Hello and welcome back once again to the ThreeSpires Physiotherapy blog where we take a look at all things physiotherapy and health related. In this blog I thought that it would be nice to continue looking at conditions that physiotherapists regularly see and treat in practice. In this case: a tricky to treat condition called Plantar Fasciitis and we will try to cover assessment, diagnosis, causes and potential treament options for plantar fasciitis whilst also making this more relevant by using a case study of a recent patient with Plantar Fasciitis.
What is Plantar Fasciitis?
This can be a highly painful, debilitating and long lasting condition that is notoriously difficult to treat and get rid of. In fact a quick bit of googling will show that some patients can suffer from it for anything up to 2 years! Plantar fasciitis involves pain at the heel or along the base of the foot and is generally considered to be an irritation of the plantar fascia.
What is the Plantar Fascia?
Well as with most things in physiotherapy before you can understand exactly what plantar fasciitis is, it is necessary to have a brief look at a bit of anatomy and to understand the structures involved especially the remarkable plantar fascia. Firstly the heel and ankle is made up of several bones, the actual heel bone is called the calcaneus, above which is the talus and to the sides of which are the two bumps of the ankle joint - the malleoli which are made from the tibia and fibula. Inserting into the posterior aspect of the calcaneus is the Achilles Tendon and running from the calcaneus down the length of the foot is a piece of connective tissue called the plantar fascia.
This piece of fibrous and strong connective tissue provides support for the base of the foot (the plantar aspect of the foot). It is quite a remarkable piece of anatomical structure in that it performs a number of roles: it helps with shock absorption through walking and running: as you strike down on the floor during gait the plantar fascia absorbs some of this impact and stores some of the energy and then releases this back as you push off. It also has a key role in maintaining the medial arch of the foot which you will see if you look down at the inside of your foot. Sometimes this piece of connective tissue will get overloaded and become irritated and when this happens this called plantar fasciitis.
What are the Symptoms of Plantar Fasciitis?
Typically someone with plantar fasciitis will experience pain in the ball of the heel on weight-bearing and walking. They will often describe it as feeling like there is a stone in their heel/shoe or when it is particularly bad like walking on broken glass. It is generally worst when first getting out of bed and taking those first few steps of a morning; once the patient has got going and walked a bit things will generally ease off a bit. People who do a lot of walking, are on their feet a lot or have jobs such as postmen and the police where they have to walk long distances each day are especially prone to plantar fasciitis.
What Causes Plantar Fasciitis?
This sounds like a simple question but is in fact a subject of much debate and research. In general it is thought that Plantar Fasciitis is caues by overload of the tissues of the plantar fascia by either too much standing, walking or running. There are many current theories that foot type, foot posture and shoe type may make getting Plantar Fasciitis more likely but currently these remain unproven.
Who is at Risk of Plantar Fasciitis?
Anyone who walks or stands on their feet can potentially get plantar fasciitis but there are some groups of people who are much more likely to get plantar fasciitis. Anyone who spends a large proportion of their day on their feet such as postmen, police officers, factory workers and workers in supermarkets are especially prone to plantar fasciitis and find it very difficult to get rid of once they have it. Runners and long-distance walkers are also prone to plantar fasciitis and it can be very disruptive to their activity.
How is Plantar Fasciitis Diagnosed?
Usually this is done from assessing symptoms and combining these with the results of physical testing. There is not often any reason for imaging such as an ultrasound scan. Commonly patients will initially have gone to their GP complaining of heel pain and will then have been referred on to a physiotherapist. The physio will take a full history, do a physical assessment and based on the combination of these factors make a diagnosis of plantar fasciitis. It is important to get an accurate and early diagnosis of your plantar fasciitis as this allows the best management and treatment plan to be devised and for your to get back to your activity as soon as possible. Delaying a diagnosis and letting things worsen will only lengthen the rehab process needed for your plantar fasciitis
Treatments for Plantar Fasciitis?
