Plantar Heel Pain Treatment in 2020? Everything You Need to Know in One Place.
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TRANSCRIPT
Introduction
We have all heard of Plantar Fasciitis (Heel Pain) at some stage in our lives. It is a term that gets thrown around so regularly that you feel like it’s a contagious disease that half of the population has caught. Well it’s not quite THAT common, but it has been predicted to affect approximately 10% of the population at some point in their lifetime. The thing with Heel Pain is that it is not always the Plantar Fascia causing the problems and it is regularly misdiagnosed as Plantar Fasciitis.
So to save you some time, what we’ve done for you in this E-Book is summarise the mountains of information out there on the internet regarding heel pain into an easy to read handbook. You’ll get clear information about what heel pain is, the different types/causes and what you need to do to rid yourself of this persistent heel pain. We’ll cover topics including:
Plantar Fasciitis, Fasciosis or Fasciopathy?
What is Plantar Fasciitis and how do I know if I have it
Foot Anatomy - The Complex Beast
What Are The Other Types of Heel Pain?
Do I need to get imaging?
Why Did This Happen to Me? The Contributing Factors
How Do I Get Better? Your Treatment Options
What Can I Expect? What is a Podiatrist’s role in my recovery
What is Plantar Fasciitis and How Do I Know If I Have It?
Plantar Fasciitis is one of the most common causes of foot pain in the running and non-running population. It more commonly impacts people aged 40 - 60 years old and equally affects both males and females. The injury is chronic in nature and is often seen as an overuse injury resulting from increasing activity levels too quickly without adjusting over time.
Some of the most common signs and symptoms include:
Pain/stiffness when first stepping out of the bed in the morning (might last a couple of steps or might last a few minutes)
Pain/stiffness when getting up after prolonged sitting
Generally warms up when you get moving
Location of pain is most commonly around the inside/underside of your heel
Pain can range from mild stiffness to a sharp pain
**Location of common pain has been highlighted in attached images
As well as Plantar Fasciitis there are many other forms of Heel Pain which we will briefly touch on, but first let’s take a closer look at our foot anatomy
Plantar Fasciitis, Fasciosis or Fasciopathy?
Plantar Fasciitis is a term that gets thrown around every time someone complains of foot pain involving the heel or arch. But did you know that this diagnosis or use of the term Plantar Fasciitis is in many cases incorrect? Recent studies involving heel pain have found very few if any inflammatory markers within the Plantar Fascia itself, meaning that in most cases there isn’t any inflammation present in this chronic condition. Because it is not acute and does not have inflammation present, literature suggests we shouldn’t be using the term “Fasciitis”. Due to it’s more chronic/degenerative nature, it is believed that a better term for the condition is Plantar Fasciosis or Plantar Fasciopathy.
* For the purpose of Familiarity I will continue to call it Plantar Fasciitis throughout this handbook
Foot Anatomy - The Complex Beast
The foot is a very complicated structure with one quarter of all your bones within your feet. They are collectively made up of 54 bones, 60 joints, 40 intrinsic muscles, 26 extrinsic muscles and over 100 ligaments and other soft tissue structures.
Your Plantar Fascia is a thick piece of connective tissue which begins at your heel bone, travels the sole of your foot and splits into thinner strips which connect up with each of your toes. The Plantar Fascia’s responsibility is to help maintain stability of your arch profile as well as being a shock absorber and a spring for the many dynamic movements the foot is used for.
To help the Plantar Fascia in supporting the foot, we have many intrinsic foot muscles working to flex and extend different joints within the foot. The strength and function of these muscles are vital to the load distribution within the foot. Recently there have been some links found between weakness in these intrinsic foot muscles and the onset of Plantar Fasciitis, which highlights their importance.
What Are The Other Types of Heel Pain?
As we mentioned previously Heel Pain is regularly misdiagnosed as Plantar Fasciitis. Quite often if we delve a bit deeper and look at the individuals injury history and current symptoms we might find a different cause of their heel pain. The reason this is important is that each treatment plan will be different based on your heel pain diagnosis. So basically, you don’t want to spend months treating the Plantar Fascia if there’s completely different causing your pain.
