Plantar fasciitis (Heel Pain)

Plantar fasciitis (Heel Pain)

Is the inflammation of the plantar fascia caused due to repetitive stress applied to it.

It is usually common in active individual, obese, runners or athletes, people who spend most of their day on foot.

The pain is usually characterized by piercing or searing type of heel pain that appears in the first few steps in the morning or after a period of inactivity.

Patient may present with tenderness around the medial calcaneal tuberosity at the plantar aponeurosis.

Pain increases when walking barefoot on toes or while climbing stairs.

Patho-physiology

As the term implies plantar fasciitis is the inflammation of the plantar fascia however in all the samples reviewed there is no evidence of inflammation histologically.

However research shows that plantar fascia is a degenerative condition, hence it is better to be  called “fasciosis” than fasciitis.¹

Biomechanics of the foot during gait

There are 6 phases of gait cycle : heel contact, weight acceptance, mid stance, push off , propulsion and toe off phase. Foot goes for supination during heel contact phase followed by pronation in weight acceptance phase, in order to maintain contact with the surface. From the mid stance to the toe off phase the foot goes for supination thus making the foot as a rigid lever which is necessary for the propulsion of the foot.

Plantar fascia plays a very important role in maintaining this arch during the gait cycle of the foot. Because if plantar fascia fails to work effectively the medial arch arch would disrupt and the force required to control supination and pronation would be altered. Hence plantar fascia plays a very important role in control of supination and pronation of the foot during gait cycle.

Evidence based therapy for plantar fasciitis

• Cryotherapy or NSAIDS – Not much effective in the treatment of plantar fascia, however it provides only temporary pain relief.
•  Taping – No studies have proved the effectiveness of taping.
•  Shoe inserts-  a study was done to compare the effectiveness of the custom made orthotics and prefabricated shoe inserts with stretching. It was found that prefabricated shoe inserts with stretching showed more effect than custom made orthotics.
•  Stretching – A study shows plantar fascia stretch alone more effective than combined stretch of calf muscle and Achilles tendon.
•  Night splints – limited evidence suggesting the effectiveness of night splints.
•  Extra-corporeal shock-wave therapy – No evidence supporting the effectiveness of Extra-corporeal shock wave therapy for reducing night pain and resting pain in short term.
• Corticosteroid injection – According to Cochraine review Steroid iontophersis injecton improved only short term outcomes.²

As mentioned earlier the arch of the foot is very important to maintain stability on the surface when walking or standing. Overpronation or underpronation can have direct influence on the effective working of plantar fascia.

Overpronated foot

Overpronation of the foot is caused due to muscle weakness, tightness in the heel cord and abnormal structure of the foot. Proximal muscles such as gluteus medius, gluteus minimus, tensor fascia latae or quadriceps can contribute to the pronation of the foot. These proximal muscles help in assisting lower extremity response during gait, hence weakness of these muscles will transmit greater shock to the supporting foot structures and decreased pronation control.

Heel cord assist in dorsiflexion of the foot during gait, hence tightness in the heel cord limits the ability to dorsiflex the ankle at heel strike phase of the gait thus making the foot to over pronate more at the midtarsal joints in order to make contact with the surface of the ground.

Structural deformities include excessive sub-talar or forefoot varus.

Treatments for overpronated foot include strengthening of the weak muscles, stretching of the calf muscles, and using appropriate shoes with sufficient toe box and firm ankle grip to control the movement of the ankle within the shoes. Insoles made of polyurethane and ethyl vinyl acetate also enhances shoe support.³

Underpronated foot (Supination)

Supinated foot which is caused due to factors such as increased muscle tightness, decreased mobility within the joints and decreased plantar fascia extensibility.

Highy arched or cavus foot will have limited joint mobility to distribute the force during weight acceptance phase. Hence when foot does not pronate during weight acceptance phase, it indirectly applies a lot of tension force to  the insertion of plantar fascia at the medial tubercle of calcaneum.

Treatment for supinated foot include Stretching of calf muscles, mobilization of joints and increase plantar fascia extensibility. Appropriate shoe wear with ethyl vinyl acetate midsole provides appropriate space for the rearfoot and forefoot to move , offers much shock absorption.

