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Foot pain

Fasciitis Treatment: A Physios Guide to Fixing Heel Pain

Do your heels hurt from a lot of walking or running? Or have you been told that you have plantar fasciitis or a heel spur? Well, you are certainly not alone!

We have developed this comprehensive guide to give you the what, why and how to help fix plantar fasciitis.

What does the plantar fascia do

The plantar fascia is a strong band of connective tissue that starts at the bottom of your heel and runs along the bottom of the foot, attaching into the toes.Think of it like a big strong rope that supports your foot and helps you move.

It is important for:

Maintaining your arch when walking and running
Stabilises your arch: As you push off your big toe, the fascia is put on more stretch, which lifts up the arch into a more stable position so you can propel yourself forward. This is called the windlass mechanism. You can see in the diagram below how when the big toe is pushed up, that pulls on and tightens the fascia, lifting the arch up. For more info on the windlass mechanism, you can see this previous post.

What is plantar fasciitis

In a nutshell: It is a thickening of the plantar fascia due to overload.

A massive 4% of the population over 20 have plantar fasciitis and it is a massive cause of loss of function. It is essentially an overload injury where multiple factors combine to increase the load/pull on the fascia. This overload combined with not enough time for the tissue adapt leads to mal-adaption.

Essentially, it adapts wrong and ends up getting thicker and dysfunctional.

Other common names of Plantar Fasciitis

Plantar fasciopathy or fasciosis
Plantar heel pain

Is fasciitis inflammatory?

No. There has been shown to be some inflammation early on in the pathology but on the whole, it is not an inflammatory injury after the first 1-2 weeks.

This is why over the last ten years, a lot of the medical profession and research down around this condition have been leaning towards calling in plantar fasciopathy, not fasciitis. For now though and the purpose of this article, we will continue to call it fasciitis for continuity. (1)

Fasciitis symptoms

Pain upon waking and taking your first few steps –This “startup pain” is because your plantar fascia and calves have been in a contracted, shortened position all night.
Sharp stab or a dull ache in your arch or at the heel.
Pain after long period sitting.
Pain that eases gradually in a walk or run as it warms up

Risk factors for Plantar Fasciitis

Limited ankle or big toe range of motion
High body mass index/Overweight
Older age,
Prolonged standing.

The best Plantar Fasciitis Treatment

Now that you know the what, why and how of how fasciitis can happen, we can move on to the main thing. How you can help your plantar fasciitis get better, faster.

These are the main things that need to covered in a comprehensive treatment of plantar fasciitis

De-load the fascia through alteration of exercise or load
Support the foot and fascia
Improve strength of the calf muscles for better control and shock absorption
Reduce the pull on the plantar fascia by
1. Improving flexibility in the calf and plantar fascia
2. Improving ankle dorsiflexion range if needed
And last but importantly, we gradually load the plantar fascia to re-align the fibres and get rid of the thickening

Here are those steps laid out in far more detail:

1. Reduce load

Plantar fasciitis happens from the repeated load on the plantar fascia without enough recovery. So, simply, to help give it a chance to recover, we need to reduce the weight bearing load to a degree. It isn’t about stopping completely, that is barely ever needed.

For Plantar Fasciitis, it is all about the relative rest

This means resting the fascia, compared to what it has been doing and what overloaded it. For example, if you were running 5 or 6 days a week, you could cut that down to 3 times per week, every second day. There isn’t a set exact guide for this but the big thing is to listen to your body. If you have more morning pain the next day then ease off a bit more and don’t do quite as much.

Not satisfied with decreasing your running or walking or too sore to keep going? Then on the rest days or as an alternative, try getting on a bike or rowing machine and get your exercise in another way.

2. Support the foot

Helping support under the plantar fascia and encouraging good foot motion can be great for relieving pain when you have plantar fasciitis. There are a few options to help here including:

Orthotics – These help support the medial arch and cushion the heel and are recommended for up to 1 year
Gel heel pads – Great to help reduce impact and give a soft surface for your heel
Fasciitis compression sleeves – These great socks can mimick arch taping really well and we have found they can give patients great relief

3. Improve strength

Studies have shown that people with plantar fasciitis have calf weakness, as well as ankle and calf tension2. This can increase load and contribute to fasciitis as the calf is then absorbing less impact and there is less control.

