My approach to treatment and why. Exercise, pain relief and shockwave therapy.


So many people I have seen and spoken to recently seem to have been suffering from plantar fasciitis, it's painful and will stop you running. As a result, I thought I would have a go at writing a blog on what this annoying condition is and the treatments I use - and why including shockwave therapy when it's not improving with conventional physio. It's not just difficult to pronounce, it's also tricky to treat!!!!! Here goes.......

The first thing that I must point out before you read this blog is that it is intended as an informative blog to help with your understanding of plantar fasciitis. It is not intended to replace medical expertise. If you are unsure about anything then consult a suitably qualified medical professional as there are other things that mimic plantar fasciitis.

Plantar fasciitis, policeman’s heel and plantar fasciopathy are some of the phrases and words that describe the same clinical entity. Pain under the heel or arch when weight-bearing, that is usually worse after periods of rest – most noticeable in the morning for the first few steps when getting out of bed. 10% of all running injuries are accounted for by plantar fasciitis (Chandler and Kibler, 1993).

The plantar fascia is a connective tissue, which is structurally a lot like a ligament and passes from your heel, under your arch and fans out to your toes (see image below). A word with the ending ‘itis’ means inflammation. This is misleading in plantar fasciitis as the inflammation is only really seen in the very early stages. The problem is more of a degenerative change seen in the collagen fibres within the fascia (Lemont et. Al. 2003) and is classified as an overuse injury.

The Plantar Fascia; Graphic by Injurymap

As with many things in the sports injury world, there does not appear to be a single treatment that has been demonstrated to consistently give the best effect (Badatunde et. Al. 2018), so there is not a one size fits all or set menu approach for plantar fasciitis. This is probably because people are individuals and may respond in different ways to different treatments and have slightly different presentations, with different needs. However, they did find that over the counter anti-inflammatory medication and a ‘wait and see’ approach were the least successful interventions. In fact……… there is some evidence to suggest that delaying treatment could lead to the pain hanging around for longer (Wolgin et. Al. 1994). This makes it a little difficult to give general advice as treatment is specific to the individual, other than - don't leave it and hope it gets better, this will often make it last longer than necessary.

I try to use a systematic approach to treating plantar fasciitis:

  1. Settle the area down by offloading the fascia.
  2. Identify any causes and predisposing factors.
  3. Treat the causes and predisposing factors.
  4. Gradually expose the fascia to load.

Since plantar fascia pain seems to be related to overuse or overload, it makes sense to me that you first need to take a step back from what you are doing initially. I am not keen on stopping people participating in the exercise, but my experience of plantar fascia pain is that you are very rarely able to push through the pain and it gets better - it's overuse, why would continuing to overuse it help? Therefore, I suggest RELATIVE rest. This means, exercising to a level where everyday discomfort is just about the same – not going for 10 mile run one day, and paying for it the next day. This takes a little trial and error since you don’t know your limits until you have crossed them!

In this 'settling things down' phase, pain relieving techniques and advice can be helpful. 

The rehabilitation plan should help to resolve symptoms as quickly as possible, but it’s also nice to get some instant (all be it short term) relief too. For this, I usually recommend insoles, taping and/or ice massage.

There is evidence to suggest that using an insole may be helpful in reducing your pain (Whittaker et. Al. 2018) and it doesn’t seem to matter whether this is customised or something off the shelf or whether it was a firm or soft insole. However, insoles will not work for everyone. This seems to be consistent with what I see anecdotally, and I normally suggest trying something like heel cups.A low Dye taping technique has been shown to be clinically effective in decreasing pain in the short term (Radford

 et. Al. 2006) and so this can be helpful too. There is a link to a video of this technique here.
 

Risk Factors

There seem to be a huge amount of risk factors that have been identified in the literature, and so there is lots to look out for. Here is a review of the literature that looks at the key risk factors, but these include:
  • Sports that involve running
  • Increased arch height 
  • Increased ground reaction forces with lower medial arch
  • Running in spikes and street running
  • Running more Km a week
  • High BMI
  • Prolonged standing in the day
  • Forefoot pronation
  • Excessive or limited dorsiflexion
  • Varus knee alignment
  • Tight hamstrings 
So there is quite a list! These areas need to be assessed and if possible, they need to be changed in order to resolve pain. This may take the form of specific exercises or simply advice on training load.

