How to STOP Plantar Fasciitis Coming Back or Switching Feet!

Barefoot - plantar fasciitisPlantar fasciitis is a painful foot condition caused by overstretching and degenerative tears of the plantar fascia – the long arch tendon which runs from the heel to the forefoot and supports the arch of the foot.

It is a fairly common condition which develops gradually through overuse, especially in runners and walkers / hikers. Pain tends to start under the heel and often radiates into the arch of the foot, being worst first thing in the morning.

There is plenty of advice out there on how to treat plantar fasciitis which centres on rest, cold therapy, massage, stretches, electrotherapy, acupuncture and orthotic insoles. Generally this is a slow but successful treatment regimen.

But what is rarely covered, is how to prevent this condition coming back, in the same foot, or in the case of NBA player Joakim Noah, in the other foot! Chicago Bulls Center Noah is suffering with the condition now in his right foot, after missing 18 games in the 09/10 season with the same problem in his left foot! Noah has learnt from his first experience of the condition where he tried to continue playing and says:

“I think the difference was last time I just tried to keep fighting through it and fighting through it, and (this time) I’m just trying to be smart about it.”

That’s good advice for all plantar fasciitis sufferers out there! Don’t try to carry on. The more you push through the pain, the more damage you are doing and the longer it will take to recover.

How Can Plantar Fasciitis Switch Feet?

Joakim Noah’s case is not that uncommon. Often plantar fasciitis will start off in one foot and then develop in the other foot, either within a few days or weeks, or some time later, after the initial injury has healed.

The cause of this is usually biomechanical – do to with the way we walk or run. At the time of injury, when weight bearing on one foot is causing us pain, we tend to (knowingly or subconsciously) change our gait to reduce the pressure on the painful area. This often means putting more pressure on the other foot and stressing the fascia on that side, resulting in a bilateral case of plantar fasciitis.

As in Noah’s case, the pain can develop much later, when the original injury is all but forgotten. In these circumstances, the cause is likely to be due to muscle imbalances which were probably worsened during the first bout of injury.

Whilst walking with a painful foot we tend to shorten our stride, especially when the affected foot is behind. This means that the hip flexor muscles are not stretched and the Glute muscles are not required to extend the leg back as far, which over a long period and if untrained in other ways, can cause weakness.

To compensate for these imbalances, the heel of the trail leg lifts up prematurely, which reduces the eccentric loading of the calf muscles. This means the force used to propel the rear leg forwards in reduced. This forward swinging is really important as it helps to supinate the opposite foot ready for push-off. Reduced supination means an increase in overpronation which stretches the fascia with every step, eventually leading to PF in the opposite foot to where it started!

This combination of tight hip flexors and weak gluts also causes an anterior pelvic tilt, which shifts our body weight forwards, onto the forefoot. In order to counteract that and prevent us falling flat on our faces, the calf muscles contract, resulting in tight calf muscles and another major cause of plantar fasciitis which further increases overpronation to compensate for reduced ankle motion.

How Do I Stop That Happening?

There are a several things you should be doing to prevent an injury returning or indeed becoming a bilateral issue:

  1. Firstly, address both sides from the onset. You are likely doing exercises for the painful foot to increase calf muscle flexibility and intrinsic foot muscle strength, so take a few more minutes to do them on both legs.
  2. Try not to alter your gait cycle. Rest as much as possible and try not to walk around more than absolutely necessary. The more you walk, the more pain you feel and the more you alter your gait, placing extra stress on the other foot.
  3. Look at the other causes. Do you have tight hip muscles? – Probably if you are sat down all day. Are your glutes firing strongly and in conjunction with your hamstrings? Address these problems to stop the condition jumping to the other foot!
  4. Continue with your exercises beyond the painful stage. Don’t be fooled into thinking that the pain has gone so you can stop stretching your calves and hip flexors and stop strengthening your glutes and foot muscles. Keep going to maintain your improved foot function.
  5. Consider your footwear on an ongoing basis. Try to wear good supportive shoes at all times, especially when you know you will be doing a lot of walking. Continue wearing insoles if these were prescribed for you and change running shoes regularly.
  6. Consider losing weight if you are over your recommended weight as this will reduce the stress on the fascia.
  7. If you are a runner / walker or play any sport, make sure you return gradually and don’t rush back. This is a sure fire way of the condition returning.
  8. Have a regular sports massage to maintain the condition of the calf and hip flexor muscle in particular.
  9. Rest and ice at the slightest onset of pain.

Having suffered with plantar fasciitis once, it is something that you need to consider for the rest of your life. A sufferer will always be prone to the condition, but following the steps above and being aware of the stresses you are placing on your feet and how you can reduce them can go a long way to preventing the injury coming back.

Botox Injections for Plantar Fasciitis Treatment

The plantar fascia under the sole of the footThe plantar fascia

Following on from our post last month covering some recent research demonstrating the effectiveness of electro-acupuncture in the treatment of plantar fasciitis, a new study has been published in Foot and Ankle International which has found promising results in PF sufferers using a new form of treatment.

A group of researchers from the Autonomous University of Nuevo Leon in Mexico undertook the study, comparing the effect of Botox injections and the more traditional Steroid injections.

InjectionCorticosteroid (also known as Cortisone) injections have been used as a treatment for many chronic conditions, including plantar fasciitis for years. Corticosteroids are potent anti-inflammatories which may be administered by injection, orally or by a technique called iontophoresis. The main aim of a steroid injection is to reduce pain and inflammation sufficiently to allow a rehabilitation programme commence. However, they have been shown to have a short-term effect and to also increase the risk of tendon rupture.