Strengthening the calf is important but often when the plantar fasciitis is irritated, it can be too sore to do. Never fear though, we have provided a couple of different levels of strengthening for you to work at daily:

level 1: Theraband Calf Strengthening

As per the picture below, push your foot down again a resistance band (TheraBand for example) and then control back up.

Repeat this for 3 sets of 12 repetitions and adjust the tension of the band to make it easier or harder

Level 2: Heel raises

Starting on two feet, and holding onto a wall if needed for support, raise up onto your forefoot as shown and then slowly control back down over three seconds.

Do this for 3 sets of 12 repetitions and when that is easy, start doing them on one leg at a time.

Note, if there is more than a little pain then start with level 1.

4. Reduce the pull

Both the calf and the plantar fascia attach onto the heel and some fibres of the Achilles tendon actually wrap around and attach to the plantar fascia. So it makes sense that any tension in the calf, plantar fascia or ankle can increase the pull at the heel and worsen fasciitis.

Here is a quick test t see if you have enough ankle range:

If you can’t get your knee touching the wall when your foot is 10cm (4 inches) without your heel coming off the ground then you have some work to do! Here are the top three exercises to regain ankle range and reduce plantar fascia and calf tension:

1. Ankle mobilisation

Improve the dorsiflexion range in your ankle if you failed the ankle range test above. See the video demo below for an easy ankle self-mobilisation at home. Alternatively, if you don’t have a band (you can get one here if needed), you can lunge your knee back and forth towards the wall for about 3 sets of 20 reps.

2. Calf stretch: Hang one heel off a step at a time to stretch out your calf and hold this for 30 seconds each side.

3. Plantar fasciitis deep massage: Use a hard ball or a massage ball to roll out the sole of your foot. Do this between the heel and balls of your foot, NOT under the heel. Do this slowly and firmly for 1-2 minutes to relieve the plantar fasciitis – You can also use a small frozen water bottle!

5. Gradually load

The final aspect of rehab is to load the plantar fascia. The idea behind this and in some recent, successful research is to treat it like a tendon injury. In tendon injuries such as Achilles tendinopathy, the tendon is thickened and the fibres and dysfunctional due to overload. The big part of tendon rehab thing that helps this a lot is putting gradually more load through the tendon. This causes the tendon to adapt and change for the better.

Looking at it like this and treating the plantar fascia like a tendon (even though it technically isn’t) looks to be gaining good results in research and the clinic and is becoming a mainstay or plantar fasciitis rehab over the last few years.

If you want to read further about this, you can check out the main research paper here, with their main conclusion being:

High-load strength training may aid in a quicker reduction in pain and improvements in function

Otherwise, if you don’t want to read a research paper:

This is the main exercise that is used to load and strengthen the plantar fascia to ultimately help fix plantar fasciitis

The high load strengthening exercise is done as per the image below. A small towel is rolled up to raise the toe up (hence, putting the plantar fascia on stretch) while doing a heel raise off a step. Go up and down slowly (count 3 seconds each) and hold at the top for 2 seconds.

This can be started two-legged and progressed to one-legged as it gets easier. You can then add a backpack with something heavy in it to add a little extra load. Keep doing this until you are pain-free.

plantar fasciitis strengthening exercise

Rathleff Et al. 2014

Conclusion:

And that’s it – all the information, treatments and tools that help fix plantar fasciitis.

Unload, Support and Gradually strengthen

Thanks for reading, you will most likely also enjoy our Comprehensive Plantar Fasciitis Rehab Guide

Foot pain

The Human foot – Amazing video of foot mechanics

• By PhysioPrescription

The human foot is an amazing thing and something we rely so much on – It shouldn’t be taken for granted. This is a great video by the BBC that demonstrates and discusses our amazing natural foot mechanics of our feet and how it works to keep us moving efficiently.

There is some dissection in the video so be warned if you are a bit squeamish, but it is well worth it!

There is also a great explanation in here of the plantar fascia and windlass mechanism and how this natural spring mechanism helps us move – you will be surprised how complicated our feet are!

What do you think about our foot mechanics? Pretty bloody lucky aren’t we.

Foot pain, Health, running, Shin Pain

Stress Fracture in Foot From Running: Heal Faster and Stronger

• By PhysioPrescription

$Stress fracture shin$ A huge 20% of runners get a stress fracture in foot from running – often when building to a big race! We will try to answer questions like what a stress fracture is, why runners are so prone to them and also how to get them better, faster.(3)

What is a stress fracture?

