Plantar Fasciitis - Revisited

Figure 1 - Plantar Fasciitis - Injury / pain site

We published a very brief article on plantar fasciitis (PF) in 2011. We felt it was time to revisit this problem with a much more comprehensive article, aiming to give more detail on how to manage this injury.

The following journal article - Diagnosis and Treatment of Plantar Fascitiis - is a great resource to refer to if you are suffering from PF. This blog post will use our own experience in treating PF and information from journal articles such as the one above.

The basics

PF typically causes heel pain in the sufferer (see figure 1) around the inside and underside aspect of the foot. This pain is most often worst in the morning, especially the first few steps of the day. Walking around will generally improve this morning discomfort after a short period.

PF can be very tricky to clear up and no single treatment method seems to be highly effective in isolation. Often a number of interventions will be needed in combination to resolve the issue. Having said that, PF is a self-limiting condition and the report above does indicate that 90% of PF injuries will resolve with 'conservative', i.e. non-surgical, treatment. This statistic is backed up by our own experiences in the clinic, with the high majority of PF cases we see clearing up without surgical intervention being required.

Risk factor and causes 

1) Low arches (or over pronation) and high arches. It does appear that anything that bio-mechanically challenges the arch and, in turn, the plantar fascia will increase the risk of injury.

2) High volume of weight bearing activity, whether this is walking, running or standing. The statistics show that, if you are on your feet a lot, you will be more likely to suffer with PF.

3) Being overweight or being obese. High body weight will increase the load on the foot and plantar fascia.

4) Tightness and/or weakness of the calf, Achilles or intrinsic muscles of the foot.

5) Poor bio-mechanics; in particular adduction and internal rotation of the knee (see this post) leading to increased pronation at the foot and off axis forces on the plantar fascia.

6) Other factors such as a sedentary life style, a sudden increase in training volume, a leg length discrepancy or landing heavily on the foot are all additional reported risk factors.

Other problems that can appear to be PF (Differential Diagnosis).

Sometimes injuries will appear to be PF but are actually something different. This often can occur with a 'self diagnosis'. For example, there may be a nerve impingement issue, such as tarsal tunnel syndrome. Below is a list of injuries that may at first appear to be PF but are actually a different injury altogether:

Click to see a larger version

Treatment options for PF

As I said before there are many treatments available for PF and in most cases it is necessary to combine more than one approach. The treatments required will differ from person to person depending on the individual's circumstances.

1) Rest (or relative rest)

The simple aim is to perform less of the activity (or activities) that are causing you pain. If walking for more than 45 minutes is causing increased pain then, do your best reduce the time that you are on your feet. Every time you irritate the injury, you are perpetuating the issue.

2) Massage, ice and stretching the plantar fascia (see picture below)

Top left: Massage the foot with a tennis ball or an even harder (and smaller) bouncy ball. This should not be painful to do, and if it is painful, reduce the pressure. Try this once a day for 5-10 minutes per application.

Top right: You can also try ice massage with a bottle that has been frozen. Again try this several time a day for 5-10 minutes per application. Beware, there is a risk of ice burn with this treatment so make sure your tissue is back to normal temperature before re-applying.

Bottom left: Ice massage is most useful in the early stages of the injury when inflammation is likely to be present. In more chronic injuries ice is still useful but only as a pain reliever.

Bottom right: Stretch the plantar fascia by pulling your toes upwards with your hand. This stretch is easier to do by crossing your ankle over the opposite knee.

1) Using a ball for self massage 2) Ice / massage with frozen bottle
3) Ice cube massage when acute 4) Stretching of the plantar fascia

3) Calf stretching

This is often the first treatment that will be given for PF. Evidence shows that PF suffers are often have very tight calves. With these stretches you should aim for 30 second holds (minimum) around 20x per day. This will give you, cumulatively, 10 minutes stretching on the problem side per day. Time the 30 seconds as it will be a lot longer then you think!

4) Taping the foot for support and proprioceptive feedback

Taping, as shown below and in the image at the top of the blog can help to 'off load' the arch of the foot and support the plantar fascia. The tape can also give additional proprioceptive feedback to the brain helping with improved positioning of the foot.

