevalent in middle-aged people as aging tissue and overuse tendencies are greater. However, it may also occur in individuals who are on their feet a lot; such as servers, retail associates, factory workers, or athletes, just to name a few. Plantar Fasciitis can affect one foot but can also be found to affect both feet to varying degrees.

Symptoms and Patterns of Plantar Fasciitis

  • Stabbing or burning pain that’s usually worse in the morning
  • Pain with rising following prolonged periods of rest
  • Once you’ve taken a few steps, the pain normally reduces
  • Pain often returns after long periods of standing
  • This cycle often repeats, creating repetitive strain to the tissue
  • On occasion the inflammation can be caused by a sudden tear in the plantar fascia such as after an accident or “overdoing it” during an activity
  • The acute phase of Plantar Fasciitis can last for 4-6 weeks if left untreated

What many people don’t realize is there are different stages of injured tissue. The suffix describes the stage of the injury. The suffix “itis” refers to the inflammation process of the injury (pain, heat, swelling, redness). When pain persists or becomes more of a chronic condition the suffix “osis” or “opathy” is used to describe degeneration of a tissue which has failed to heal.

Plantar Fasciosis or Plantar Fasciopathy is the term used to describe heel and/or arch pain caused by overuse, degeneration and lack of healing to the plantar fascia tissue. This condition develops over time and after inflammation has decreased. If left untreated, Plantar Fasciosis and/or Plantar Fasciopathy can last for months or even years.

Symptoms of Plantar Fasciosis/Fasciopathy That Differ From Plantar Fasciitis

  • Pain when climbing stairs or rising onto your tiptoes
  • Mild to moderate pain in the heel during activity with an increase in pain following activity
  • Throbbing heel pain at the end of the day
  • Chronic swelling in your heel that doesn’t seem to go away or has been present for a prolonged period of time

 

Common Causes of Plantar Fascia Conditions

Increased physical activity and overload is the most common contributor to damage of the tissue

    • Plantar Fascia conditions are common for individuals that participate in long-distance running, jogging, walking or stair climbing. Activities such as these can place too much stress on your heel bone and the soft tissue attached to it, especially as part of an aggressive new training regime. Even household exertion, such as standing on ladders, moving furniture or large appliances can trigger irritation to the tissue and create pain.

Poor footwear choices

    • Inappropriate shoe choice for the activity or a broken down shoe is often a major contributor. Shoes that are thin-soled, loose or don’t fit properly, lack arch support or the ability to absorb shock will not protect your feet. Improper shoes can cause added stress to your heels.

Abnormal walking patterns

    • Instability, or compensations from other injuries can negatively affect heel injuries.

Flat feet (over-pronation) or high arched (rigid feet)

    • Foot type can negatively affect gait patterns (the way you walk) which can lead to added stress and force on the plantar fascia causing injury and pain.

Limited ankle dorsiflexion caused by a tight Achilles tendon and calf muscles

    • The gastrocnemius is thought to be the only contributor of calf tightness. Based on gait mechanics and muscle contraction throughout the gait cycle, the Soleus muscle is what we like to call the “unsung hero”. Based on its location, activation and muscle fibers, the condition of this muscle can play a major role in Plantar Fasciopathies. Another known contributor is weakening of the toe flexors (flexor digitorum brevis) and of the peroneals (peronus longus specifically). These muscles are housed deep in the calf, contribute to ankle range of motion and play a significant role in arch mechanics and lower limb stabilization.

Repetitive stress with muscle dysfunction

    • Pressure and strain on your feet from long hours of walking or standing such as a standing desk, factory or retail workers can lead to stress, tension and increased force through the foot joints, muscles and plantar fascia. An increase in activity or change in activity such as painting, gardening, climbing ladders or hiking on uneven terrain can also be a potential cause.

Recent weight gain

    • The extra weight and hormone changes that occur with excess weight can be a contributing factor. This increase in load to your feet and plantar fascia can cause excessive strain and damage to the tissue.

Trauma

    • Involves excessive pull on the plantar fascia. This can include stepping of a curb, step or tripping suddenly

Arthritis

    • Certain types of arthritis can cause inflammation in the tendons which can affect the bottom of your foot, which may lead to Plantar Fasciitis.