Silicone heel pad can further enhance shock absorption.³

By Dr. Liana Thomas (PT)

Reference –

1. Plantar fasciitis  A degenerative process without Inflammation (Harvey Lemont et al.)
2. Plantar fasciitis (Charles Cole, Craig Seto et al.)
3. Plantar faciitis and the Windlass mechanism : A Biomechanical Link to clinical practice (Lori   A. Bolgia et al. )

SUCCESS STORY OF HEEL PAIN

Success Story of Heel Pain (Plantar Fasciitis)

53 year old female patient came with complaints in right foot.
Pain was worst in morning & aggravates by standing & walking for longer duration.
Professor by profession; standing for longer is the demand of occupation.

She has already consulted with many doctors. Tried medication & therapy but no long term relief. "Medicines will help to reduce the symptoms (pain & discomfort) which will help temporarily in this cases. Long term help will be to find out the root cause & manage it better way."
She was allergic to few anti-inflammatory medicines.

Bio-Mechanical Examination-

Static Examination:

• Transverse Arch- Reduced Bilaterally
• Medial Arch- Pronounced Bilaterally
• Sub-talar Joint- Supinated Bilaterally (More on right side compare to left side)
• Knee- Genu valgus (Right knee is slightly lower than left knee)
• Calf & Hamstring muscles was moderately tight bilaterally.

Dynamic Examination:

• Gait Pattern- Poor heel to toe pattern
• Heel Strike- Lateral heel strike bilaterally
• Stance Phase- Supinated at sub-talar joint bilaterally
• Toe Off- From the 2nd Meatatarso-phalangeal joint bilaterally

Foot Size:

• Right Foot- US 5 1/2 wide
• Left Foot- US 6 wide

Investigations:

• X-rays reveals Calcaneal spur right side.

Diagnosis:

• Right Calcaneal Spur

"Root cause of her right heel pain was stiffness of plantar fascia due to her high arch foot type. This resulted in spur formation at its origin.This spur developed because of repetitive pull of the plantar fascia which lies underneath of our foot sole. Appropriate arch support will stop this pulling of ligament will help her eventually."

For more details watch this video (Click the link)- Heel Pain diagnosis & Treatment

Or to read click this link- Heel Pain

Treatment & Advice:

1. Cold Pack 3-4 times a day 20 minutes each time
2. Prescribed Strive ready to wear orthotic footwear.

• Follow up: After 2 week

1. 80-90% pain relief
2. Prescribed wide width sport shoe US 6 1/2 wide
3. Bio-Advance Orthotic medium density insole along with lateral raise
4. Customized exercise regime was given.

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Runners: Are you on right track…?

“You know you are a runner when your running shoes are the most expensive shoes you have”

Above line is absolutely true for runner. But expensive shoes doesn't assure that it will be right shoes for your feet. Achieving your desired goal for marathon needs consistent efforts & dedication. Injuries are not new for runners.  These injuries are barrier for your training. Many times you assume that injury&/pain is happening due to excessive running for which your body is not habituated yet. But few injuries become long term like IT band syndrome, Achilies tendintis, Plantarfascitis(Heel Pain) etc. Right medical advice can help you on time to time recovery.

Sometimes person has to give up their passion of running which is very disturbing for runners.

This article is an attempt to give you new insight for your running injuries. Marathon running is a quest in which so many people help you to understand your body Physiotherapist, dietician, trainers and last but not the least Podiatrist are those expertise to  whom you approach after getting any injury. Mentioned above all expertise you are aware but may not be aware of Podiatrist. Podiatrist we can say are foot doctors. Dear runners your feet are most important in living your "pace passion".

"Podiatry is the field of medicine which deals with most important aspect of running i.e. shoes & orthotics."

Yes you are right I am talking about Podiatry science. 

Dear runners your feet are so much important to live your pace and passion

.

Podiatry is a branch of medicine devoted to the study of diagnosis and treatment of disorders of the foot, ankle and lower extremities.

Most of the runners experience pain in calf, shin, heel even knees apart from that blackening of toe nails are few common problems which can be treated with Podiatry.

Am I Pronator/Supinator? is common question asked by patients who are runner.

This image is self explanatory about how to identify whether person is pronatory/supinator.