5) Non steroidal anti inflammatory drugs (NSAIDs)

NSAIDs such as Ibuprofen should always be taken under the supervision of your GP. However, topical 'gel' based applications will be most helpful in the early stages of PF. The gel based applications in this instance are arguably more effective and safer than the tablet form.

6) Night splints and orthotics

The use of night splints is the only treatment that has been shown to work effectively in isolation without the use of other treatments. The splints work by holding the calf and plantar fascia in a stretched position overnight. However, they can be uncomfortable and disturb sleep.

Orthotic devices are designed to 'off load' the plantar fascia and support the inside arch of the foot much like the taping is designed to do. For this intervention it is advisable to see a podiatrist who specialises is orthotic prescription as off the shelf orthotics can be hit and miss.

7) Corticosteroid injections

Your GP may consider this option after all other conservative treatment options have been undertaken unsuccessfully. This will often prove to be successful if there is inflammation still present at the injury site as these injections are a powerful anti-inflammatory. There are, however, risks associated with this treatment option such as rupture to the plantar fascia.

8) Plantar fasciotomy

Only a very small number of cases will require surgical intervention, this is very much a last resort.

The round up

PF can be extremely tricky to treat; it really can be a stubborn issue to resolve. With that in mind, make sure you seek advice and treatment as early as you can. This injury will often change from an inflammatory based issue to a degenerative tissue problem if left untreated. It is much easier to treat while it is still in the early inflammatory stage. 

Rotator Cuff Muscles: The basics

Rotator cuff exercises

If you have injured your shoulder in the past it is likely you will have heard of the rotator cuff muscles. You may also have been given specific exercises to strengthen them. Many people, however, have very little idea what these muscles are and what they are primarily designed to do.

The rotator cuff muscles are a group of 4 muscles with the main role of stabilising the shoulder joint. The shoulder joint (known as the glenohumeral joint) is inherently unstable. This is largely because the joint capsule is very shallow. The benefit of this shallow joint capsule is that it allows a large range of motion at the joint. This does mean that the stability at the joint is compromised. This is where the rotator cuff muscles come in. They are very small muscles that attach over the joint coming from the front, back and top of the joint. When the muscles are functioning correctly they will co-contact (firing together) to stabilise the joint through it's large range of motion.

If these muscles contact in isolation rather than co-contracting as a group they perform very specific movements. Below are the names of each individual muscle and the specific action it creates:

Supraspinatus: Abducts, or elevates, the shoulder joint.
Infraspinatus: Externally rotates the shoulder joint - or turns it outwards.
Teres Minor: Externally rotates the shoulder joint - or turns it outwards.
Subscapularis: Internally rotates the shoulder joint - or turns it inwards. The subscapularis muscle also works to depress the head of the humerus. This prevents the joint getting compressed during overhead movements.

Due to the specific actions each muscle creates, exercises to isolate and strengthen the rotator cuff muscles are often broken down into their separate actions:

Abduction (Lifting the arm away from the body) - Click here to see a series of exercises to strengthen the Supraspinatus => 5 Exercises

External Rotation (Turns the arm outwards) - Click here to see a series of exercises to strengthen the Infraspinatus and Teres Minor => 7 Exercises

Internal Rotation (Turns the arm inwards) Click here to see a series of exercises to strengthen the Subscapularis => 5 Exercises

As always with this type of blog post, it is for information only, please consult a musculoskeletal therapist before starting any of the above exercises. Rehabilitation exercises always need to be specific.

Two exercises to help a 'stiff' upper back

If you spend most of your working day bent over a desk it is likely you will end up with a stiff upper back or neck. 

This type of posture is not limited to desk-workers though. Tradesman (e.g. plumbers or tilers) may also have their upper body constantly in a forward position while working; this is called kyphosis. People who spend lot of time driving will also be susceptible to this type of posture. 

If you find that, by the end of the day, your upper back (between the shoulders) and neck are very stiff the exercises below are very likely to help your stiffness. Both exercise 1 and 2 (below) are designed to create extension in the upper back and thoracic spine. This is very important as we all spend far too much time in a flexed or forward position. By creating extension in the spine, these exercises can 'off set' some of the poor posture that has taken place through the day.

