Most common cause of PF is excessive tensile load applied to plantar fascia. This excessive tensile loads are either due to excessive physical activities such as the case with runners and athletes which jump. Another type of overloading is excessive chronic tensile load which is a result of poor biomechanics or foot deformities.
Heel pain is one of the most common musculoskeletal complaints in the practice of physical rehabilitation.
Incidence and prevalence:
Incidence peak is in middle age adults for the general population and younger in runners.
Typically plantar fasciitis is pain in the heel, especially during the initial few steps after waking up. Some other symptoms are: sensitivity and tightness in the heel or the he arch while walking or running.
Patients who suffer from this condition still use old medical terminology, which is no longer used by medical professionals. It was believed previously that heel pain is caused by formation of heel spur. However, this has been disproved a long time ago. Since it is visually appealing for patients to imagine that they step on a sharp bony outgrows, patients still believe that the heel spur is what is causing their heel pain. This reflection couldn’t be further away from truth. Heel spur syndrome does not exist by itself. Pain in the heel is actually a soft tissue, not a bone problem.
Plantar fascia is a soft tissue component of the heel. Hence, the term is “plantar fasciitis” for acute conditions and “plantar fasciosis” when it becomes chronic. Plantar is an anatomical term, which refers to the sole of the foot. Plantar fascia is a tough, inelastic fibrous band composed with three layers spanning the length of the foot. Pain associated with plantar fasciitis is specific to the plantar heel (bottom of the heel), unlike the pain presenting on the top of the heel, such as Achilles tendonitis. Heel pain may become of neurogenic origin and often mimics plantar fascitis. This type of pain is due to mechanical irritation of the small branches of the tibial nerve. The medial calcaneal branch is one that is affected most often. The causes of heel nerve pain are, however, quite different and require differential diagnosis as well as a totally different treatment approaches. The heel nerve pain is also very common but much less frequently diagnosed.
Primary function of plantar fascias is to support the foot’s arch and to return elastic energy during propulsion phase as a heel comes of the ground but the great toe is still on. It raises the arch and resupinates the foot in order to change from shock absorber during the ground contact phases of gait into a rigid lever, which is necessary for propulsion. The proper function of plantar fascia is one of the most important biomechanical mechanisms for human locomotion.
Plantar fasciitis is considered as an overuse syndrome, which is the result of excessive repetitive tensile and compressive forces of the plantar fascia. When we walk, the load is applied on the arch of the foot causing the height of the arch to drop (pronation) in order to absorb ground reactive forces during loading. This is a height drop (pronation) of the arch when excessive or prolonged places tension on the plantar fascia. If the tension (load) applied to the plantar fascia were greater than what can be tolerated, the fascia would become initially inflamed and if not compensated or treated it would become degenerative. That’s why; the term plantar fasciopathy is due to the similarity of histological (microscopic tissue anatomy science) chronic tendon repetitive overuse called tendinopathy. Therefore, the direct cause is the excessive load and forces travel through the plantar fascia. The bigger picture of heel pain and plantar fasciitis is in abnormal biomechanics of human gait (walking). Since human gait is an extremely complex subject we wouldn’t go into details in order to keep the reader unconfused.
Classic presentation of plantar fasciitis is not uncommon, so clinical examination is a must. In more complex cases ultrasound diagnostic is very useful for assessment of the disease stage, as treatment options will depend on it. However, radiological diagnosis is only a good measure of visualizing the structural pathology. It does not explain what causes plantar fasciitis. The best type of the examiner causes and contributing factors analysis is a complete and advanced gait analysis.
There are very good news for patients with plantar fascitis. Heel pain is highly treatable in the hands of an experienced practitioner who’s using a comprehensive approach. There are quite a few non-invasive options, so if all you get from your doctor is a steroid injection and a pair of orthotics, you might want to think about running out of there.
But before we go into treatment options for heel pain we will look into the other common causes of heel pain.
The portion of a sciatic nerve, which runs on the back of the thigh, is a tibial nerve. Tibial nerve travels down to the medial ankle where it comes to the surface superficially. There it branches into three parts as it leaves from inside of the tarsal tunnel. The branch, which is often clinically involved, is the medial branch of the tibial nerve. It runs close to the plantar fascia on the inside of the heel. Tethering or compression of this branch can mimic plantar fascitis.
Examination of mechanical nerve irritation and thorough symptom assessment should be the tool to use in the differential diagnosis of this problem. Neurodynamic assessments can reproduce symptoms. Of this condition. Symptoms range from pain at the medial ankle as well as pain through the ankle and medial heel pain. Occasionally slight numbness or other altered sensations may be preset, sliding and tensioning the nerves through available range of elasticity in nerve tissue while performing a neurodynamic maneuver can elicit a response, implicating the pain.
