Don’t let plantar fasciitis knock you off your feet

Active Patient

Tips and treatments for healing heel pain

Distance runners and dancers suffer from it. So do cashiers and those who wear worn out shoes. Plantar fasciitis, the painful foot condition that centres on the heel is one of the most common causes of foot complaints in adults.


If you treat a lot of active individuals in your clinic, you may have come across plantar fasciitis, or an irritated plantar fascia.

Plantar fascia is the thick band of connective tissue that starts at the heel bone and fans out to the toes on the bottom, or plantar, surface of the foot. It acts as a support mechanism, holding the bones and muscles of the foot steady while it’s in motion, or even standing still. The term “fasciitis” simply means the fascia is injured.
Achilles tendon and Plantar fascia

Symptoms

How can you tell if your patient is suffering from plantar fasciitis and not just typical foot pain? The most common symptom of plantar fasciitis is pain near the inside, or medial aspect, of the heel and sole of the foot. It might be felt first thing in the morning upon getting out of bed as the feet hit the floor or getting up out of a chair after sitting for a period time. Even movements that stretch the plantar fascia, like extending the big toe or ankle dorsiflexion can cause a sufferer to wince in pain. While walking or slowly jogging might lessen the pain as the heel warms up, the relief is only temporary and will return again once activity stops.

Risk factors

People who play a lot of sports, who work at a job that requires a lot of walking on concrete or hard floors, or who are always on the go are more likely to develop plantar fasciitis than those with sedentary jobs or who spend more time on the couch than the basketball court. Running, marching, dancing and jumping are some activities that can trigger or make plantar fasciitis worse.
Achilles tendon

Even carrying a few extra pounds, standing stationary for long periods of time, or having decreased ankle flexibility can increase the risk of an irritated fascia.

Ballerina

Plantar fasciitis is especially common in people who run. Distance runners and sprinters should be especially vigilant of the following:

  • Excessive training or increased activity • Poor fitting footwear
  • Running on unyielding surfaces like concrete
  • Flat feet (pes planus)
  • High arches (pes cavus)

If left untreated, plantar fasciitis can develop into heel spurs from repetitive trauma to the affected tissues. A heel spur, or calcification near the attachment point
of the plantar fascia, is easily diagnosed with an X-ray.

Home care treatment

There are plenty of things a patient can do on their own to help alleviate plantar fasciitis symptoms.

Rest

If you suspect that a patient’s foot pain is being caused by plantar fasciitis, suggest they limit athletic activities and get a lot of rest to help ease symptoms. You might also recommend avoiding excessive and repetitive movements that cause impact to the heel specifically, but at the same time emphasize that activity should not be stopped completely. No foot movement at all can cause the plantar fascia to stiffen up and pain symptoms to return.


Icing

You may want to recommend your patients apply an ice pack to the area for up to 20 minutes four times a day to help relieve pain and discomfort. Gentle massage and a few minutes with an ice pack just before exercising can also be an effective treatment method.

Protective footwear

Cushion-soled shoes, arch supports, gel pad inserts or heel cups may do wonders for providing temporary pain relief. Silicone inserts are likely to provide better support than felt pads or rubber heel cups. Pharmacies that specialize in orthopedic supplies often carry splints that are worn overnight, and work by placing the foot in a position that provides pain relief and a gentle stretch at the same time. Wearing supportive shoes or sandals indoors can also be helpful, especially after getting out of bed first thing in the morning. Though it may seem comfortable to your patients
and feel like it’s providing relief, remind them that walking barefoot may cause pain symptoms to return or worsen, even if floors are carpeted.

Rehabilitation exercises

Stretching and strengthening exercises may be helpful, but remind patients to ease into them slowly and with care to avoid causing more pain. Home exercises include the calfplantar fascia stretch, foot/ankle circles, toe curls and toe towel curls, as illustrated here.