COMMON FOOT RELATED CONDITIONS WHERE PODIATRY CAN HELP:

• Pain in calf muscles: Typically described as tired aching legs. Because of faulty foot posture (Flat feet or high arch) can reduce efficiency of calf muscle.

• Toe nail blackening: Many runners use one size bigger shoes with misconceptions that foot swells after running. Due to this foot slide inside the shoes & can lead to blackening of toe nails. This way using tight or loose fitting shoes both can lead to blackening of toe nails.

• Achilles Tendinitis: Further calf muscles can get strained at its insertion which is back side of heel which is called as achilies tendinitis. To know more click here...

• Plantarfascitis: Pain below heel which aggravates after rest initially. Later it also aggravates after running certain distance. Pain is due to inflammation of plantar fascia which is ligament below the feet. To know more click here...

•  Ankle pain: While running you may land up in ligament injuries. High arch person (Supinator) is prone for straining of ligament/muscles on outer side of ankle. Overpronators can injure inner side of ankle. Sometimes patterns are variable depend on many factors like tibial varus/uneven terrain. To know more click here...

•  Shin Pain: Pain in inner/outer side of shin area known as shin splints. Including alignment issue, calf tightness and running surface also causing factor for the pain

•  IT Band syndrome: Runners are very prone to ITB (Ilio Tibial Band) injury deu to following factors.

1.  Narrowed stance in running and loss of double limb support
2.  Fatigue of the hip abductor group producing a “droopy pelvis”
3. Female runners are more susceptible to ITB problems due to slightly wider pelvis

Apart from above knee pain, back pain is also very common in runners and closely related to altered lower limb biomechanics.

ORTHOTICS Vs INSOLES:

Many people pick up off the shelf available insoles & feel that they are sorted with their flat feet/any foot correction. But it is absolutely wrong. Orthotics need to customize as per your particular foot alignment which is expertise task.

Podiatrist need to do through evaluation of lower limb biomechanics & then design orthotics accordingly.  As mentioned earlier it’s not only pronation/supination issue but alignment all proximal joints is important.

Before making orthotics it is important to be sure that your running shoes are appropriate. Following is basic guideline for shoes.

1. Basic shoes test:  There are few basic shoe tests are necessary, before going in arch pattern.

•  Flex Test—by pushing down on the shoe, the breakpoint, should be firm but not provide
  significant resistance.   
  
•  Torsion Test—by twisting the shoe in opposite directions, this will check the stability of the soling.  If the shoe twists over on itself, inadequate support.
• 
  
  
• Counter Test—by grasping the heel of the shoe, apply pressure to the heel counter with your finger.  If the counter collapses with little/no resistance, the shoe is not supporting the heel.
  

2. Shoe size: Shoes should appropriate to your foot size as well as width. If your foot is broad then you should buy Wide shoes & not a size bigger. 

After wearing shoes there should be thumb nail gap between shoe front & your longest toe.

With proper traning, right shoes and orthotics can drastically boost your performance. V-Care Clinic is working in the field of Podiatry since many years. We follow guideline provided by UK Podiatrist. To know more about your feet & posture visit us.

Our Address.

V-Care Clinic

305 Akruti Arcade, Opp. Wadia School, Azad Nagar Metro Station, J. P. Road, Andheri West, Mumbai 4400053

e-mail- doctor@vcarerehab.in

web- www.vcarerehab.in

contatc- 022-65585515

Other Problems

KNEE PAIN

Knee Pain

As explained earlier, foot is the supporting structure/ base of the human body. Any change in the alignment of foot will reflect its effects on other proximal joints.

Knee Deformities

 Most commonly people suffering from flat feet are more prone to knock knees (Genu Valgus) deformity in the knee joint which affects outer compartment of knee joint whereas people with high arch are susceptible to bow legs (Genu Varus) deformity which affect the medial compartment of the knee joint.

LIMB LENGTH DISCREPANCY (LLD) & BACK PAIN

The human body is an epitome of balance. If there is any deviation from this balanced state the system go into malfunction. The same holds true while considering the length of lower limb. If there is any difference in the length of the two limbs, it alters the position of the pelvis. This in turn affect the spine resulting in Scoliosis i.e. tilting of the spine on one side.