So if it’s not always Plantar Fasciitis then what could it be causing your pain? Well it could be any of the following:
Plantar Fasciitis
Baxter’s Nerve Entrapment
Tarsal Tunnel Syndrome
Quadratus Plantae Muscle Overload
Plantar Fascia Tear/Rupture
Adductor Hallucis Strain
Calcaneal Bone Oedema
Calcaneal Stress Fracture
Subcalcaneal Bursitis
Fat Pad Atrophy/Inflammation
L5/S1 Radiculopathy
Heel Spur
Although a little bit more rare, it could also be one of the following underlying conditions contributing to your pain.
Psoriatic Arthritis
Rheumatoid Arthritis
Gout
Fibromyalgia
Infection
Seronegative Spondyloarthropathies
Do I need to get imaging?
This is a great question and one that we get asked a lot! Imaging can be fantastic for diagnosing acute injuries and more sinister conditions, but at times can be misleading when diagnosing chronic injuries/conditions.
First thing we need to mention with this is that many “irregularities” found on X-Rays, MRIs, CTs, Ultrasounds aren’t necessarily causing your pain. As I’m sure you know, we are all created a little bit different from one another and with this comes many “irregularities”.
Below is a common scenario which takes place around imaging:
EXAMPLE: Mark presents to his local healthcare professional with heel pain which he has had for 3-4 months and is sent for an x-ray to figure out what’s causing his pain. Following this imaging, he receives his results which state he has a heel spur. His healthcare provider sees these results and diagnoses Mark with a heel spur and says this is the cause of your heel pain. Now this sounds pretty normal, so, what is wrong with this scenario?
Many studies have looked into heel spurs and found that approximately 20% of the population have non-symptomatic heel spurs, with a low correlation between having a heel spur and having pain. So what does this mean? Well, this person likely had this heel spur for a while without having any heel pain and it could potentially be the surrounding structures (Plantar Fascia, Muscles, Nerves) contributing to and causing their pain. Mark’s diagnosis should be based on more than just imaging, it should take into account his history, description of the pain and physical and dynamic assessment completed by the health professional.
The most important take-away here is not to place too much emphasis on your imaging results. They can be useful to exclude or confirm certain things, but should never be used as a guessing game. The findings of your imaging results are often normal for your age and aren’t always relevant to your injury.
Why Did This Happen to Me? The Contributing Factors
This is a great question and one most people are wondering. Whenever looking at an injury which has progressed over time there are often multiple factors which lead to the pain starting and preventing it getting better. To understand which of factors have caused your injury you need to do a deep dive into your lifestyle (eg. exercise habits, work life, changes to routine, stressors) as well as complete a thorough assessment of your body and how you move (eg. strength and mobility testing & walking/running assessments)
The factors that play a role in your injury can be clearly split into two categories; Intrinsic Risk Factors (Internal to your body) and Extrinsic Risk Factors (anything external to your body). See the table for examples of each.
Intrinsic Risk Factors:
Strength and endurance of muscle groups
Flexibility and mobility
Age
Weight
Limb length difference
Foot type
Walking / Running biomechanics
Mental health / stressors
Extrinsic Risk Factors
Training errors
Surfaces being trained on
Footwear
Socks
Orthotics
Work environment/demands (prolonged standing)
So why is it so important for you and your health professional to know what is causing your injury. Well, without this information you will not know what needs to be rectified in order to allow your body to begin healing. You should use your list of contributing factors as a checklist for what you need to do to be pain free and back doing the things you love.
How Do I Get Better? Your Treatment Options
This is the big question! What do I need to do to get myself better?
What we’ve done here for you is list some of the most common treatment options we use or see here at Movepod Podiatry. There are certainly some more available but these are the ones we believe are most relevant.
These treatment options which we discuss include:
Home/Gym Strengthening
Mobility Sessions
Extracorporeal Shockwave Therapy (ESWT)
Dry Needling & Manual Therapies
Footwear & Orthotics
Cortisone Injections
Sleep
In addition to these treatment options we also place a large focus on “load” management. When we talk about load we are considering all forms of load including running, strengthening, work related load, stress etc. All these things should be considered as a potential contributing factor to your injury and involved in your recovery.
Strengthening:
Everyone’s individual strengthening needs are independent based on their required areas for improvement. This being said, there are a couple of specific strengthening and activation exercises useful in recovering from Plantar Fasciitis.
