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Plantar Fasciitis – That Pain In the Heel!

I’ve met alot of people of all ages who have suffered from plantar fasciitis and it is truly one of those painful, inconvenient and possibly chronic conditions that I hope you can put past you as soon as possible.  But what is it?

plantarfasciitisThe plantar fascia is a thick fibrous material on the bottom of the foot. It is attached to the heel bone (calcaneus) and fans forward toward the toes. It is responsible for supporting the arch of the foot.

Common Signs and Symptoms: The most common complaint is pain in the heel, which can extend into the arch and/or ball of the foot. The pain is usually worse in the morning with the first few steps being difficult, and then gradually eases with walking. As the day progresses, the pain can worsen with prolonged standing and activities such as walking (especially barefoot), running, jumping, and climbing stairs. Resting and unloading the foot can often ease the pain, along with stretching the plantar fascia before getting out of bed in the morning. Some individuals may also benefit from orthotics.

Why does it happen? Repeated strain causes overstretching of the fascia, leading to micro tears and inflammation. The overuse and repeated strain on the fascia is often attributed to activities that require prolonged standing and weight bearing on the feet. Other factors that make an individual more likely to encounter this problem are:

  • Tightness of the calf muscles
  • Flat feet or high arches, and excessive foot pronation
  • Obesity or a sudden increase in body weight
  • Rapid increase in training intensity, distance, and/or duration
  • Hard training surfaces
  • Improper/unsupportive footwear
  • Aging and heel fat pad atrophy

How can I help you with physiotherapy? Upon confirmation of the diagnosis of plantar fasciitis, I will teach you several exercises to help stretch and release the plantar fascia. In addition, a lower extremity strengthening program will often be used so the muscles can help evenly distribute the forces that go through the plantar fascia. will also identify factors that may have contributed to the problem and work with you to prevent the condition from returning in the future. Other therapeutic modalities that may be used in the clinic during treatment include ultrasound, laser, electrical current, ice, and taping.

Leanna Taggio, Physiotherapist

Don’t Let Your Achilles Tendon Be Your ‘Achilles Tendon’!…How To Fix The Pain.

Achilles tendon injuries commonly affects people who subject their feet, legs and body to alot of repetitive pounding and quick dynamic pushoffs.  Over the years, I’ve participated in many different running and jumping sports…basketball (my first love!), karate, track & field (junior high triple-jump champ!), and most recently taekwondo at All Star Martial Arts.  In the past 2 months, things have started to take their toll on my 40 years young Achilles tendons and I’ve entered the early stages of injury…which has served as a stimulus for me writing today’s bog post!

But I’m not going to talk about my Achilles tendons because I’ve only just started doing some self-treatment on it.  Instead, let me share the story of one of my patients, David.

David is a 50 year old, transportation business owner who still enjoys taking part in his favorite past time: soccer.  He plays in a local Aurora mens’ league throughout the year both indoors and out.  It’s how he stays fit and how he beats the stress of work and life.

Back in May, David came by my Richmond Hill chiropractic clinic on the referral of a teammate who had seen me previously for successful treatment on his shoulder pain.  David told me that he had gradually developed pain in both of his Achilles tendons over a period of 2-3 months.  He experienced quite a bit of stiffness in the morning getting out of bed that would loosen up somewhat after moving around.  But during the workday, there would always be some low grade stiffness.  He continued to play soccer despite what he called the ‘minor irritation’, but would definitely feel more stiff and sore the next day.  Lately, the pain had become more constant and he had to resort to talking some Advil before soccer games.  He knew it was getting progressively worse and figured it was time to get it fixed.

David’s symptoms were pretty consistent with most folks who come to me for treatment of the Achilles.  It often occurs in ‘older’ athletes and is of a gradual onset with achiness, stiffness and soreness being the early warning signs.  However, once it becomes severe, each step you take can be very painful.  Three types of Achilles injuries are possible: insertional, paratenonitis and non-insertional.

The least troublesome of the Achilles tendon overuse injury is paratenonitis. This injury represents an inflammatory reaction in the outer sheath of cells that surround the tendon. The first sign of this injury is a lump you can feel that forms a few inches above the Achilles attachment. Treatment for Achilles paratenonitis is to reduce the swelling with frequent ice packs.  Wearing a night brace can also be effective with paratenonitis because tissues immobilized in a lengthened position heal more rapidly.