A stress fracture, as the name suggests, is a small fracture in a bone. It is a partial or incomplete fracture caused by the build up of stress to a localized area of bone.

Stress fractures aren’t your usual fracture that happen due to a big fall or collision, they are due to repetitive strain, which is why runners are so at-risk, but more on that soon.

What causes a stress fracture?

Bones get stressed when there is a load placed through them, whether this is from the shock of your foot landing on the ground or from your muscles pulling on the bones to move you and absorb the shock. Stress fractures can basically be classified into two types:

1. Fatigue; This is caused by an abnormal stress (more than the bone is used to) to a normal bone.

2. Insufficiency; These fractures arise from the application of normal stress through a bone that is abnormal – such as mineral deficient or abnormally rigid. This is most prevalent in nutrient deficient and older population with osteoporosis and arthritis.

Stress Fracture in foot from Running

The type that is most common in the active population, as you can guess I’m sure, is the fatigue stress fracture. Generally the “abnormal force” that causes this bone-fatigue is due to:

Increasing training intensity or distance,
Wearing inappropriate shoes or not progressing into new shoes
Training on hard surfaces or due to poor alignment of the feet

The problem with bones is that they adapt a lot slower than muscles – when muscles can adapt and improve within a few weeks, bones can take a few months! This means that as your muscles improve and your lungs do too, you can go further and faster. The only problem with that is that your bones are still trying to adapt to the initial increase in training. This delta in adaptability can cause stress fracture in foot from running.

Bone Adaptability

$stress fracture cycle$

Romani et al. Journal of Athletic Training 2002;37(3):306–314

Think of bone remodeling like renovating a house: Winter hits, and without thick walls it is bloody cold. So you adapt and decide to insulate the walls.

Your bones are the same, they get an increase in stress through them and think hey, I need to get stronger, but before your bones get stronger, just like insulating your walls, the current walls need to be taken downs first.

The problem is if you increase training load or intensity in this time when the bone is actually weaker, when trying to remodel, you can push it over the edge and cause a stress fracture.

In fact, there’s even a window of about a month where bone becomes weaker after an increase in training stress because of the way the body remodels bone, as described above, which increases the risk of stress fracture in foot from running.

Your body first tears out some walls in the bone structure before it can put in new ones, much like remodeling your house.

Where do Stress Fractures happen?

Stress fractures in runners are most common in the shin bone, the navicular bone in the foot and the 2nd and 3rd metatarsals (long bones in the foot) – stress fractures through these three bones make up over 50% of all stress fractures.(1)

Note: Shin splints does not mean stress fracture. Shin splints is a generalised, umbrella term that is used to describe pain in the anterior shin – this can be a number of things so be sure to have your shin pain diagnosed by a professional.

Why are runners so at risk for stress fracture in foot from running?

Stress fractures account for a massive 20% of athletic injuries and are very common in endurance activities, especially distance running. This is hardly surprising as running requires thousands of repetitive steps on every run – now if you do any of these for example:

Increase training mileage too fast (more than 30% in two weeks for example)
Start using new minimalist shoes all of a sudden
Increase training intensity

Just to name a few! This will be putting more load through your bones than they are used to. If they then aren’t given time to adapt to this and get stronger – they will actually suffer repeated micro trauma and will fracture

A stress fracture typically feels like an aching or burning localized pain somewhere along a bone. Usually, it will hurt to press on it, and the pain will get progressively worse as you run on it, eventually hurting while walking or even when you’re not putting any weight on it at all.

Sometimes, if the stress fracture is along a bone that has a lot of muscles around it, like the tibia or femur, these muscles will feel very tight.

How to heal strong and fast and get back to running ASAP.

Firstly, get it diagnosed by a professional. The vast majority of stress fractures heal within 8 weeks, but it is important to have it diagnosed as soon as possible so that yo know for sure what it is.

Secondly, rehabilitation of a stress fracture can be split into three phases:

Phase 1: Relative rest (rest and protect phase)

The goal in the first phase is to rest the injured area to give it time to heal, while maintaining aerobic fitness. This is the main goals:

Rest the injured area: No running or loading up the area. Listen to it, if it hurts, stop. A moon boot may be needed and will definitely help you heal strong.
Maintain fitness through swimming and cycling
Seek treatment from a physio – This does help as it is important to maintain full range of motion and to unload the injured area
Ice to decrease inflammation and limit secondary damage
Do not take anti-inflammatory medication if you can help it (you don’t want to stop inflammation and slow healing)(2)

Phase 2: Strength, conditioning and rehab for stress fracture in foot from running

In this stage we need to ensure the causative factors behind the injury are sorted out. Things such as, tight muscles, muscles with poor endurance or controlled and training error.