Exercise 2 requires a foam roller. If you do not have a foam roller I would recommend getting one, as there is great benefit in doing both sets of exercises. However, if you haven't got one don't worry as you can start right away with exercise 1. For this exercise all you require is a large bath towel. The exercises can be done multiple times daily.

Exercise 1 - Instructions 

1) Roll up a large bath towel, length ways, as tightly as possible - and place on the floor

2) Lie across the towel, with it underneath your mid back and your arms out stretched. 

3) Take deep breaths and aim to relax the muscles in your back, chest and neck as you breathe out.

4) Lie for 3-10mins in this position whilst repeating the exercise. 

You may feel a few pops or clicks in your back as you lie down on the towel - this is normal.

Exercise 2 – Instructions

1) Lie on your back and position yourself so that your mid back (thoracic region) is on the foam roller.

2) Cross your arms behind your head and slowly roll backwards and forwards on the foam roller.

3) Repeat this exercise 5 x 1 mins.

A full size printable sheet of the exercises is available here

Exercise 1.

Thoracic Extension Exercise - Towel

Exercise 2.

Thoracic Extension Exercise - Foam Roller

Is it normal to have a tight IT band?

Everyone has a tight IT band, right?

Anyone who has had massage or soft tissue work done on a tight IT band will know exactly how tight and tender this area can get. It really is quite horrible.

For those of you that haven't heard of the IT band before it is simply a piece of connective tissue that runs down the outside of the thigh. The IT band is short for the iliotibial band (sometimes also known as the iliotibial tract). Along with a muscle called call the tensor fascia lata the IT band helps stabilise the knee, from the outside, in weight bearing activities such as running and hiking.

A tight IT band can cause a number of problems such as anterior knee pain and IT band syndrome. It can get tight for a number reasons, however poor bio-mechanics in walking and running as demonstrated in the video in this blog post are most often related to increased tension in the IT band.

The two major tests that we use in the clinic to assess the tension in the IT band are:

Obers test

Thomas test 

In a significant number of cases we will find these tests show 'positive' results, indicating that the IT band is overly tight. There are many reasons for this including poor bio-mechanics as mentioned above. However, one aspect that must not be missed is that many people simply put their body under huge load without taking the appropriate measures to offset this load. High training volume, with poor postural patterns (e.g. poor sitting position at work), can lead to imbalances, increased tension and specific weaknesses in the tissue. If your training volume is high, and you are not carrying out regular basic maintenance on yourself, then it is very likely you will end up with a tight IT band and consequently injuries can occur.

So, back to the original question, 'Is it normal to have a tight IT band?' My answer, NO, it is not normal however it IS very common. For this reason it is hugely important to carry out regular self maintenance e.g. Foam rolling, mobilising, self trigger point work, stretching, glute and core strengthening exercises, balance and proprioceptive work as well as regular massage will all help reduce your chances of developing a tight IT band. 

What exactly is a tendonitis injury?

In its most basic terms a tendonitis injury is where a tendon - usually at its insertion point - becomes inflamed. The suffix ‘itis’ in the term tendonitis simply means inflammation.

You will also see tendonitis being spelt tendinitis - this isn't a different term; simply a spelling variation.

There are many examples of tendonitis injuries, some common ones are:

• Patella tendonitis
• Achilles tendonitis
• Rotator cuff tendonitis
• Bicipital tendonitis
• Tennis elbow / golfer’s elbow (both types of tendonitis)

Tendonitis injuries generally come about through over-use or repeated overload of the tendon.

Symptoms include a gradual onset of pain, aching in the tissue and localised tenderness at the injury site. Occasionally there will be reddening of the tissue around the injury site. There may also be palpable nodules on the tendon.

One problem with tendonitis injuries is that they are often mis-diagnosed. Many of these injuries are NOT inflammatory based, in many cases the tissue has degenerated instead. If this is the case the injury is now called a tendinosis and will need to be treated in a different way. Imaging, such as an ultrasound scan, can confirm which type of process has occurred.

As a general rule longer term degenerative tendinosis occurs in the slightly older patient. Inflammatory based tendonitis will occur in the younger to middle aged patient, though there is no consensus on the exact incidence of these injuries.