There are a few key muscle groups which we want to focus on which will assist the Plantar Fascia function and help in redistributing ground forces. These muscles include the calf complex (consisting of 3 main muscles), the intrinsic foot muscles (consisting of 20 smaller muscles) and the Plantar Fascia itself.
Below are 3 handy little exercises which will help to get you started at home. For further advice and more in depth strength programming, it is best to visit a healthcare professional.
Plantar Fascia Calf Raise:
This exercise is set up with a towel folded twice and rolled up at one end like in the images. You can move through the below progressions based on your own individual strength and tolerance. You will complete the heel raises at a tempo of 3 seconds up, 2 second hold at the top and 3 second release downwards.
Progression 1: Completing the exercises with both feet at the same time
Progression 2: Going up with two feet, lifting one and coming down on one foot
Progression 3: Completing the entire exercise on one foot
Intrinsic Foot Muscle Strengthening:
Your intrinsic foot muscles are the many little muscles built into your foot to help in stabilising the arch and controlling fine movements of the toes. After years of stuffing our feet into shoes which don’t fit, a lot of these muscles have switched themselves off and stopped working for us.
We’ve added a couple of exercises below for intrinsic muscle activation using the toes and an arch activation exercises using intrinsic and extrinsic foot muscles.
Arch activation with band:
Completed with band across the top of midfoot, just in front of the ankle. This band will be pulling your arches inwards
Your goal is to use the muscles under the arch and through the inside of the ankle to raise up through the arch and resist the band
Toe Flexors:
Run a band under the bottom of your foot and stand on it whilst you use the long end to pull up the toes
Use the toes to push down against the band. Try to keep the toes straight and avoid curling them as you push down into the ground.
Extracorporeal Shockwave Therapy (ESWT):
This one sounds a bit scary and like some kind of electrotherapy but it’s not. ESWT is a hand held device used by your practitioner and is applied to the skin overlying and surrounding your injured area. This device creates sound waves which produce a direct mechanical force and cavitational force within your bodies tissue.
There is still lots of work to be done in figuring out the mechanism of action with regards to ESWT and many conditions we use it toe treat. Our current understanding is the belief that is assists in increasing blood flow to the injured area, stimulating collagen formation in tendon injuries, as well as having an analgesic effect due to the impact it has on the nervous system.
Shockwave treatment has been found to be effective in assisting with Plantar Fasciosis treatment particularly the more chronic cases but is not a standalone treatment. It works well in conjunction with a number of the other treatment options listed here and should always be paired with strengthening.
Dry Needling & Massage:
Almost everyone knows what acupuncture is but not so many have heard of dry needling. Dry needling is believed to stimulate myofascial trigger points within a muscle, reducing tension within this muscle. In the case of Plantar Heel Pain, needling can be done in a number of different trigger points including ones through the calf muscle as well as intrinsic foot muscles. In regards to massage, whether you are completing it at home or having someone do it for you we would want to be working across the foot instead of up and down the foot.
Below we have included a quick and easy self massage which you can complete yourself at home using a lacrosse ball.
Like shockwave, these treatment modalities are most effective when paired with an effective strengthening and mobility program.
Mobility/Flexibility Exercises:
In some cases your mobility might be contributing to the reason you first got Plantar Heel Pain as well as why it hasn’t healed itself yet. The muscles, fascia and joint restrictions in the leg and foot can cause limitations in freedom of movement. These limitations have the ability to impact the efficient function of the Plantar Fascia, contributing to it’s overload and subsequent pain.
Below we have included two handy mobility exercises focusing on your foot and ankle mobility which you can complete at home:
Ankle Mobility:
Set yourself up like you’re completing a lunge
Bend you knee forward over your big toe as far as it will go and “pulse” back and forth at your end range
Complete this same thing over each of your toes, mobilising the ankle in multiple directions
Big toe mobility:
Set yourself up kneeling on the ground with your big toe folded underneath you
Rock back and forth on your big toe to stretch it out each time you rock back
Footwear and Orthotics:
As previously mentioned, the shoes we wear have a huge impact on the way in which our feet function. If we stuff our feet into poorly fitted shoes which restrict our toes, then as the years pass our feet will take on the shape of our shoes and we will lose muscle control. Each shoe brand and model has its own characteristics which may suit one person and not another. It’s important to find the best shoes for your and ensure that it is correctly fitted based on how your foot functions and exactly what types of activities you want to be doing in that shoe. You should enlist the help of your chosen health professional who has a good understanding of different types of footwear or can point you in the direction of someone who does.