This is the phase that you will enjoy as unlike the first phase, it isn’t all rest and unload – You can take control of your recovery by doing the right rehab exercises to ensure the stress fracture heals strong and fast. Your exercises need to address these areas:

Increase muscular endurance (calves, glutes and hamstrings)
Improve core and pelvic stability
Work on balance training (proprioception)
Address flexibility issues
Re-train running pattern

Phase 3: Safe progression back to full activity

This is where you ease your body back into it while allowing the bone to strengthen and heal – without overloading again.

In the second blogpost in this stress fracture series, I am going to detail phase 2 and 3 – the exercises that you can do to help speed up recovery and have you healing strong. These are all exercises that can be done at home so there is no excuse for them not being done!

Foot pain, Health, Lower limb

Arch Pain? Easy Self-Treatment

• By PhysioPrescription

In today’s world of concrete pavements, cushioned shoes and sedentary lifestyles – Our feet get stiff, imbalanced, achy and neglected. This often leads to arch pain and plantar fasciitis (or fasciopathy) but luckily these is a way to help loosen off your arch!

It is time to take 2 minutes to wake up your feet and get them loose and mobile again with one simple exercise.

Our feet lay the base for our entire body to work off and they really are an amazing piece of machinery, they:

Absorb impact
Propel us forward with spring-like mechanisms (see more here)
Have cat-like reflexes
Balance out and lay the foundations for our whole upright body

The amazing human foot: This BBC documentary on the human foot gives a great insight into all the structures that combine to give the foot the ability to take all of our weight, day in day out. At 18-19 minutes you can see the plantar fascia that runs along the bottom of your feet clearly and how it gets tensioned as you walk, acting like a spring – this is the spring that you are going oil up with this treatment today!

The feet really do have a lot to do, and have a lot of weight and forces going through them every single day. This combined with us tending to keep them cramped up in fabric coffins for the better part of the day, or even worse in flat shoes and flip-flops – leaves them needing a little R & R.

So how can you say “thank you feet” and give them some relaxation and mobility?

Take a ball, any ball will do (I prefer to use a lacrosse ball as they are grippy and firm) but the firmer, the better. Place it under you foot, apply some pressure and slowly roll it around the bottom of your foot.

Maintain a comfortable pressure, while rolling it into all the tight spots in the sole of your foot – namely the inner arch and outer arches of your feet between your heel and the ball of your feet.

Do this for two minutes on each foot and feel the difference. You do this while standing or sitting (under the desk at work even), so really there is no excuses 🙂

This is a great little exercise to really loosen up the Fascia (connective tissue), massage the muscles and mobilize the bones, and as a bonus, it increases your flexibility.

As a quick test to see if your tight feet are affecting your flexibility – before you start the myofascial release, slide both hands down your legs and see how far down you can get (toe touch), and remember how far down you get. Roll out both feet for two minutes each and then re-test – Most of you will be pleasantly surprised that you get significantly lower down

And YES if you have Plantar Fasciitis or Heel spurs – This will really help you.

So, if you have any foot arch pain, heel pain, calf pain or just generally want to look after your hard working feet – Take a few minutes out of your day and get this done and you will be much better off for it.

Thanks for reading, you will most likely also enjoy our Comprehensive Plantar Fasciitis Rehab Guide and these past blog posts:

Please share, like or comment if you want more

Foot pain, Health, running

Numbness in toes while running? Here’s your solution

• By PhysioPrescription

Pain, tingling and numbness in toes?

How you tie you laces may be the problem!

If only all our problems were so easy to fix…

We all do it; sit down, slip our socks on (apart from the bare-foot runner among us) and proceed to firmly and decisively tighten and tie our laces.

Great! And away you go, but unfortunately this little ritual is often done wrong – with all the best intentions I know! But wrong none the less.

Tightening up the top few rings of our shoes as firmly as we can – ensuring stability, a firm fit and feel-good-factor right? When in reality you are strangling your foot’s blood vessels and nerves, causing paresthesia (Tingling and numbness) in your foot and more commonly, your toes.