If there is no morning stiffness or stiffness during walking it is another sign which rules out involvement of plantar fascia.
In order for any movement to occur nerves need to be able to glide and slide within soft tissues and bones. Movement of the nerves within anatomical canals (mechanical interface) needs to be free of restrictions in order for optimal nerve function. Nerves must be able to move and slide within the surrounding soft tissues (known as the mechanical interface) in order for maintaining function. Tension or compression of the nerve tissue causes decreased blood flow and inflammatory reaction. The treatment of inflamed nerves due to irritation by altered movement of the interface (soft tissue bone interface) needs to be directed to mechanosensitivity quality of the nerves.
There are a lot of talks about addressing biomechanics but few clinicians understand applied biomechanics. Most practices use old treatment paradigms because they are afraid to venture into unknown areas such as biomechanics and gait analysis. Also true dynamic biomechanics cannot be low tech. The truth is that most of what is visible to the human eye is mainly compensatory in nature. It takes knowledge, experience and technology to distinguish the compensation from real cause of movement dysfunction. A good example is a traction injury to the tibial nerve during a slight midfoot overpronation that only becomes a problem at the end of the race. It is impossible to catch this biomechanical cause without computerized gait analysis. The term neuromechanics is self explanatory in the sense that there is continuity of the tissues where nerve mechanics are dependant on overall body mechanics. Tibial nerve injury is a good example of this paradigm.
Conservative treatment of plantar fasciitis is based on four broad categories of care; 1) passive biomechanical care, 2) non-invasive anti-inflammatory methods, 3) specialized heel pain physical therapy (or active biomechanical approach) and 4) regenerative therapy. Let’s take a closer look at each of these four categories and see how they should work together.
There are a variety of foot inserts and assortment and other corrective devices such as heel lifts, arch lifts, stretching splints and many more. There are over the counter foot inserts as well as custom made orthotics. Clinical studies showed that when used only on their own these measures have very little effect. They are however good supplemental modalities which should be used in conjunction with other heel pain treatment.
The second caring category is the anti-inflammatory usage. Anti-inflammatory include steroid injections, oral anti-inflammatory medications, ultrasound, topical medications and cold laser devises. Using anti-inflammatory, bear in mind that we are treating a problem that as we know has a mechanical nature. Therefore anti-inflammatory are effective only at the initial stage of plantar fasciitis. Beware of steroid injections into planar fascia. This type of injection rarely achieves any curative effect. Moreover, multiple research studies proved that steroid medication actually weakens muscle and tendon tissue and eventually leads to tears in the plantar fascia.
Extracorporeal Shock Wave therapy is scientifically proven non-invasive treatment for plantar fasciitis approved by FDA. Studies report a 92% success in treatment of chronic plantar fascitis. This proprietary technology is based on a unique set of pressure waves that stimulate the metabolism, enhance blood circulation and accelerate the healing process. Damaged tissue gradually regenerates and eventually heals.
Please review our ESWT page for more information:
Plantar facsitis and heel pain can truly be considered a gait (walking) related disorder. Comprehensive hands on approach and specialized treatment of gait related disorders are the most successful intervention for heel pain disorders, especially combined with above-mentioned treatments. Because physical therapy not only treats the pain but actually treats the cause of these disorders – poor biomechanics and motor control of gait (walking) and running.
An extensive and detailed clinical examination and diagnosis is first and foremost. The combination of clinical examination and biomechanical assessment can differentiate whether the heel pain is caused by tensioned tibial nerve or by plantar fasciitis. We use diagnostic ultrasound to visualize soft tissues around the heel, as well as structures within tarsal tunnel. In more complex cases, like for runner’s heel, we use a computerized video gait analysis.
Once the cause and contributing factors are identified with biomechanical analysis and assessment of nerve movement against the interface we institute an individualized heel pain therapy using most advanced techniques for: foot joint mobilization, fascial stretching, biomechanical specific lower kinetic chain strength and motor control of walking retraining. We also utilize CAREN (Computer Assisted Rehabilitation Environment) a technology that is very helpful for regaining/retraining balance and motor control of walking. For runners and athletes we provide; running style and technique retraining, shoe fit consultation as well as corrective foot esthetics if necessary (in our experience, however, when the function of the foot is restored athletes rarely need orthotic intervention).
Heel pain originating from tibial nerve gliding dysfunction can be successfully treated with above described approaches and neurodynamic nerve flossing techniques. Heel pain treatment should always be integrative and comprehensive.