If the paratenonitis gets worse, it may eventually turn into a non-insertional Achilles tendinosis. This injury involves degeneration of the tendon approximately 2-4 cm above the attachment on the heel. Because this section of the tendon has such a poor blood supply, it is prone to injury and tends to heal very slowly.

Insertional tendinitis refers to inflammation at the attachment point of the Achilles on the heel. This type of Achilles injury is extremely difficult to treat and typically occurs in high-arched, inflexible individuals, particularly if they possess a Haglund’s deformity.  Because a bursa is present near the Achilles attachment, it is common to have an insertional tendinitis with the retrocalcaneal bursitis.

As the body tries to go through the repair process, fibroblasts or collagen producing cells create different types of collagen during different stages of healing.  However, because most people do not give the tendon adequate time to remodel and heal by not appropriately engaging in relative rest, a repeated series of small partial tears begin to form and actually act to ‘over’ lengthen the tendon.  And typically what we see is a unequal increase in the range of ankle dorsiflexion (pointing toes towards the head) on the injured Achilles side.  This is what was exhibited in David’s case.

I mentioned the need for ‘relative’ rest.  With David, that meant several weeks off from the ballistic sport of soccer while he actively engaged in exercise that would assist recovery and proper remodeling of the Achilles tendon…much to his chagrin.

One particularly effective treatment protocol is to perform heavy-load eccentric calf muscle exercises.  Research has shown that these exercises have been repeatedly shown to be highly effective in the management of non-insertional Achilles injuries.  The next time your family doctor recommends trying a cortisone injection for the Achilles pain, tell him you’ll try eccentric exercises instead…cortisone injection have been shown to lower the stress necessary to rupture the Achilles tendon.  You can kiss your sport season goodbye after that!

Another thing I got David to do were some closed kinetic chain tibialis posterior muscle exercises.  A weak tibialis posterior muscle can cause compensatory stress placed on an already overworked Achilles tendon.

Besides aggressive strengthening exercises, another effective method I used with David is a form of deep-tissue massage called Graston Technique.  This technique involves the use of stainless steel instruments scraped over affected tissues.  Many of my patients fondly refer to them as “Dr. Keith’s medieval torture tools”.   The theory behind this type of aggressive massage is that induces microtrauma that stimulates fibroblasts to accelerate repair of tissues in the extracellular matrix (e.g., collagen, elastin and proteoglycans).  Using laser therapy after a Graston session also helps with pain improvement and tissue healing.  Lately I’ve also been experimenting with kinesiology tape on the Achilles and other muscle injuries…it’s that stuff you see the Olympic beach volleyball players wearing.  Neat stuff.

7 weeks after starting treatment, I cleared David to return to play.  He’s happy soccer player once again. 🙂

Now it’s my own turn.  Admittedly, sometimes it’s hard to follow the doctor’s advice!  I can’t engage in ‘relative’ rest quite yet.  I have 3 more weeks of training until my Taekwondo black belt test on August 18th…after that I will gladly engage in some rest!!!

Send any questions you may have to:   drtse@meridianspineandsport.ca!

Your soon-to-be-black-belt-in-Taekwondo chiropractor,

Dr. Keith

 

 

Effective Treatment for Plantar Fasciitis

Over my 9 years of chiropractic practice, I’ve had the opportunity to treat a large number of patients who have suffered with plantar fasciitis of varying degrees.  From marathon runners, to homemakers, to construction workers and the elderly, plantar fasciitis affects a wide range of people types at different stages of age and activity levels.  The most common thing amongst them all is that it developed seemingly out of nowhere and the pain is worse in the morning when taking the first steps out of bed or after prolonged sitting.

This was also the experience of “Greg”, a 47 year old male software engineer who came to me for treatment back in May.  In his younger years before life got busy with family, he was a long distance runner which may have been the instigating factor for the onset of plantar fasciitis causing an almost degenerative process to occur.  Keep in mind though that some people who are INACTIVE for most of their lives are also susceptible to plantar fasciitis for other anatomical or biomechanical reasons.