The human foot is an incredibly complex piece of machinery with 26 bones, 33 joints, 20 muscles and many ligaments all combining to move you around all day, taking thousands of steps and acting like a natural spring.

But it too much compression is placed on the foot – The is a lot of places for your little nerves to get trapped, pinched and compressed.

Definitely not something we want on our runs!

So whats the easy fix?

A lot of seasoned runners will know this and do this already but believe me they are far out numbered by those that don’t.

Answer: Tighten your laces from the toe-up. Ensuring that the last two rungs are no more than 80% of the max tension.

This gives your feet breathing space, which makes for much happier feet and a much happier runner!

Win, win!

Give it a go, alter than ritual and be forever better off.

Note: In mostcases, foot and toe numbness and mild pain are due to improper equipment or technique, so relatively easy to fix when the offending problem is sorted out. BUT if it continues after the problems are fixed – it is time to consult a professional and check that there is no underlying pathology.

Thanks for reading and striving to improve yourself! Get out there and put it into practice 🙂

If you have any running related questions – head on over and ask the team at The Running Forum, a great community, that is always happy to help – and as always you can comment below.

Calf Pain, Foot pain, Health, Shin Pain

Flip-flops and moon boots

• By PhysioPrescription

Whenever I see a patient with a lower limb injury come into the practice wearing flip-flops I cringe inside. Really, these simple bits of plastic are causing a lot of pain and injury and are not something you should wear all day.

Flip-flops absolute lack of arch or heel support puts you at risk of unnecessary pain and injury. We are (I am generalizing here) so careful to wear the best footwear when exercising, keeping up to date with the latest running shoes, orthotics, braces etc but when it comes to relaxing and what we wear outside of work and sport – we aren’t so smart. A study found that in a large shopping center, 43% of all women were wearing flip-flops(1) – That is a huge amount of foot, calf, shin, knee and back pain! Yes this may keep Physio’s and podiatrists in business but it keeps a lot of the population out-of-pocket – And often there is a very simple thing you can do to ease your pain and injuries….

Throw your thongs away!!

Really flip-flops aren’t that bad if you just wear them to the beach, around the changing room or shower etc – It’s when you start wearing them out shopping, to lunch, all day, everyday that they can cause real problems. What problems can flip-flops cause you may ask? and why? Flip-flops can lead to:

Plantar fasciitis
Stress fractures – Hence the moon boots
Shin splints
Calf pain and strains
Foot pain e.g. Mortons neuroma, metatarsalgia
Low back pain
and more

And Why?

Flip-flops change the way we walk

They wouldn’t be so bad if our feet weren’t so weak and de-conditioned. Yes we evolved to roam the open plains and jungles barefoot but now that we live in this concrete world – we need a little more protection for our feet. Also because we so often wear cushioned supportive shoes the rest of the time, our feet are not able to handle the complete lack of control and support when wearing flip-flops – Like sleeping on a nice comfy bed one night and then on concrete the next – You will get sore right?

And because they change the way we walk, we use our muscles in a different way, while increasing the shock going through and feet and legs due to lack of shock absorption. Wear them for a long time and the repetitive strain leads to overuse injuries. For example:

Every time you step, you need to squeeze and scrunch your toes to hold the flip-flops in place! Meaning your feet and calf have to work very, very hard = tight, tight calves.
Due to the total lack of arch support the arch can repeatedly over-pronate, increasing the stretch on your plantar fascia. Repeat this over hundreds of steps and you get micro-tears, inflammation and pain. You can read more about this here.

Good things in moderation

So, you don’t need to go and throw your flip-flops out but PLEASE limit the amount you wear them as they can be a huge cause of pain and injuries. This is also such an easy thing to change that can drastically improve your function and decrease injury risk, so why not do it huh?

Addendum: As a proud Kiwi I feel I should give a quick history on the proud origin of flip-flops.. or should I say Jandals! The flip-flops was originally invented in Auckland, New Zealand in 1950. The idea came from the original Japanese sandals which allied soldiers saw while doing occupation duty in Japan during WWII. The original name Jandal (Japanese sandal) was trademarked so that lead to other countries having t come up with other names such as:

Flip-flops
Sandals
Slippers
Thongs, etc

So wear this great invention in moderation and save yourself a lot of trouble. Please Share, like and comment away!