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Tag Archives: Plantar Fasciitis

John Lackey – Pitching With Plantar Fasciitis

John Lackey, right-handed starting pitcher for the World Champion Chicago Cubs, will be 39 years old in October. He is dealing with plantar fasciitis in his right foot, yet will start Tuesday’s game against the Braves after getting some extended All Star Break rest. Lackey was effective over six innings in his last start on July 5th before going on the 10-day DL the following day. This will be his first start since being activated.

Baseball players have successfully played through fasciitis before, Albert Pujols being one of the most visible and recent examples. But eventually Pujols succumbed to surgery as his condition worsened while he continued to play (even with a reduced role as DH). The condition can be quite painful and – even for a non-athlete – get in the way of performing routine activities. However, surgery is only a last resort.

The likelihood that ten days of rest will have resolved Lackey’s problem is not great. It becomes more about how (or if) the condition can be managed enough for the pitcher – whose numbers have suffered in comparison to the 1916 season – to be effective.

The Plantar fascia

The word plantar refers to the sole of the foot, and the plantar fascia is a thick fibrous band of connective tissue in this region that extends from the heel to the forefoot. It assists with stabilization of the arch. Fascia occurs throughout the body and overlays the muscles, organs, nerves and blood vessels. It acts as a restraint to keep our tissues and structures in place.

“Itis” means inflammation, in this case of the fascia. As with tendinitis, it is generally felt that a degree of degeneration is also occurring. This is known as tendinosis when referring to tendons. It is much like what happens with conditions such as tennis elbow or patellar tendinitis, which are also due to overload.

The fascia in the foot is particularly strong and is prone to stresses and small tears. Plantar fasciitis, a common cause of foot pain, is an overuse syndrome set off by too much tensioning of the fascia’s attachments to the heel. Though there is an increase incidence of heel spurs in sufferers of fasciitis, spurs, which are generally not within the fascia, do not always cause pain. However they may contribute to a predisposition to the condition.

Weakness of the muscles of the calf or foot/ankle impact function and also predispose to injury by placing more stress on all the related tissues. There is reportedly no definitive evidence that either a high or low arched foot predisposes to plantar fasciitis.

The onset of fasciitis is usually gradual rather than from trauma, and the problem is often stubborn, especially if left untreated. Generally speaking, the faster treatment is initiated after the onset of symptoms, the more accelerated is the recovery.

Women who wear high heels much of the time are prone to fasciitis because the calf muscles and fascia become tight due to the positioning of the foot and ankle. People whose work requires that they spend an inordinate amount of time standing or walking (particularly on hard surfaces) and those who are significantly overweight are also more prone to plantar fasciitis. Prolonged walking, and especially running, which requires a more forceful push-off, are likely to increase inflammation and pain. Jumping will do likewise.

The pain that occurs with this condition is often exaggerated in the morning because the fascia and heel cord (Achilles) are relaxed during sleep. Those first steps when the area is put on stretch can be especially problematic. That is why night splinting to keep the area on mild stretch is so helpful in treatment. The pain, which can be either sharp or dull, often feels like a pulling and is more common after inactivity than with movement. Hence standing for long periods worsening symptoms.

Fasciitis can involve tenderness along the band of the fascia in the arch or be more toward the heel. Putting the fascia on stretch by bending the toes back (dorsiflexion) – especially along with dorsiflexing the ankle (flexing it toward one’s head) – makes the area much more tender to touch. Plantar fasciitis must be distinguished from other conditions such as Heel Pain Syndrome, where the pain is more exclusively localized to the heel.

Treatment for plantar fasciitis focuses on relief of inflammation as well as stretching the fascia itself and reducing its soft tissue restrictions as well as stretching the calf and Achilles. Fascia stretching has proven most effective when it is non weight-bearing and specific to the area. There are many other ways in which to stretch, especially by taking a more dynamic approach and focusing on inhibiting muscles that limit the flexibility of the tight structures. One note of caution if stretching statically and when weight-bearing is to AVOID hanging the heel down off a step. This puts the midfoot structures at risk and also increases incidence of future Achilles rupture. It is best to keep the foot supported on the floor or on a wedge when stretching in in this position.

Treatment of fasciitis should also include assessment of, and attention to, areas of the foot that are related and may impact flexibility of the calf or pliability of the fascia. For instance, if the ankle or the joint at the base of the big toe lacks full mobility (into dorsiflexion) the soft tissues may not be able to stretch adequately. In these instances, restoring mobility to the joints may be necessary to get the desired result.

