Plantar Heel Pain

Original Editor - Mariam Hashem

Top Contributors - Mariam Hashem, Jess Bell, Lucinda hampton, Kim Jackson, Tarina van der Stockt and Habibu Salisu Badamasi

Introduction

Plantar heel pain, also known as plantar fasciitis or fasciopathy. Differentiation between terms is important because there is a number of causes that can cause or contribute to the heel pain and not all of them relate to the fascia.

Plantar heel pain is most common in middle-aged women. The reasons for the high incidence in women are not known, however, it has been linked to early menopause. The hormonal changes are believed to attribute to a weakening of the fascia and maybe an increased stress.

The symptoms of plantar heel pain are in middle-aged women are associated with:

• Prolonged standing
• Recent changing of shoe wear
• Stress

The pain tends to be particularly bad in the morning causing the patient to struggle when they get out of the bed and start their day.

Patients usually use the internet to look up for education, advice and remedies for their symptoms. Some patients we see at the clinic may have tried strapping, rolling the foot on the ice bottle, rolling it on golf balls, and doing various stretches. And often they would say these treatments have been particularly painful, but they haven't made a difference to the pain. This drives patients to look for professional advice.

If we look at the literature, there are some pretty good studies showing that physiotherapy will have positive benefits on plantar heel pain. HOwever, when it comes to the clinical practice, different measures should be considered to apply research findings properly and see positive results. Often, the treatment that works for a woman might differ from the treatment that works for a man. The level of activity is an important factor as well as the patient's history. Considering individual factors and using clinical reasoning skills are mandatory when it comes to the treatment of plantar heel pain and other MSK issues.

Assessment

Subjective Assessment

Pain Location. Physiotherapists are skillful at figuring out the source of the pain. In other words the pain driver.

Pain Behaviour: It is important to understand the nature of the pain to get an idea of the main contributing factor. The pain can be neural or mechanical Also, ask questions to investigate the pain pattern across the day and the aggravating and easing factors.

Allowing patients to talk about their pain can be very insightful and we can help us recognize catastrophizing behavior which is common in chronic pain patients.

One of the useful motivational interviewing tips is to give your patients time to reflect on what they said. Try and summarize what they told you to understand the impact on the quality of their life.

Objective Assessment

Observe and Assess:

1. Foot, lower leg and the entire kinetic chain.
2. Posture-related problems such as leaning backward and shifting the weight to the ankles during gait or if the weight is mostly on the toes.
3. The shape of the foot e.g. collapsed arch on one side. You can link the history of trauma from the subjective assessment to the findings on observation.Also, compare the foot shape with the other foot, a bilateral collapsed arches will be treated differently from somebody that comes in with steep thick high arched feet. The pes planus foot is not going to respond to the same treatment strategies as your very rigid pes cavus foot.
4. Aska bout and examine orthotics and footwear. The shape of footwear and the level of comfort they experience with.
5. Neural examination is also recommended. Some patients might describe some kind of bizarre pain which might be in different locations often disregarded because the main concern is the foot pain. Therefore, neural dynamics should be included in your assessment (Alshami)
6. Gait Assessment

Things to observe during gait:

• Overstriding
• Short strides
• Pounding or heavy throbbing on one side
• Slapping with the foot
• Walking with inverted foot/feet

Case Study

A 50 year old professional woman who travels for work from city to city on a weekly basis. She wears high heels and regularly runs from a meeting to the next.

On the weekends she travels home and that's her time to exercise. This patient is a very good competitive cyclist who has recently decided to take up marathons as well. In order to achieve her training goals, she fitted in her busy schedule treadmill running during the week at the hotels she stays in and distance cycling on the weekends.

At one conference, she decided to wear flat shoes because there was a lot of walking involved. Two days later, the pain started in her feet. She reported burning pain in the heels felt like electric shocks when she put her feet on the floor in the mornings.

She went to see a physiotherapist who did some shockwave therapy which she didn't find helpful. She was then referred to an orthopedic specialist who took some x-rays and found a heel spur that probably explains the pain. So she was put in a boot during waking and working hours for six to eight weeks and asked to stop exercising. At night, a splint was advised. In addition, rolling the foot on a PVC pipe was recommended to ease the pain.