The correct and most effective treatment fro your plantar fasciitis will depend upon factors such as severity of your symptoms, how long you have had your plantar fasciitis and how modifiable your daily activities such as walking are. As mentioned earlier Plantar Fasciitis is an extremely difficult condition that is hard to treat and treatment of Plantar Fasciitis is a subject of constant research. Below are some options for the treatment of Plantar Fasciitis, mostly they ae based on research but also they draw from my own experience of what works as a physiotherapist:
- Rest: as in general plantar fasciitis is an overload irritation of the tissues then taking a break from weight-bearing will be one of the key strategies for getting your symptoms improving. Now this need not mean something as impractable as being off your feet completely for the next 2 weeks. I completely understand that everyone has work to do but there are always ways of avoiding being on your feet too much and by rest I mean just being on your feet less. For example: if you work standing on your feet all day then it is worth having a chat with your employer about getting a seat to sit on for at least part of the time. Ways of alleviating the load on the plantar fascia can make an enormous difference over the period of a few weeks.
- Avoiding Barefoot Walking: many of the patients that I see have beautiful hard wood floors that look amazing but are unfortunately really unforgiving on the surfaces of the heels and the base of your feet. As such one key thing to avoid with plantar fasciitis is bare foot walking. Now tis doesn't mean that you can't walk barefoot on the beach but instead means that you should always be wearing something soft and supportive when walking on any hard surfaces.
- Exercises: Calf raises and specific foot strengthening exercises have been shown to be helpful for Plantar Fasciitis but it would probably be best to have an assessment with a physiotherapist to determine which combiation would be best.
- Heel Cups: Gel cushioning underneath the heels that are affected can be helpful. There are a large number of brands out there and it is necessary to choose a set of heel cups that fit your shoes well and are comfortable.
- Orthotics: Insoles that support the plantar fascia can be helpful for some patients but again it would likely be necessary to have a full assessment of your Plantar Fasciitis before trying them.
- Acupuncture: For some patients with Plantar Fasciitis acupuncture can be helpful to reduce pain and improve recovery.
To help look at how Plantar Fasciitis can be treated in might be helpful to have a look at a case study:
The patient in this case study (Mrs S) was a physically fit and active female in her mid 60s who had recently returned home from a walking holiday with excruciating heel pain. The pain had begun on the next to last day and due to her wish to complete the walk, she had walked about 18 miles the following day with an extremely painful heel. Later that week once she had returned home she gave us a call at ThreeSpires Physiotherapy and arranged for an initial assessment and treatment session at home. On initial assessment she was clearly limping and did not want to stand on the affected heel and found it extremely painful to be touched on the base of the heel. She also had poor balance (it was not good on the unaffected side) and a mental note was made of this to be looked at in later sessions in order to prevent her plantar fasciitis from re-occurring. After a discussion with the patient it was recommended that she initially rest her heel, use ice and also some anti-inflammatories to bring down the initial irritation and also to get some gel heel inserts to allow her to walk more comfortably.
Electro-acupuncture was used to reduce pain at the heel and improve healing, with the ball of the heel and structures around the heel being targeted with the needles. The patient responded very well to the acupuncture and at the next session (3 - 4 days later) reported a large drop in pain. Within a couple more sessions the patient had made a great recovery and was able to walk with minimal pain and was able to start to slowly build up her walking and activity levels again.
Over the course of the next 2 months she received approximately 6 sessions of acupuncture and a series of exercises targeted at improving her balance. At the last session she had no pain and was able to walk as far as she had previously and was delighted. What is more her balance had significantly improved and she had a home exercise plan to continue with in order to reduce the likelihood of her plantar fasciitis coming back.
A key question that the patient asked several times throughout our sessions was: "Why is my plantar fasciitis improving and why do some people have it for so long?" In my opinion the answer to this was that she had sought help very quickly and was able to stop irritating her plantar fascia and start helping it to heal much earlier than people who just simply try to ignore the pain and think that it will go away. By seeking help early, doing the right things and getting some effective treatment she had been able to avoid a long and frustrating journey. Certainly in my opinion and experience the people who are most resistant to treatment are those who have been avoiding seeking help for months and months and see a physio when they are in absolute agony! By this point it is usually extremely difficult to help them.
I hope that you have enjoyed this blog. For anyone who has not visited the site before, we are a home visit physiotherapy service based in Lichfield but serving anywhere within 25 minutes drive including areas such as Burntwood, Cannock, Rugeley, Tamworth, Burton, Sutton Coldfield and Brownhills. If you would like to book an appointment with one of our physiotherapists or would simply like more information about plantar fasciitis then you can contact us by phone on 0788 428 1623 or via email: email@example.com
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