In severe cases along with the spine the ribs also undergo rotation causing a rib hump. Once the vertebral bodies start rotating the spinous processes deviate more & can even compromise the respiratory capacity in sever case.

Treatment:-
If the reason for the scoliosis is LLD then it is advisable to detect the exact length of discrepancy. This can be corrected by adding the exact amount of compensation in the footwear to prevent further deterioration of the spine. Another important aspect is physical therapy intervention to maintain the flexibility & strength.

ACCESSORY NAVICULAR BONE

Accessory Navicular Bone

Accessory Navicular bone is a congenital condition in which an extra bone or cartilage which is present next to the Navicular bone on the inner side of  foot just above the arch region. In most of the cases it is undiagnosed as it does not give rise to any symptoms.

Accessory Navicular Bone

However a few percentage of people with accessory navicular develop a painful condition called as Accessory Navicular Syndrome.

Causes:-

• Recurrent trauma to the ankle or foot such as ankle sprain.
• Improper size & pattern of footwear which causes friction against the extra bone.
• reduction in arch.
• Injury to Tibialis posterior tendon.

Symptoms:-

• Redness & swelling over the inner side of the foot in the arch area.
• Pain on palpating the area of extra bone.
• Pain while walking & standing activities.

CALCANEAL APOPHYSITIS

An apophysis is a growth plate which is present at the end portion of the bone when there is no accompanying bone, Calcaneal apophysitis is an inflammatory condition which affects the growth plate present in the heel bone (Calcaneum). It usually occurs in kids falling in the age group of 8-14 years as till the age of 14 years the growth plate continues to grow. Repeated stress or trauma to this sensitive area results in inflammation & damage to the growth plate.

Causes:-

It is most commonly seen in kids participating in sports which result in high impact over the heel area which ultimately damage the still underdeveloped growth plate. Furthermore kids who have other alignment issues such as flat feet or high arch are more susceptible to this damage.

Symptoms:-

• Pain in the heel area.
• Excessive pain on squeezing the sides of heel.
• Pain on standing or walking which become worse as the time increases.
• Limping
• Inability to perform activities such as running, jumping & skipping.

HIGH ARCH

High Arch

High Arch

Pes cavus foot type is the complete opposite pattern to that of flat feet. People with pes cavus foot type have well defined & deep arch. The only areas of contact with the ground are the heel & forefoot.

Arch Patterns

Consequently these people have a tendency of bearing more weight on forefoot. As mentioned earlier the arch pattern influences gait pattern. As a result these people load on the outer border of foot while walking as there is no contact on the inner side of the foot with the ground, which is termed as "SUPINATOR". 

people with high arch are more susceptible to develop knee problems owing to hard heel strike which causes excessive pressure to act 

on the heel & knee.

Deviations

Most common problem faced by people with high arch are:

• Heel pain/Plantar fasciitis

  

  Shoes Worn Out in Supinators

• Early OA of knee.
•  Ankle sprains.
• Corn and calluses on the outer border of foot.
•  Weakening of the Transverse arch leading to further complications such as Bunion, Meta tarsalgia and Morton’s Neuroma.

HEEL PAIN

If you are waking up with acute pain at your heel, then mostly you are suffering from plantar fasciitis. This is one of the most common foot problems. Many times pain is very severe & disabling.

What is plantar fasciitis?

Plantar Fasciitis (plantar fasciosis) is inflammation of the plantar fascia. The planar fascia is a strong bowstring like ligament that runs from the calcaneus (Heel Bone) to the tip of the foot. When the plantar fascia is stretched too far its soft tissue fibers become inflamed, usually where it attaches to the heel bone. Sometimes the problem may occur in the middle of the foot. The patient experiences pain under the foot, especially after long period of rest. If inflammation persists for longer duration it can lead to calcaneal spur.

Causes: Plantar Fasciitis is not usually caused by a single injury, such as a twist or fall, but rather the result of repetitive stress and pounding of the heel. Still following factors play important role in increasing severity of plantar fasciitis.

1. Arch Type: Flat feet, High arch or in between.
2. Footwear: Wearing too flat or too high heel footwear.
3. Lifestyle: Continuous standing, walking  or running.
4. Body weight: Overweight results in more stress on platar fascia.
5. Osteoporosis: Weak bones will aggravate pain.