Eight weeks later, she was still not able to walk. She was frustrated and felt unfit. So she presented for a second opinion to physio.

Remember: The spur is not the cause of the symptoms!

The spur is only an indication that there are some traction forces on the Plantar Fascia. Identifying these traction forces and the reason these forces generated a spur should be our way of thinking to help address the symptoms.

Also remember the Plantar Fascia is integral to the Achilles tendon complex. So by unloading and immobilizing the fascia, all these tendons are now unloaded. The Achilles and tibialis posterior tendons are responsible for unloading the foot when it's in contact with the floor/ground. Unloading these tendons can possibly make the tissue weaker and consequently increasing the stress on the Plantar Fascia. Immobilizing means taking the tendons' assistance away and applying more stress on the Plantar Fascia resulting in more pain to your patient.

Addressing the pain

In this patient's case, it was urgent to try and sort out her morning problem as this was the main complaint. Starting the day with pain contribute to the quality of the whole day.

Stretching the Plantar Fascia in a non-weight bearing position was recommended by (article) and is a great way to warm up and ease the fascial pain at the start of the day. (image)

Manage the load. The patient still has to be mobile and active at work and it was important to help her to return to running in the evenings on the treadmill. Although treadmills are great in the short term, they can be problematic because they do increase the tension and load on the Achilles tendon. So by running thirty minutes to an hour on the treadmill the load on the soft tissue structures is significant. Switching to stationary cycling while she's at work, in the week, and swapping with running on the weekends was advised.

Instead of running on the treadmill, the patient can do trail running, undulating, different terrains, with more cushion, and shorter runs twice a day. All these strategies were introduced to manage her load over the twenty-four hours. If there is a lot of tendon issues, a response to the training load can be seen over twenty-four hours. So in this case, the patient was asked to monitor her response to the load over twenty-four hours.

This patient also had rigid feet from wearing high heels for years. Manual mobilization for stiff feet can be beneficial (evidence). Manual mobilization, myofascial releases were used to release the foot and make it more pliable and more shock absorbent. Other manual techniques to be used:

• Calf muscle release
• Mobilize the Calcaneus so that it sits neatly under the Talus.
• Release the Plantar Fascia
• Improve the mobility of the first metatarsal phalangeal joint.

Improve the capacity of that Plantar Fascia. Stretching can be helpful but it won't be enough to improve the tolerance of the tissue for running. (Rathleff article called, "Load me up, Scotty") the windlass mechanism was used to improve the capacity of the Plantar Fascia so it works like Jill Cook's wonderful work on reactive tendinopathy. Where you can use isometric sustained holds to reduce the pain for that first two weeks by asking the patient to extend her toes over a rolled-up towel to induce and load the foot in the windlass mechanism. Then instead of doing more repetitions, she did 5 isometric holds holding each of them for 45 seconds with her heels just slightly off the ground then lowering down very slowly followed by a one to two-minute rest. This exercise was started bilaterally then as she improved it was done unilaterally.

Another advice to this patient was to do Pilates and/or yoga work, to release and mobilize her overall neural system. Tibial Nerve mobs can be done and taught to the patient. bring into there but working on the overall flexibility and mobility is important to counteract the stationary posture obtained at work and through most of the day.

Foot-wear was also addressed. Clearly, high heels were contributing to the pain, putting a lot of load and stress on the metatarsal heads. To counterbalance, a nice pair of wedges (to avoid toes hyper-extension and putting the plantar fascia in a stretched position)and nice rocker-bottom heel or sole can be utilized. So the patient loaded-off her foot while she didn't compromise her work dress code.

The patient agreed to keep a diary of her symptoms, modified the load as necessary, and increased the load gradually. Within two weeks, the pain was shifting and she was improving.

Plantar heel pain is not a simple problem, knowing from history that this patient was going through menopause, she was advised to check with her doctor if the hormonal changes are contributing to her symptoms.

There are other methods to desensitize the area and improve the motor control that can be used such as brushing the feet at night after a tough day and mirror therapy.

Differential Diagnosis:

• Tibial Nerve
• Fat pad
• Kinetic chain problems