To confuse matters even further the term tendinopathy can also be used. This describes the overall symptoms of the injury and is an umbrella term which describes both pathologies i.e. a tendonitis or a tendinosis.

As stated previously, treatment for these injuries will differ depending on the exact underlying issue. In both cases, however, there will need to be a period of rest - or relative rest - to allow the tissue to respond to treatment. Biomechanical / technique issues will have to be assessed as more often than not these are contributing heavily to the tendon problem.

These types of injuries can be complex and will require very specific treatment plans.

However the main thing to take away from this blog post is to not 'work through' a problem like this. You must take early rest from any activities that aggravate the problem and seek advice early. These injuries are MUCH easier to address in their early stages of development rather then when they have become chronic.

In summary:

Tendonitis = an inflammatory based issue.

Tendinosis = a degenerative process

Tendinopathy = a ‘catch all’ term that could be a tendonitis or a tendinosis.

6 Great Core Stability Exercises

Why is core stability so important and how can I improve it?

The muscles in your core are very important to whole body function. During movement they keep your hips and spine in the correct alignment which in turn helps to prevent awkward and incorrect biomechanics. Poor biomechanics can lead to injury. For example if you are running and have poor core stability, your core muscles will weaken as you become fatigued and this usually lets your hips tilt forwards or side to side. This can put excessive strain on other muscles such as hamstrings/glutes and cause them to tighten and possibly tear.

So if you want to avoid injury I would strongly recommend adding a few of these exercises into your workout regime! Pick 2 or 3 to begin with and as you get better at them you can swap exercises or increase the number of sets and reps you are doing.

To start with try doing 3 sets of 10 reps or 30 seconds and progress from there.

These exercise videos were put together by a couple of friends and I at university and not only show you how to do the exercises but talk you through them as well.

1. Medicine Ball Twists

2. Sit Ups With Twist

3. Forward Plank

4. Side Plank

5. Superman

6. Trans Ab Heel Lowers

How to treat your own Knots and Trigger Points.

A tool to help trigger points - click picture

A knot is simply where a very localised section (or portion) of muscle has gone into a heavy spasm.

Everyone gets them and they tend to occur in very common areas.

One of the most common places that people get trigger points is the area just between the shoulder blades - running up to the base of the neck.

This blog post is going to teach you a very quick and practical way in which you can treat your own trigger points and knots - all you will need to do this is a tennis ball.

Before you read the rest of this post have a read of a previous post I wrote called - What is a trigger point (or Knot).

Trigger points respond very well to having direct pressure applied to them - this is something that you can do at home yourself. This can be supplemented with Sports Massage sessions at a sport's injury's or massage clinic.

This principle is very simple: you use a tennis ball (or 'back nobber' - pictured above) to apply pressure to your trigger points, in a kneading fashion.

How do I do it? The easiest way to apply the pressure is by trapping a tennis ball between a wall and your back (the area between the shoulder blades). You will need to make sure you have the ball positioned over a trigger point, though bear in mind you may have more than one trigger point in this area.

Once you have you have positioned the ball in the right place you should gently move side to side over the trigger point. This movement will be very small. If you have more than one trigger point, repeat the exercise where necessary.

How do I know I'm on a trigger point? This is simple. The areas that are tender will be the trigger points. As you move over them you might feel the tennis ball bump over the knot. You may have to move around a little to find the epicentre, but generally your instincts will tell you where to work.

How much pressure should I use? On a scale of 1-10 (1 = no pain / 10 = excruciating pain) aim for the mid numbers - 4, 5 or 6 - on that scale. You may feel like you want to go higher but avoid outright pain. A 'good discomfort' or a 'releasing discomfort is what you should be aiming for.

How long should I do this for? In the region of 1-5mins per trigger point. The main aim is to reduce your discomfort levels at the trigger point by about 50% before you move on to the next one. Ideally you will want to do this daily.

Finally, if your discomfort levels with the trigger points go up, it's likely you've used too much pressure initially. Leave the area for a couple of days to let it settle and try again with lighter pressure. If you are still having problems at that point then send us an email.