Botox is a neurotoxic protein used more famously in cosmetic procedures to reduce fine lines and wrinkles. It does however have other medical uses, which include reducing excess sweating, chronic pain, neuropathy, headaches and migraines.

Botox works by decreasing muscle contraction through blocking nerve impulses. The protein is injected into the muscle tissue using a fine needle and so does not require local anaesthetic.

Recent Research

This latest research into the use of Botox versus steroids for the treatment of plantar fasciitis used 36 volunteers who had been suffering with plantar fasciitis for a minimum of three months, with no other injuries or complications and no previous therapeutic injections.

The participants were randomly assigned to one of two groups. The control grStretching the sole of the footoup received a corticosteroid injection into the medial plantar surface of the foot. The test group received three injections of Botox into the Gastrocnemius and Soleus calf muscles. Both groups were instructed to stretch the plantar fascia of the foot regularly.

Evaluation was performed over a period of 6 months, at 15 days, 1 month, 2 months, 4 months and 6 months post injections.  The Visual Analog Scale (VAS), Foot and Ankle Disability Index (FADI) and American Orthopedic Foot and Ankle Society (AOFAS) Score were used to evaluate the effects of treatment in both groups.

The results indicated that whilst initially there was no difference in perceived pain and disability between groups (at the 15 day follow-up), the Botox group began to show improvements by the 2 month mark with VAS scores of 1.9 ± 1.51 points, compared to 3.4 ± 1.24 for the control group. These improvements continued throughout the time frame of the study, with the Botox group reporting 1.1 ± 1.5 points at the 6 month point, where those in the steroid group continued to deteriorate, with a final score of 3.8 ± 1.15.

Conclusion

So, at first glance, Botox injections appear to be a promising form of treatment for plantar fasciitis. The desired effect is different to that of the more traditional steroid injection. Rather than treating the area of pain, inflammation and degeneration, the use of Botox injections targets one of the main causes of plantar fasciitis – tight calf muscles.  It is always preferable to treat the cause of an injury rather than the symptoms and so to me, this form of treatment makes sense.

My only question concerning the methodology of the study is why the participants were asked to stretch the plantar fascia alone and not the calf muscles? Increasing the calf muscle flexibility has been shown to be important in plantar fasciitis rehabilitation and to be far more effective than stretching the fascia itself. Perhaps the authors decided not to stretch the calf muscles as they did not want the possibility of calf stretching being responsible for any improvements.

As with all potential new treatments, further investigation is required. Studies with larger participant numbers should be undertaken, as well as studies comparing Botox injection only against a thorough plantar fasciitis physical therapy protocol.

Reference: Elizondo-Rodriguez J et al. Foot Ankle Int. 2013;34:8-14.

Acupuncture Effective for Plantar Fasciitis Pain Relief

AcupunctureAcupuncture – needle insertion

A recent study published in the American Journal of Chinese Medicine has found that a form of acupuncture is highly effective in easing the pain associated with Plantar Fasciitis.

Plantar Fasciitis is an inflammatory, degenerative condition of the fascia under the sole of the foot. It is distinguished by pain in the heel which may radiate into the arch of the foot, which tends to be worst in the mornings and on standing after periods of non-weight bearing.

Causes of plantar fasciitis are often linked to foot biomechanics, with overpronation being among the most common causes, and often exacerbated by tight calf muscles.

Treatment of plantar fasciitis is aimed at decreasing pain and inflammation, and then correcting any contributing factors. Rest, anti-inflammatory medications and the application of ice are recommended. The use of insoles or orthotics to correct overpronation and stretches for the calf muscles may also be prescribed.

Unfortunately for its sufferers, plantar fasciitis can be a long-term condition with many cases lasting months, if not years. Surgery is an option for those with persistent symptoms where conservative treatment is unsuccessful. Surgery involves ‘releasing’ the plantar fascia by cutting 30-50% of the fibres connecting the fascia to the heel bone. This has a success rate of 70-80%.

New Research
The latest research uses electro-acupuncture in addition to more conventional treatments. The control group took anti-inflammatories, stretched daily and wore shoe inserts. The test group also received electro-acupuncture treatments twice a week. The study lasted a total of 5 weeks.

Electro-acupuncture is a relatively new form of treatment, in which the needles are attached to a device that generates continuous electrical impulses and transmits them through the tissues. It works in a similar was to TENS (transcutaneous electrical nerve stimulation), except in this case the impulses are passed directly into the tissue to be treated.

The results of this study demonstrated that those patients who had additional electro-acupuncture treatment had a decrease in symptoms and perceived pain (measured using a visual analog scale – VAS) as well as a significant increase in foot function (measured with the Foot Function Index). Those in the acupuncture group demonstrated an improvement in VAS score of 80%, compared with only 13% in the control group. This was maintained at the six week follow-up.

Implications
Previous research surrounding the use of acupuncture for the treatment of plantar fasciitis has generally shown a moderate improvement in symptoms, although some studies were of particularly low quality (for example – no control group).

No other articles (that I have found) focus on the use of electro-acupuncture for the treatment of PF and so perhaps this is a particularly beneficial form of treatment which produces significantly better outcomes than standard acupuncture.

Further high quality research is required to confirm the efficacy of such treatments, but certainly the use of acupuncture and electro-acupuncture should be serious considerations for those suffering from and treating long-term plantar fasciitis.