Thursday, 2 February 2012

plantar fasciitis

So here we go. 
Before we get started I feel I should probably introduce myself and explain why I am further cluttering the internet with sports injury help. As a physio student in my final year I have felt occasionally you can be fighting a tough battle with patients when it comes to self help information on the internet, this is in no means the patients fault. From my limited experience I have found that a patient who takes an active interest in their problem is going to rehab more successfully. However the success lies on the accuracy and simplicity of the information given. Granted all the info is out there, to allow a suitable rehabilitation process from an injury, for the majority of niggles that the average evening pavement treaders and the weekend trail warriors come up against. However sometimes it can be put across in a non practical fashion that can lead to further complicating something that could have been easily prevented.  So that’s the plan, rearrange the current information and hopefully add a few touches of my own. As I am starting this now with 3 months left of my degree it may be an interesting development of my own knowledge as well- which will probably result in an uncomfortable read in a few years time when looking back. But never the less on top of the posts I place up that I feel may be of interest please feel free to email with specific questions or requests to posts.

I am currently training for the London marathon in April. Therefore I felt it would be fitting for the next week or so to add posts regarding common running injuries. Which touch wood I am currently free from.  As running itself is a fundamental aspect of most sports it is not limited to road running/plodding so hopefully there is some benefit to a wider sporting population.

Plantar Fasciitis
Straight to the business end of the runner. The picture below shows exactly where I am referring too when discussing the plantar fascia.

To save any unnecessary reading on your part I will begin with the potential signs and symptoms to allow you to make an informed guess as to whether it is the plantar fascia that is causing your heel pain.
Signs and symptoms
     PAIN- this is going to be the initial reason that sparked your interest in self diagnosis, in the case of plantar fasciitis the pain will be in the bottom of the foot with local pain on the bottom of your heel
           The pain may be brought on instantly when you run, or after a short distance- it is likely that after the run the pain will have increased. Usually patients would refer to it as an ache, or burning.
            The pain is not exclusive to when you run. Walking may cause the pain, some footwear may cause more discomfort than others. Are your shoes offering you the support you need ??
      Pain may be worse in the morning when you first get out of bed.  Overnight your movement will be limited. Therefore inflammation may build up. As part of the body’s natural inflammatory process chemicals arrive that the pain receptors in your foot do not appreciate. Therefore your pain is greatest in the morning. This may be exaggerated by a busy day previously. In some cases once you have been moving the foot for a few minutes or showered the pain may decrease.
     It may be tender to touch the underside of your foot
     The underside of your foot may feel generally tight

What ?
 If you are experiencing any of those symptoms then you may find it interesting to read on.
        Plantar fasciitis is an inflammation of the thickened band of fibrous tissue that runs from your calcaneal tuberosity (heel) through to your metatarsal heads. This tissue helps to support the arch of your foot. Excessive stressing of the fascia can cause micro tears of the tissue resulting in further pain.

The inflammation and pain is caused by overstretch and overuse of the fascia. 

This is generally down to other underlying biomechanical issues

  • Flat feet.
  • Shoes with little support
  • Weight gain
  • Over pronation
  • Tight plantar fascia (PF)/ gastroc-soleus complex
These underlying issues may have been with you for years therefore not being the immediate reason for the pain (although they would need correcting) it is when you couple the poor biomechanics with an increase in load that your body starts to fail. For example- have you increased your mileage recently? Changed your running shoe, perhaps to a more lightweight flat? Changed running surface? Any one of these variants could be the straw that broke the proverbial camel’s back (or caused your heel pain)

Exercise limitation is always a hard thing to advise- especially when so much of physiotherapy is grounded in exercise prescription. However cessation of the aggravating activity is the most sensible option. However don’t take this as a professionally prescribed excuse to swap running for recumbence or badminton for box sets, as there are many other activities to maintain your fitness levels that limit the stress applied to your heel. Cycling and swimming would be my personal suggestions as both are very low impact. However if the heel pain is felt during the exercise, stop.
I feel it is important to split the advice given into 2 categories to enable you to gain an understanding of why you are performing the activities.

Pain relief
PF stretch
Heel cups/insoles
Calf stretch
Limit use of high heels
PF strengthening
Ice massage
Appropriate choice of permanent insoles to encourage supinated foot posture
Self massage
Night splint

Pain Relief
As it is an inflammatory condition it is paramount to get on top of pain relief- specifically the inflammation. Therefore over the counter NSAID such as ibuprofen can be beneficial when taken as the recommended dose.
A heel cup will help to reduce the impact on the tender area during heel strike. Whereas an insole with help correct your potentially poor foot posture which will aid the natural shock absorbing ability of your foot and ankle
Boys and girls take a step down from the high heel for a short while, you wont be looking too good in those lucky heels if your grimacing the whole night.
Ice massage. I would advise to put a water bottle in the freezer. Once its frozen place it under your foot and roll it for around 8 minutes. You will gain the beneficial effects of massage with this technique
Correctly taping your foot can provide immediate pain relief for some patients by taking the tension off the PF

This is the PF stretch, I would advise to stretch as far as comfort allows, hold for 20 seconds. Attempt to perform 3-5 times a day

This stretch can be coupled with a standard calf stretch to help to release some tension from the ankle, and to encourage a better foot posture in the long term

To help strengthen the PF and the foot musculature place a sheet under your foot, whilst sitting attempt to create a higher arch by scrunching the sheet. Perform this 8-12 times. (Over the internet it is hard to prescribe amount of reps, as people will fatigue at different levels) the one thing I would stand by is work within the limits of pain.
Ideally insoles will be prescribed by a professional. But when it comes to running it is vital to have your gait analysed to ensure you have the right support to limit further injury with your running style. You can also pick up insoles over the counter at chemists and sports shops. They may provide you some relief.
Self massage is just a case of getting stuck in really. This can be done with your hand or a selection of balls. As you can imagine the massage pain will increase as you go from a tennis ball to squash ball to golf ball. Have a play see what you like/ dislike. I expect this to feel uncomfortable, but if it is making your pain significantly worse after the massage reduce the pressure in which you are performing it.  
It doesn’t stop there. Time to being pain free is very variable. Some may experience pain reduction in a matter of weeks whereas for others it may take months- even years. 
However once you are pain free there are exercises you should continue to perform to address the underlying issues we mentioned earlier.
The gait analysis is the first step. This will allow you to return to running safe in the knowledge that your feet a supported.
Take up bare foot running. This isn’t practical I appreciate. However when your foot is in a running shoe the 26 muscles of your foot do not have to work as hard to stabilise. Therefore taking it back to basics and running barefoot is ideal; the most realistic way to perform this is on sand. With the added difficulty of trawling through the soft sand your muscles will be working harder than ever.
  Alternate the running surface. Constant pounding of the concrete can be taxing on your body not to mention the boredom (personally). Mix it up find some grass, Forest tracks, or hit the dreaded treadmill.
There we go.  I hope you found some interest in this instalment. And remember this is in no way a replacement for a professional assessment and treatment session. So if you have any concerns get a referral.
Thank you
 Adam Rutter

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