Both premade and custom orthotics have had some useful effect in helping to manage Plantar Fasciitis. It has been proposed to assist in shock attenuation and redistribution of load across the foot. The important thing to note with orthotics is again that they are not a standalone treatment or a “silver bullet” treatment for anything. They should always be paired with the other treatment options which have been listed here.
Cortisone Injections:
Corticosteroids have an anti-inflammatory and an immunosuppressive effect when used on injured tissue. The important thing to note with cortisone is it doesn’t actually heal the injured area, only settles down the symptoms for a period of time. What we often see with people who have previously received Cortisone injections is that they have had 2 or 3 injections with temporary relief, but without any paired treatment. The issue with this is that there is some temporary pain relief but they’re not doing anything to resolve the injury long term. There is also a belief that Cortisone can actually have a weakening effect on the Plantar Fascia and increase the risk of rupture if too many injections are administered.
If going down the path of Cortisone injections, ensure that you ask your health care practitioner about which treatments they plan to pair with the injection (eg. strengthening, mobility, footwear etc)
Sleep:
This is your secret ingredient for injury healing and it should not be underestimated. Our muscles and body tissues recover and rejuvenate as we sleep each night so it is crucial to injury rehab. Having the odd bad nights sleep here or there isn’t going to dramatically impact your healing, but some common bad sleep habits over time can have a negative effect.
Everyone’s sleep and recovery requirements are a little bit different but we have listed some general guidelines for sleep hygiene.
Keep your coffees for the morning! Consuming stimulants like caffeine in the afternoon has the ability to impact your ability to fall asleep when you head hits the pillow
Get out there and exercise during the day. Exercising regularly has a positive impact on your sleep hygiene - if you’re unsure best type of exercise to do with your heel pain then see the “load management” section
Turn off those screens before bedtime. Focus on setting a time restriction of not using your phone or compute before bed (eg. 60 minutes)
Work out a good sleeping environment including a comfy blanket and pillow, a dark room with limited street light or noise and avoid hot stuffy rooms
If you have any other health hygiene questions ask your health professional about the best place to find more information
Load Management:
One of the first questions we get is what can I do and am I supposed to just completely rest my foot. Our answer to this is almost always the same “No, you definitely shouldn’t completely rest your foot”. The Plantar Fascia loves to be loaded and will generally respond well if loaded in the right way at the right time.
The way people can often go wrong is they have big fluctuations in load where they will go for a big walk or run and because it’s sore they will take a long period of rest. We want to try make this movement a bit more regular across the entire week. If you’re a walker or a runner one way of doing this might be to reduce the distance/duration of your sessions and spread them more evenly across the week.
Your Podiatrist or Physio will be able to recommend the best load management plan for you and help you to begin working on strengthening and other aspects specific to you during this phase.
Your Podiatrist’s Role and What to Expect
Prevention Of Heel Pain
Your Podiatrist’s role in this is to take every relevant aspect of your lifestyle and how your body functions to figure out what has happened to you and why it has happened. From there they should present you with the best possible treatment plan available to you and assist you in making decisions about your injury. Their primary goal is to facilitate your journey in getting back to doing the things you love.
At Movepod Podiatry our patients leave their initial appointment knowing what their injury is, what factors have contributed to this injury occurring, what we need to do to get them pain free and how long it will take to get there. This is delivered both verbally and as a written management plan which they can take home and pop on the fridge as a roadmap for recovery.
Everyone’s recovery is a bit different when it comes to Plantar Fascitiis depending on factors including how long they have had it, what caused it and what their current work/sporting demands are. Although things are different for everyone, it is crucial that you expect the following things
Be patient, Plantar Fasciitis recovery can take up to 6 months, although we see most cases recover within 8-12 weeks
There’s going to be some bumps in the road. You will have days or weeks where you’re feeling great, but then have a very sore day. This is completely normal and doesn’t mean you’ve gone backwards
Trust the process
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