Calf Stretch

Calf stretch exercise

Sit with legs straight out and loop a towel around the foot. Gently pull the top of the foot towards the body. Hold for 10 to 30 seconds. Complete a set of 5 and aim for 2 sessions a day. Modify this exercise by pushing the ball of the foot against the towel, which also effectively strengthens the foot muscles.

Ankle Circles

Foot/ankle circles

While sitting, rest one leg on a chair keeping the other foot on the floor and alternately point and flex the raised foot 15-20 times.

As part of the same session, make small circles with the foot by rotating the ankle. Complete 2-3 sets by rotating clockwise 15 times and then reverse for another 15 times.
Toe Curls

Toe curls

Standing on a thick book, curl the toes over the edge and then straighten. Complete as many repetitions as possible within a 2 minute period, twice a day.
Toe Towel Curls

Toe towel curls

Curl toes around a towel then grip and release for 1 to 2 minutes, twice a day.

Hydrotherapy – alternating foot bath

Alternating hot and cold foot baths can be extremely helpful with reducing pain and increasing circulation to speed healing.
Foot Bath

Contraindications: Do not use alternating hot and cold foot baths in patients with cancer, vascular disease (including diabetes), diminished sensation or hemorrhage.

Caution: Always finish with a short cold bath, except for those with rheumatoid arthritis, whose condition is aggravated by cold. End treatment with a warm bath in this case instead.

Supplies

  • 2 basins or tubs for feet
  • Hot water
  • Bath thermometer
  • Cold compress for head
  • Towels
  • Cold water

Directions

  1. Prepare a tub of hot water at a temperature
    of 40 to 43ºC. Do not exceed 49ºC.

  2. Prepare an alternate tub of cold water at a temperature of about 7ºC.

  3. Immerse feet in the tub of hot water for 3 minutes.

  4. After 3 minutes, change feet to cold foot bath and immerse for 30 seconds.

  5. Make 3 complete changes between the hot and cold tubs (3x-hot/3x-cold).

  6. Always start the treatment with the hot bath and finish with the cold.

  7. If the patient starts to sweat, place a cold compress on the forehead.

  8. Dry feet thoroughly and let the patient rest on a bed for at least 30 minutes before going home.


In-office therapies

The following is a list of plantar fasciitis treatment options you might try with your patients.

Nutritional supplements

Vitamin C is the key for initiating connective tissue repair. A deficiency can result in decreased tensile strength of fibrous tissues, like those found in the plantar fascia. Recommended dosage for the purpose of tissue repair is 1 to 3g daily.

Zinc is an important factor in tissue regeneration and repair and works together with vitamin C to increase the tensilestrength of wounded tissue. In fact, animal studies show that zinc deficiency is a contributor in delaying wound healing. Patients with chronic injuries, high stress levels, or those who exercise at an intense level are at an increased risk for zinc deficiency. A daily dosage of 15 to 30mg is recommended to help to speed healing.

Fish oil is rich in the omega-3 polyunsaturated fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), and has been found to be a factor in suppressing the
production of inflammatory mediators. In a double blind, placebo-controlled study of 49 patients with rheumatoid arthritis, those who supplemented with fish oil for 24 weeks showed less morning stiffness and fewer tender joints than the control group. Recommendeddosage is 2 to 3g daily, but may require two to six months to take full effect.

Soft tissue or manual therapy

In many plantar fasciitis cases, manipulation of the soft tissue can provide a measure of relief to sufferers. Through observation and palpation, aim to lengthen the tightened areas between each of the points that support the arches: the heel, the first metatarsal head and the fifth metatarsal head. Work your way posteriorly and loosen the Achilles tendon and the muscles attached to it, including the soleus and gastrocnemius muscles. Instrument-assisted therapies, like Graston, Fibroblaster and Gua sha, are also helpful tools to break down scar tissue, adhesions and fascial restrictions.