Though cortisone injections may provide temporary relief (studies show most patients have recurrence), they also come with an increased risk of rupture. The interesting thing is that treatment of chronic plantar fasciitis sometimes includes surgically lengthening the fascia (a procedure that Albert Pujols had), something that rupture may accomplish naturally. The downside is the time spent totally out of commission while healing in either case.

‘Tis the Season for Running: Here is a list of the Top Four Running Injuries and What a Physical Therapist Can Do For You

Now that fall is around the corner, runners tend to experience not only changes in training volume but also intensity and form of exercise (running outdoors vs. running indoors). Cold, rainy weather tends to push runners indoors onto treadmills. Whether you are a seasoned runner or just beginning, it is not uncommon for injuries to occur. The yearly occurrence of running injuries ranges between 37-56%.  A majority of the injuries that we see are caused by overuse. These type of injures are more subtle and usually occur over a period of time because of repetitive trauma to joints, bones, or tendons. As physical therapists we can address not only the cause, but help you heal.

Here is a list of the top 4 running injuries and how to prevent them.

Runner’s Knee

 

This is also commonly known as “patellofemoral syndrome.” Runner’s knee is due to the irritation of the cartilage that lies underneath the kneecap. Almost 50% of all running injuries involve the knee.

Risk Factors: Overpronation (inward movement of arch/ankle), Weak quadriceps, hips, and glutes.

Change in Running Form: By shortening your stride length and landing on a slightly bent knee, you can decrease the load on the knee by about 30%

Achilles Tendinitis           

The Achilles tendon is the connection between the calf and heel. Tendonitis occurs when the tendon tightens and becomes too sensitive. About 11% of running injuries involve this particular tendon. Pain is typically felt in the calf and/or behind the heel bone that is experiences as a dull ache.

Risk Factors: Excess increase in training intensity, Weak/Tight calves, improper running shoes.

Shin Splints

This is one of the most common injuries we see with treadmill training as many people do not use an incline. The achy pain in the front of the lower leg is due to small tears in the muscles that surround the shin bone.

Risk Factors: Excess increase in training, Improper running shoes, Flat feet or high arches.

Plantar Fasciitis   

Every time the foot strikes the ground, force is absorbed through the leg that is several times our body weight. This is one of the top foot complaints among runners. Pain is typically a dull ache in the arch or bottom of the foot that is usually worse first thing in the morning.

Risk Factors: Tight hip flexors, Weak abdominals, History of low back pain, Very high or very low arches, Excess pronation or supination

Not only can we address these risk factors, but we can also assist in helping you perfect your running form, help you determine appropriate footwear, and teach you how to become a more efficient runner.

“If you want to become the best runner you can be, start now. Don’t spend the rest of your life wondering if you can do it.” ~ Priscilla Welch

Joann Nunez, PT, DPT practices at our Rockefeller Center and Fashion District locations. 

 

Plantar Fasciitis Gets In The Way

For a guy whose foot is “hurting real bad”, Albert Pujols of the Angels is off to a great start this season. Though he is playing most games at DH rather than first base to limit the time he is on his feet, the logic, clearly a compromise, is flawed; He hits (and walks), therefore he stands and runs…

The 33 year-old Pujols, who is suffering from plantar fasciitis in his left foot, has played in all 17 games this season. He is batting .317 with two home runs and 13 RBIs and leads the team in on-base percentage (.436) and on-base-plus slugging (.944). Manager Mike Scioscia commented

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that Pujols is tolerating the pain enough to not miss a start and continues to produce at the plate. Yes, but he also commented that, as the season progresses, Pujols’ condition is worsening. Here we go again… Just ask Marcus Camby or, even better, Joakim Noah for their thoughts…

The Plantar fascia

The word plantar refers to the sole of the foot, and the plantar fascia is a thick fibrous band of connective tissue in this region that extends from the heel to the forefoot. It assists with stabilization of the arch. Plantar fasciitis, a common cause of foot pain, is an overuse syndrome set off by too much tensioning of the fascia’s soft tissue attachments to the heel. Though there is an increase incidence of heel spurs in sufferers of fasciitis, spurs, which are generally not within the fascia, do not always cause pain.

“Itis” means inflammation, in this case of the fascia. As with tendinitis, it is generally felt that a degree of degeneration is also occurring. This is known as tendinosis when referring to tendons. It is much like what happens with conditions such as tennis elbow or patellar tendinitis, which are also due to overload. The onset of symptoms is usually gradual.