Symptoms

• Pain at the heel when standing.
• Throbbing or piercing type of pain.
• Pain in the first few steps in the morning after a period of inactivity.
• Pain while walking barefoot, on toes or while climbing stairs.
• Tenderness along the inferior surface of the heel

Causes: Plantar Fasciitis is not usually caused by a single injury, such as a twist or fall, but rather the result of repetitive stress and pounding of the heel. Still following factors play important role in increasing severity of plantar fasciitis.

Treatment:

• Rest: Temporary rest is important to allow plantar fascia to heal
• Cold pack: Helps to reduce inflammation. Recommended 3-4 times a day, 20 minutes each time (Not recommended for diabetic patient)

• Taping
• Right orthotics: To support your plantar fascia & correct your faulty alignment
• Supportive shoes: Orthotics with proper supportive shoe gives long term relief
• Exercises: Generally higher arched feet require a strict stretching program and flat feet require a gradual strengthening program and more support.  One should not do stretching in acute pain.

What to avoid:

1. Barefeet walking on hard surfaces 
2. Wearing too flat or too high heeled footwear
3. Heel Cushions: Silicone or foam heel cushions commonly available from pharmacies do nothing to actually cure this condition and at best provide temporary comfort.

Success Story- Click this link 

https://youtu.be/YfOE5jx5HVM

For more details visit- www.vcarerehab.in

FLAT FEET: All You Need To Know ?

"The human foot is a masterpiece of engineering & a work of art."
                                                                                                           -Leonardo Da Vinci

The human foot consists of 26 bones, 33 joints, 107 ligaments & 19 muscles which work together to balance your whole body. No wonder this great artist has named it a masterpiece 1/4 of all bones in the human body are in the feet. Standing in the kitchen for cooking, walking down to buy vegetables playing any sport, or dancing are all the activities we can do because of our feet. Healthy feet are key to an active lifestyle. Human feet are designed to walk on natural surfaces like soil & sand, but instead of that, we are walking on hard surfaces like pavements or marble. That's why the incidence of foot problems. Out of all flat feet is the most common & unnoticed problem. If is it not diagnosed at the right age, it can lead to serious complications in the future. I get many patients saying, " My physiotherapist told me, I have flat feet & my family doctor says I don't have flat feet, I don't know what exactly flat feet mean...!"

Flat Feet

What is Flat Feet ?

We have a small gap on the inner side of our feet when we stand, when this gap is not there it's called flat feet. Everybody is born with flat feet, as a child starts walking his/ her arch starts developing. First, five years of age are crucial for arch development.

Effect OF Flat Feet On Posture:
All joints in our body work together. As feet are base of our body it affects entire posture. Following image will give you clear idea about how flat feet can affect alignment of all proximal joints.

Effect of Flat Feet

Causes:

Knee Pain

• Ligament laxity.
• Muscle weakness/ Hypotonia of muscles.
• Fracture/ trauma around ankle joint.
• Family history.
• Obesity.

Symptoms:

• Tired achy legs.
• Heel pain, Knee pain & back pain.
• Recurrent ankle sprain (Poor Balance)
• Early osteoarthritis of joints.
• Corn & Calluses etc.

Treatment:

Orthotics: 

Custom-made orthotics are the main line of treatment for flat feet. People always try to get some off

the shelf orthotics & course it doesn't help their problem. Orthotics correction should be based on lots of variables like the severity of flat feet, age, weight, lifestyle, alignment of proximal joints, etc. Thus shelf things are not advisable. A Podiatrist is a right person to prescribe the orthotics.

     Podiatry is a branch of medicine specializing in ankle & foot problems. A Podiatrist doctor will do a thorough assessment of your alignment, diagnose the problem & then provide a customized solution for the same.

After certain age flat feet are not correctable but orthotic intervention can prevent further damage.

Shoe Test

Supportive Shoes:

Good supportive shoes are recommended for flat feet. Criteria for supportive shoes are rigid soles & firm ankle control. One should not able to twist (Torsion Test) & or bend (Flexibility Test) easily. Usually spots shoes are the best supportive shoes. For a person with flat feet, anti-pronation shoes are recommended.

Exercise:
To strengthen foot & ankle muscles & maintain an ideal weight.

Case Study

Testimony