Posts in heel pain
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.

Weakened Foot Strength and Orthotic Use in Patients with Heel Pain

In our previous posts we have documented the weakness and atrophy of the foot's "core" muscles among patients with heel pain.   Heel pain is one of the most common foot and ankle diagnoses we see in our Boulder Physical Therapy Practice.  This condition is commonly treated with manual therapy and exercises targeting the lower quarter.  A targeted area for exercise involves the foot's core muscles which contribute to stability and function of our arch.  Without adequate strength and control of the arch we are more at risk for conditions such as heel pain and plantar fasciitis.  Recent research highlights the importance of these muscles and the negative impact foot orthoses may have on their function. 

McClinton and colleagues studies 27 patients with heel pain compared to matched peers who ddi not have any heel pain (JOSPT 2016).  Participants' foot strength was tested using two clinical tests for foot "core" strength.  Not surprisingly, the patients with heel pain had significantly less foot strength than their asymptomatic peers.  Interestingly, longer use of foot orthoses was associated with lower performance on these strength measurements.   Stabilization of the arch with foot orthotics may weaken the foot's core muscles because they prevent these muscles from performing their natural function.  

Patient's are encouraged to contact their local PT on the most appropriate treatments for their heel and foot pain.  

Ankle Mobility Techniques

Ankle mobility is essential for both daily walking tasks as well as higher level athletics and sports participation.  In our Physical Therapy practice in Boulder we see a loss of dorsiflexion, bending, among athletes with lower extremity injuries and conditions.  A lack of ankle bend, dorsiflexion, has been associated with many conditions including heel pain, plantar fasciitis, ankle sprains, stress fractures, achilles tendonitis, and ACL injuries.  An example of the impact of ankle mobility on performance can be found with a squat test.  Try to squat as deeply as you can keeping your heels on the ground, then repeat the squat with your heels lifted on a weight plate.  If the latter is easier you may not have the 10-20 degrees of bend required during many athletic tasks, stair climbing, or walking.  

One of the most effective ways of restoring ankle dorsiflexion in our physical therapy practice involves the use of manual therapy.  These interventions allow a Physical Therapist to passive mobilize the areas of restriction decreasing your sensations of tightness and improving your ability to move through a more full range of motion.  Often the squat test is dramatically improved after mobilizing the joints of the foot and ankle to improve ankle bending.  

boulder physical therapy ankle mobility treatments

In our experience, ankle mobility is more quickly restored when these manual therapy techniques are followed by home exercises designed to move through the newly acquired range of motion.  A recent study examined the impact of two exercises designed to restore ankle bending in individuals who lacked the normal amount of motion in their ankle.  Jeon et al. randomized 32 individuals to either a static stretching group or a group performing a similar stretch using a band (J Athletic Training. 2015).  Individuals underwent the stretching protocol (15 reps x 20 second holds) 5 days a week x 3 weeks under the supervision of a Physical Therapist. 

boulder physical therapy ankle mobility with strap

The authors reported both groups improved their ankle range of motion after 3 weeks, but greater improvements were noted in the group utilizing the strap.  The strap may help localize the movement to the area of joint restriction making the exercise more specific to the individual.  To learn more about the examination and treatment of your ankle mobility contact your local Physical Therapist. 

Intrinsic Foot Muscle Atrophy and Heel Pain

Plantar Fasciitis is a common overuse condition affecting many runners in Boulder.  Authors report it is the 3rd most common running related injury and total costs involving plantar fasciitis cost over 375 million dollars per year (Taunton et al. 2002).  Much of these costs can be attributed to the chronic nature of the condition reaching up to 12 months in some individuals.  Treatment by a Physical Therapist involving manual therapy to the lower quarter joints and strengthening exercises have been shown to accelerate recovery and shorten this duration of symptoms.

The plantar fascia is a passive restraint to forces across the foot and ankle when we stand or weight bear on one foot.  In addition to the plantar fascia we are able to use hip and leg muscles, muscles crossing the ankle, and intrinsic foot muscles, deep in the foot, to absorb these running forces.  Commonly in patients with plantar fasciitis we find reduced strength and balance throughout the leg.  A key element to successful treatment of plantar fasciitis involves restoring both global strength in the leg and local strength in the foot to reduce abnormal loading patterns across the heel and arch of the foot. 