Diabetes

    • There may be a link between Plantar Fasciiopathy and Diabetes. More specific research is still required, but there could be a correlation between degenerative changes in tissues due to compromised blood supply.

 

Treatment and Prevention

Activity modification

    • Reduce the activity or at the very least the intensity of the activity that caused the problem in the first place. We’d like to note this can often be temporary! We want you to be active, but first and foremost, pain reduction and healing is the goal. You don’t want things to get worse!

Orthoticsfootwear modifications improve function

    • Provides correction to abnormal walking patterns and to limit excessive pronation which reduces the amount of strain on the tissue. In high arched rigid foot structures orthotics act to minimize destructive forces placed on immovable joints and act as a shock absorber for the tissues of the foot. Custom made or over-the-counter orthotic options are available.

Replace your shoes

    • Updating your footwear with appropriate shoes for your personal biomechanics and activity can yield immediate results. Get rid of your worn down or inappropriate shoes. Wearing sensible shoes is an integral part of every treatment and prevents excessive unwanted forces from being placed on the fascia as well as other parts of the body.

Mobility, strength and stretching

    • Improvement in ankle range of motion with mobility exercises. Focusing on stretching of the Achilles tendon, calf muscles and plantar fascia. Additionally target muscle strengthening for the improvement of lower leg, calf and foot function. These activities are imperative to promote correct alignment and function of the tissues as they heal. These activities should be done every day.

Gentle massage

    • Massage of the plantar fascia helps to promote blood flow and healing in the area, and can coincide with the strengthening and stretching exercises.

Icing for Plantar Fasciitis

    • Effective in reducing pain and inflammation in Plantar Fasciitis. Using a frozen water bottle, gel or ice pack for 10 minutes on then 10 minutes off. Repeat 2x. When your skin starts to feel numb, it’s time to give your body a break.

Heat for Plantar Fasciosis

    • Using a wheat bag may be used to assist with the rehabilitative process once inflammation has been ruled out.

Foot compression sleeves such as the FS6

    • The FS6 Foot Compression Sleeve can provide some relief to the healing plantar fascia. They can be worn on one or both feet and be utilized daily as an added layer to a treatment plan.

Night splint stretching therapy

    • Using a night splint will allow a gentle stretch to the affected tissue, allowing it to heal in a lengthened position. We prefer the rigid splint over a sock style as the sock can hyperextend the foot at the metatarsal joints, which can lead to injury and strain. The firm splint can be modified to stretch the forefoot as needed. We recommend the M2 Night Splint.

Maintain a healthy weight

    • This will reduce strain and abnormal forces to the bones, joints and ligaments of not only your feet, but your whole body.

 

Alternate Therapies

These therapies can be beneficial treatments as well. They should be performed by qualified professionals such as a Chiropractor, Physiotherapist, Osteopath, RMT or Sports Medicine Physician. Be sure to research each therapy and professional before you decide.

  • Acupuncture and dry needling
  • Massage
  • Taping
  • Ultrasound
  • Shock wave or laser therapy
  • PRP (Platelet-rich plasma) treatments

Consistency is key. Once the pain from Plantar Fasciitis or Plantar Fasciopathy is gone, it is human nature to stop exercises and treatment plans. It’s important to continue on with the rehabilitation of the fascia for several months.

Can the pain come back?
The simple answer is yes.

However, adopting the rehabilitation routine as a regular part to your day, activities and lifestyle can improve your outcomes.

Sources:
Plantar fasciitis
Mohammad Ali Tahririan, Mehdi Motififard, Mohammad Naghi Tahmasebi,1 and Babak Siavashi2
J Res Med Sci. 2012 Aug; 17(8): 799–804.

Plantar fasciitis: A review of treatments
Luffy, Lindsey MSPAS, PA-C; Grosel, John MD; Thomas, Randall DPM; So, Eric DPM
Journal of the American Academy of PAs: January 2018 – Volume 31 – Issue 1 – p 20-24

Whittaker GA, Munteanu SE, Menz HB, et al.
Foot orthoses for plantar heel pain: a systematic review and meta-analysis.
Br J Sports Med 2018: 52: 322-8

Sullivan, J et al. Musculoskeletal and activity – related factors associated with with plantar heel pain.
Foot and Ankle International 2015, Vol 36 (1) 37-45