Posts tagged heel pain
Foot Atrophy And Weakness Consistently Found Among Patients With Heel Pain

Plantar heel pain, including pain along the plantar fascia, is one the most common diagnoses in the foot. Individuals often experience pain with the first step in the morning or after prolonged sitting. Symptoms limit their ability to perform many standing, walking, and recreational activities. Researchers have found minimal inflammatory cells within the plantar fascia among patients with heel pain indicating an ongoing healing process of the tissue (plantar fasciosis) similar to what is noted in tendon healing. The lack of inflammation is one reason for the failure of anti inflammatory treatments, such as medications and injections, in the management of this condition.

In addition, researchers are finding significant atrophy and weakness in the arch muscles of the foot within this population. These signs are even more pronounced among patients with long term orthotic use. Conversely strengthening of the arch musculature has been shown to be a promising treatment to reduce sensitivity and symptoms from the tissues of the foot. A new review of the evidence highlights the importance of these exercises.

Osborne and colleagues in the Journal Of Sports And Orthopedic Physical Therapy reviewed the available evidence on muscle structure and performance among patients with plantar heel pain (2019). Authors found weakness in the foot and ankle musculature within the studies,, but results were most consistent in the foot. Patients with plantar heel pain demonstrated significant atrophy and weakness of the foot musculature compared to their asymptomatic peers. This review supports the utilization of foot strengthening exercises to improve the performance of this muscle group in an effort to reduce abnormal forces across the injured tissues in patients with plantar heel pain.

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Is There An Additive Effect of Ultrasound to Physical Therapy Care?

Few things remind me of how far we have come as a profession than ultrasound. Early in my career we utilized ultrasound and other modalities to help reduce a patients pain. Initially touted as a medium to deep tissue heating and healing, ultrasound has now fallen out of favor due to the lack of research benefits supporting its’ use. Little to no research supports its’ use for musculoskeletal conditions and any benefits have not been found superior to comparable placebo treatments. For these reasons we do not utilize or own an ultrasound machine in our Physical Therapy practice and instead utilize more evidence based interventions such as manual therapy and exercise for musculoskeletal conditions. A recent article examined if there was any additional benefit of ultrasound when combined with other Physical Therapy interventions.

A randomized controlled trial in the Journal of Orthopedic and Sports Physical Therapy examined the addition of either ultrasound or placebo ultrasound to a stretching program for patients with heel pain (Katzap et al. 2018). 54 patients were randomized to one of the ultrasound conditions combined with ankle and foot stretching exercises (note: stretching alone does not constitute an evidence based exercise program). Authors reported both groups improved but no significant differences were found between “therapeutic” ultrasound and placebo ultrasound. Authors recommended excluding ultrasound from treatment plans for patients with heel pain.

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Dry Needling Improves Effectiveness of Physical Therapy Treatments for Heel Pain

Plantar fasciitis is the most common cause of plantar heel pain estimated to affect 10% of the general population through their lifetime. Proper nomenclature of the pathology is dependent on the tissue involved and how long the symptoms have been in existence. “Fasciitis” suggests an acute inflammatory response, where “fasciosis” illustrates a chronic degenerative response without inflammation. Both terms describe impairments to the insertion of the plantar fascia and/or toe flexors as they attach to the medial heel. Both pathologies are also categorized by increased pain on the inside/plantar aspect of the heel, namely during the “first steps” in the morning or increased weight bearing activities throughout the day.

Manual therapy with exercise has proven to be the best course of action to manage pain and dysfunction of plantar fasciitis, however a recent study investigated the benefit of Electrical Dry Needling (EDN) as an adjunct treatment (Dunning et al. PLOSone, 2018). The study divided 111 participants into 2 groups (standard treatment without EDN vs. standard treatment with EDN). Both groups received up to 8 treatments in a 4-week period. The authors concluded the EDN group’s pain and disability improved significantly at 3 months after treatment compared to treatment without EDN.

To learn more about how Electrical Dry Needling can decrease pain and improve function, contact your local, trusted Physical Therapist.

Does Manual Therapy Improve Plantar Fasciitis?

Plantar fasciitis (fasciosis) is a painful diagnosis limiting a patient's ability to stand, walk, or run.  The -itis of the name is a misnomer because very few cases of plantar heel pain involve an inflammatory process.  Instead, a breakdown of soft tissue fibers and cells is noted in the plantar fascia reflecting the sequential stages of healing.  Contributing factors to this diagnosis include a loss of ankle mobility, calf muscle tightness, and foot weakness.  In our Boulder Physical Therapy practice we successfully treat this condition with the combination of exercise and manual therapy treatments designed to rapidly reduce and improve range of motion in the foot and ankle.  

A recent review of the available literature on the utilization of manual therapy for patients with heel pain was conducted (Fraser, J. et al. J Man Manip Ther. 2018).  Authors included 7 previous randomized, controlled trials on the utilization of this treatment in patients with plantar fasciitis.  They reported a significant short (4 weeks) and long term (6 month) improvement in patient function when Physical Therapists included manual therapy into their treatment sessions.  The authors recommended clinicians utilize both joint and soft tissue treatments, in addition to, high level exercise when treating patients with plantar fasciitis.  

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Limitations of Orthotics for Heel Pain and Plantar Fasciitis

Plantar heel pain or plantar fasciitis is the most common diagnosis explaining pain originating from the bottom of the foot.  Previously, orthotics have been thought to improve alignment of the foot and ankle but more recent research has shown the limitations of these interventions.  In our previous blog posts, we have described the inability of orthotics to reduce pain or improve function in a number of conditions including heel pain.  In addition, orthotic users show atrophy of the essential core musculature of the foot.  A recent review article was published on the available evidence supporting or refuting the use of orthotics for heel pain.

Whittaker and colleagues in the British Journal of Sports Medicine examined 19 studies including 1600 patients with plantar heel pain (2017).  The authors found orthotics did not improve pain or function in the short or long term in patients with plantar heel pain.  In addition, consistent with prior evidence there was no difference in custom orthotics compared to over the counter orthotics despite a large difference in price.  

This study highlights the limitations of orthotics for treatment of plantar heel pain.  Patients are encouraged to seek out Physical Therapy treatments, including manual therapy and exercise, for a more effective method of treatment.  

Importance of Manual Therapy in Treatment of Patients with Heel Pain and Plantar Fasciitis
boulder-heel-pain-plantar fasciitis-treatments

Manual therapy or the passive movements of joints and tissues has been shown to be effective at reducing short term pain for a number of conditions including heel pain.  Interventions including joint mobilization and manipulation are commonly provided to patients suffering from heel pain or plantar fasciitis (fasciosis) in order to restore normal mobility to the leg, ankle, and foot.  A recent research review was conducted to determine if these manual therapy interventions were more effective than other Physical Therapy interventions.

Fraser and colleagues in the Journal of Manual and Manipulative Therapy reviewed 7 previous randomized controlled trials to determine the effectiveness of manual therapy in patients with plantar fasciitis (2017).  The authors reported manual therapy demonstrated greater improvements in function at both short and long term follow up compared with stretching, strengthening, or modalities.  Authors recommended clinicians consider both manual therapy and joint manual therapy treatments as part of a individualized Physical Therapy treatment plan.