A recent article examined the size of the intrinsic foot muscles in experienced runners with and without plantar fasciitis (Cheung et al. J Sci Med Sport. 2015).  10 of the 20 runners were diagnosed with chronic heel pain (>2 years) while the others served as a control group.  The authors noted atrophy of the intrinsic foot musculature in the runners with plantar fasciitis.  We are not able to determine cause and effect in this study design but this indicates the importance of intrinsic foot strengthening in patients’ with heel pain.   The stronger these muscles become the better their tolerance to control forces across the foot in running.  In turn, less forces will be applied to the passive elements of the foot like the plantar fascia.

 To learn more on how Physical Therapy can help your heel pain contact your local Boulder Physical Therapist.


Foot Orthotics and Overuse Injury

Customized foot orthotics based off a clinical examination, plaster or foam cast have been utilized for decades in order to treat overuse injuries of the foot, ankle, knee, hip and even spine.  These orthotics are usually not covered by insurance and usually run into the hundreds of dollars compared to an off the shelf model.  Many businesses have opened up lately specializing in the prescription and fabrication of orthotics for these conditions claiming correction of the foot and ankle can change the mechanics up the kinetic chain.  Up to this point, with a few patient exceptions, customized orthotics have not been proven more effective than cheaper off the shelf orthotics.  

This blog has previously posted on many aspects of achilles tendinopathy.  A recent article examined in the British Journal of Sports Medicine randomized 140 patients with achilles tendinopathy to either a sham orthotic or a customized orthotic (Munteanu et al. 2015).  In addition, both groups were given eccentric calf strengthening exercises.  The patients were followed over a total of 12 months.  Authors noted improvement in both groups, but no difference between groups at either short or long term functional or clinical outcomes.    It appears the orthotic did not improve symptoms or function above or beyond improvements noted with the eccentric exercise.  

In short, consistent with prior research, customized orthotics are not more effective than other interventions for overuse injuries of the lower extremity.  Future research should attempt to identify any individual factors that may indicate a need for an orthotic intervention.  

Economic Cost of Running Injuries

Mend Physical Therapy has previously written on the prevention and treatment of running injuries  in multiple prior blog posts.    Running is very common form of exercise in the United States and here Boulder County. The vast majority of runners will sustain an injury in the upcoming year which will prevent them from training or competing at their intended levels.  Our prior posts have described the risk factors for these injuries and our ability to prevent them.  In particular, having a twice a week running specific strengthening program and a Physical Therapy assessment of your running gait may create the biggest impact and keep you on the trails.  

Once an injury is sustained an athlete faces an impact on both his or her training and possibly their finances.  These may be in the form of changes in footwear, running coaches, gait analysis, physical therapy visits, diagnostic tests, etc.  A recent article in the Scandinavian Journal of Medicine and Science in Sport documented the economic impact of running related injuries among athletes training for an upcoming race event (Junior, L. 2015).

Junior et al. followed 53 runners training for an upcoming 5K, 10K, or 10 mile race.  All runners participated in run training programs put on by the upcoming race events.  These programs consisted of written materials on race preparation and weekly supervised group run training sessions based on experience and ability levels.  The supervised program consisted of a warm up, cool down, and 60 minutes of run training over 5-10K focused on speed development.  

Over half, 32 out of 59 runners, sustained a running related injury during the training period with 85% of these injuries being classified as overuse in nature.  Interestingly, the authors noted a higher percentage of running injuries in the experienced group compared to those with <1 year of running experience.  Of the running related injuries, 73% caused athletes to miss upcoming training sessions and 34% lead athletes to seek medical attention.  These individuals sought medical attention from their primary care MD or a medical specialist, with 38 receiving Physical Therapy care.  

The economic impact of these injuries among these 53 runners was significant.  $6200 was spent on these 32 athletes, 66% of this cost (direct cost) went towards direct health care consultations.  Each injury was broken down into a direct cost and an indirect cost due to lost time from work.  The indirect costs from loss of work time were twice that of those directly related to health care consultations.  Due to the high financial impact of running injuries, the authors recommend runners be given injury prevention programs to prevent health care expenses and time off of work due to injury.  

To learn more about how you can prevent injuries contact the experts at Mend Physical Therapy