Loading the fascia


It then seems to be important that you gradually improve the tolerance of the tissue in the same way that we do with tendon problems. Our bodies are incredible things and when we give it a stimulus it responds to it. For example, if we lift weights that are very heavy, our body responds and gradually builds bigger muscles so that it can lift the weight easier. If we stop however, the body does not waste its time and energy maintaining that muscle and so we lose it. This is the same for tendon, bone and fascia too – it all adapts to the load placed on it and we call the process by which the body does this 'mechanotransduction'. So, with a degenerative problem, we need to apply a progressive, slow load to the structure in order to gain changes in said structure.

I tend to use 2 go to exercises with most people, they are then adapted slightly to ensure the correct load:

Left image - toe stretch from DiGiovanni et. Al. (2003). Right image heel raise from Rathleff et. Al. (2015)

I use the stretch on the left as it tends to be a comfortable stretch to do and was shown to be more effective than a general ‘achilles stretching’ routine (DiGiovanni et. Al. 2003). I usually recommend holding this for approximately 30-40s, repeating 4-5 times a day and every time before you stand from sitting.

I use the heel raise exercise on the right as it has been shown to improve foot function quicker than stretches alone (Rathleff et. Al. 2015) and so this is what I recommend. If this is painful to perform, then it may be better to try it on both feet at the same time to start. It's important to do these exercises slowly, as time under tension seems to be important for mechanotransduction.

In addition to these exercises, I will also often recommend exercises to help strengthen any other areas of the foot that are identified as weak. This is different depending on the person, but the exercises shown above, in some form are the ones I use as my core treatment. As pain becomes more manageable and you can start to do more heel raises, you should be able to start to increase the amount of running you do, ensuring not to do too much too quickly.

What if exercises don't/haven't worked?

Up until recently, if the pain was too bad or exercises just weren't cutting it, steroid injections were used routinely. However, this carries with it a number of risks including infection and fat pad atrophy - things that can cause long term issues.

Thankfully, the emergence of a number of well-conducted studies has found shockwave therapy can be helpful in a good number of people who have plantar fasciitis where exercises have not helped over at 3 month period. It is, however, important that shockwave is not used as a stand-alone treatment but in conjunction with rehabilitation exercises. It has low risk associated with it and generally takes about 12 weeks to see the full effects of treatment, although many people see improvements after their first session.

Sign off

So that's my approach. I hope you have found this helpful to some degree, whatever perspective you are reading this from. Plantar fasciitis can be really debilitating but it does get better and you will be running again soon. This was my first 'proper clinical' blog so all feedback is welcome - please be kind though. 

Thanks for reading

Josh

References
Badatunde OO, Legha A, Littlewood C, Chesterton LS, Thomas MJ, Menz HB, van der Windt D and Roddy E (2018) Comparative effectiveness of treatment options for plantar heel pain: a systematic review with network meta-analysis. British Journal of Sports Medicine, 0: p1-14Chandler TK and Kibler WB (1993) ‘A biomechanical approach to the prevention, treatment and rehabilitation of plantar fasciitis.’ Sports Medicine, 15(5) p344-352

Crawford F and Snaith M (1996) ‘How effective is therapeutic ultrasound in the treatment of heel pain.’ Annals of the Rheumatic Diseases, 55(4) p265-267.DiGiovanni BF, Nawoczenski DA, Lintal ME, Moore EA, Murray JC, Wilding GE and Baumhauer JF (2003) ‘Tissue-specific plantar fascia-stretching exercises enhances outcomes in patients with chronic heel pain. A prospective, randomized study.’ The Journal of Bone and Joint Surgery, 85(7): p1270-1277.

Lemont H, Ammirati KM and Usen N (2003) ‘Plantar fasciitis: a degenerative process (fasciosis) without inflammation.’ Journal of the American Podiatric Association, 93(3): 234-237Radford JA, Landorf KB, Buchbinder R and Cook C (2006) ‘Effectiveness of low-Dye taping for the short-term treatment of plantar heel pain: a randomised trial.’ BMS Musculoskeletal Disorders, 9(7) p64

Rathleff MS, Molgaard CM, Fredberg U, Kaalund S, Andersen KB, Jensen TT, Aaskov S and Olesen JL (2015) ‘High-load strength training improves outcome in patients with plantar fasciitis: a randomized controlled trial with 12 month follow-up.’ Scandinavian Journal of Medicine and Science in Sport, 25(3) p292-300

Whittaker GA, Munteanu SE, Menz HB, Tan JM, Rabusin CL and Landorf KB (2018) ‘Foot orthoses for plantar heel pain: a systematic review and meta-analysis.’ British  Journal of Sports Medicine, 52:p322–328Wolgin M, Cook C, Graham, C and Mauldin D (1994) ‘Conservative treatment of plantar heel pain: long-term follow-up.’ Foot & ankle international, 15(3): p97-102.