Greg was fairly tall at 6 feet and years of inactivity and careless eating had caused him to gain about 30 excessive pounds…again another possible cause for the plantar fasciitis.  Generally speaking, most cases of plantar fasciitis recover with conservative care within 6-9 months and almost 90% will recover without any residual symptoms.  They return to their normal daily activities without any problems.  In Greg’s case, he was already 3 months into this painful foot problem and he really needed to get more comfortable again as he had an anniversary cruise scheduled in 4 weeks time.

During my examination, I made Greg walk up and down the clinic hallway a few times where I noted that his pain was most exacerbated during push off of his right foot.  As I poked, prodded and palpated various soft tissue structures in his right foot, he nearly jumped off the table when my thumb hit the primary spot of inflammation and injury at the medial side of his heel bone.  This was a pretty textbook case so far but sometimes patients have more pain and tenderness in the midfoot and arch.

As I checked his ankle mobility I found that Greg was pretty limited in dorsiflexion (drawing the foot/ankle towards the head) indicating possible tightness in the plantar fascia.  As well I noted he had a problem with overpronation which almost always is a significant contributor to the development of plantar fasciitis over time.

Thus far, Greg had attempted to manage this foot problem with over-the-counter pain medication and then when that didn’t help, a cortisone injection upon referral from his family doctor.  The injection he said, “hurt like hell” and gave him about 2-3 weeks of moderate relief.  He also tried a few visits with an acupuncturist that his sister recommended with little relief.

My treatment of plantar fasciitis typically consists of some combination of Graston technique, acupuncture, BIOFLEX laser therapy and corrective exercises depending on what stage the patient is in and what he/she may have tried before.  In Greg’s case, I elected to start with Graston technique and laser.

Graston technique is a form of fascial therapy using stainless steel instruments that helps to release excessive tension in tissue and break down adhesions and scar tissue.  The greater the pressure applied, the larger the number of fibroblast produced which results in collagen fiber synthesis.  Essentially we are breaking down ‘bad tissue’ to reform ‘better new tissue’.  While the therapy doesn’t necessarily hurt for all people, Greg will be the first to tell you that Graston technique to the plantar fascia was very painful for the first 3 treatment sessions but then almost miraculously got less painful as a whole after that.

In addition to the plantar fascia, Graston technique was also applied to the calcaneus (heel bone), the outside edge of the foot, the Achilles tendon, calf muscles and even the hamstrings.  Sometimes I will even go higher into the glutes, back muscles and neck.  This is because the plantar fascia is a part of a longer ‘kinetic chain’ of tissue and function.  A kink anywhere in the system can result in pain and dysfunction somewhere else in that system.  Gone are the days when we focus on just the single problem area.  New science and understanding shows that the human body is a wonderful integration of connected parts.  After each Graston application, I would apply the BIOFLEX laser to the plantar fascia and heel for 30 minutes.  Laser therapy helps to decrease inflammation, reduce pain, improve blood flow and stimulate tissue repair.

As Greg’s symptoms improved it was also necessary to incorporate various rehab exercises to improve tissue length, strength and functionality to that kinetic chain.  Specific exercises like rotation hamstring stretches and plantar fascia stretches, towel toe crunches, tip-toe and heel walks and balance exercises were necessary to keep Greg’s improvement on track.  Finally, we also referred Greg to a chiropodist to address his overpronation problem with orthotic insoles.

At the 8 week phone call follow-up, Greg told me that he and his wife had a wonderful time cruising in the Mediterranean and that his foot was completely pain-free the whole time.  He has not had any issues with it day to day and is continuing to follow his recommended daily exercises.

I’d say this is the typical treatment outcome that you can expect when we follow this protocol and the patient is compliant with the treatment schedule and the home recommendations.  On occasion when the patient is not responding to therapy, I refer them out to try a newer therapy called Shockwave therapy.  It is a quite pricey treatment but the results seem promising for those really tough plantar fasciitis cases.  It is offered through a limited number of podiatry and sports medicine clinics in the GTA.

If you’ve been struggling with the foot pain associated with plantar fasciitis, there is hope for you!  You don’t have to live with pain!

Got any questions? Feel free to call us here at Meridian Wellness or drop an email to me at drtse@meridianspineandsport.ca!

Your friendly, Richmond Hill chiropractor,

Dr. Keith