Sports medicine acupuncture – motor point locations

Though acupuncture is often recommended as an effective treatment for plantar fasciitis, most positive reports have only been anecdotal. Research regarding acupuncture’s
efficacy shows promise, though. In a study that documented the treatment of 11 patientswith acupuncture and electrical stimulation, most indicated improved overall pain scores.

A motor point is typically located in the central aspect of the muscle. This sensitive area has a strong influence on pain management, and is also helpful in strengthening and increasing the range of motion of the treated muscles. In Traditional Chinese Medicine, these are known as Ashi points, or trigger points, in other health circles. The following are muscles that may relate to the plantar fascia, and therefore can be helped with acupuncture therapy or electrostimulation to relax the tightened and/or contracted muscle tissue.

Tibialis posterior

Location: 1 cun medial to the point between UB 56 and UB 57

Insertion: Oblique needle insertion 1 to 1.25 inches directed towards the centre of the calf

Caution: Posterior tibialis artery and nerve

Tibialis Posterior

Soleus – 3 points

Location 1: 3 cun inferior to head of fibula, on the posterior border of the fibula
Insertion: Perpendicular needle insertion with a depth of 0.5 to 0.75 inch
Location 2: 1 cun posterior from SP 8 Insertion: Perpendicular needle insertion 0.5 to 0.75 inch
Location 3: Halfway between SP 7 and SP 8
Insertion: Perpendicular needle insertion 0.5 to 0.75 inch
Soleus

Abductor hallucis longus

Location: Kidney 2
Insertion: Perpendicular needle insertion 0.5 to 0.75 inch
Abductor Hallucis Longus


Flexor hallucis longus

Location: Halfway between UB 58 and UB 59
Insertion: Perpendicular needle insertion 1-1.5 inch
Flexor Hallucis Longus

Flexor digitorum longus

Location: SP 7
Insertion: Perpendicular needle insertion 1 inch
Flexor Digitorum Longus

Tape support

Taping the affected foot with a technique known as low-dye taping may bring some relief to plantar fasciitis sufferers. Four strips of tape are applied as shown below. Caution against applying the tape too tightly and switch to hypoallergenic tape for patients who have adverse reactions to regular tape.
Tape Support

Directions

  1. Wrap a strip of tape around the ball ofthe foot.
  2. Wrap a second strip of tape around the heel, starting just below the pinky toe, around either side of the heel and back up to the first strip of tape.
  3. 3. Wrap a third strip of tape around the heel, starting just below the pinky toe, as in step 2. This time, circle the heel and wrap the tape in a criss-cross fashion, so that it ends just below the big toe.
  4. Repeat step 3. The tape does not need to align perfectly and can stay in place for up to one week.

Other options for treating plantar fasciitis

If your patient has not noticed an improvement with the above recommended treatments, you may wish to try some of these alternatives:

Pain medication – A short course of a nonsteroidal antiinflammatory drug (NSAID) like ibuprofen can be helpful to relieve pain. However, these types of medications have many possible side effects. It might be a good idea to discuss the potential risks versus benefits with your patients.

Steroid injection – An injection of a steroid (glucocorticoid) medication into the foot may relieve pain, though the effect may wear off after only a few weeks.

Casting – A walking cast with a rockershaped bottom allows the foot and ankle to be in an optimal position for pain relief and healing for the duration of treatment.

Plantar fasciitis is a common foot condition that can thankfully be managed using many different approaches. As a practitioner, you may already be using some of the options suggested here, or perhaps you have learned some new treatments you might implement in your office or suggest as at-home protocols. Having a hand in
getting runners back on track, dancers back up on their toes and people back to their physically demanding jobs is certainly a satisfying and rewarding end result for practitioners – and a huge relief for sufferers.

Pulled Muscle

Inside a pulled muscle

A strained muscle occurs when muscle fibres or attaching tendons are overstretched or torn, typically resulting from overuse, fatigue or improper form. A pulled hamstring (the muscle group behind the thigh that flexes the knee) is common among athletes, especially runners.