The pain that occurs with plantar fasciitis is often exaggerated in the morning because the fascia and heel cord are relaxed during sleep. Those first steps when the area is put on stretch can be especially problematic. That is why night splinting to keep the area on mild stretch is so helpful in treatment (I swear by it). The pain, which can be either sharp or dull, often feels like a pulling and is more common after inactivity than with movement. However, standing for long periods also worsens symptoms. That is the rationale for keeping Pujols at DH.

Fasciitis can involve tenderness along the band of the fascia in the arch or be more toward the heel. Putting the fascia on stretch by bending the toes back (dorsiflexion) – especially along with dorsiflexing the ankle – makes the area much more tender to touch. Plantar fasciitis must be distinguished from other conditions such as Heel Pain Syndrome, where the pain is more exclusively localized to the heel.

Treatment for plantar fasciitis focuses on relief of inflammation as well as stretching the heel cord – obtaining normal flexibility of the calf muscles – and reducing soft tissue restrictions of the fascia. There are many ways in which to stretch, and those most favored these days are more dynamic and focus on inhibiting muscles that limit the flexibility of the tight structures. One note of caution if stretching in the more traditional ways is to AVOID hanging the heel down off a step. This puts the midfoot structures at risk and also increases incidence of Achilles rupture. It is best to keep the foot supported when stretching in weight-bearing.

Treatment of fasciitis should also include assessment of and attention to areas of the foot that are related and may impact flexibility of the calf or pliability of the fascia. For instance, if the ankle or big toe lacks full mobility (into dorsiflexion) the soft tissues may not be able to stretch adequately. In these instances, restoring mobility to the joints may be necessary to get the desired result.

Though cortisone injections may provide temporary relief (studies show most patients have recurrence), they also come with an increased risk of rupture. Pau Gasol of the Lakers suffered a rupture of his fascia in early February. The interesting thing is that treatment of chronic plantar fasciitis sometimes includes surgically lengthening the fascia, something that rupture may accomplish naturally. The downside is the time spent totally out of commission while healing in either case.

Follow Abby on Twitter @abcsims

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Plantar Fasciitis – A Nagging Problem for Athletes & Weekend Warriors Alike

oot and ankle injuries predominate in the NBA and Joakim Noah, the Chicago Bulls big man who is currently out with plantar fasciitis, is one of the latest high profile players to suffer from this nagging problem.  Noah missed his first game on January 23rd, returned intermittently for limited minutes and has been out of action since February 27th, a relatively long absence for a non-traumatic injury.  Athletes are prone to plantar fasciitis, particularly those who do a lot of sprinting and jumping, but even quarterbacks, just like the rest of us, are susceptible.  Eli Manning, who was diagnosed during the 2009 season, is a case in point.

What is fascia?
Fascia is a fibrous connective tissue that occurs throughout the body and overlays the muscles, organs, nerves and blood vessels.  It acts as a restraint to keep our tissues and structures in place. If you have ever prepared chicken you have seen the filmy white tissue between the skin and the meat – that is fascia.  At the bottom of the foot, (the plantar surface), the fascia is particularly fibrous and connects the heel bone to the toes.  It is prone to stresses or small tears that can result in an inflammatory (“itis”) response.

Common causes of Plantar Fasciitis
Fasciitis usually develops over time rather than from trauma and the problem is often stubborn, especially if left untreated. Tightness of the calf muscles and Achilles tendon can predispose to plantar fasciitis, as can tightness of the fascia itself.  A loss of mobility at the ankle or the big toe (not being able to flex up/back sufficiently) can also lead to fasciitis by changing our movement patterns, reducing the shock absorbency of the joints, and limiting the ability of the calf and fascia to stretch to their fullest, resulting in tightness.  Additionally, weakness of the muscles of the calf or foot/ankle impact function and lead to injury by placing more stress on all the related tissues.  Other typical pieces of the cause and effect puzzle may include structural malalignment (such as a high or low arched foot) or the presence of a heel (bone) spur.

Women who wear high heels much of the time are prone to fasciitis because the calf muscles and fascia become tight due to the positioning of the foot and ankle.  People whose work requires that they spend an inordinate amount of time standing or walking (particularly on hard surfaces) and those who are significantly overweight are also more prone to plantar fasciitis.

Symptoms of Plantar Fasciitis
Swelling and tenderness to pressure or touch are generally complaints of those with fasciitis, as is a sharp pain in the heel area or arch of the foot.  One of the most common complaints is morning pain, particularly with the first steps from bed. During a prolonged period of rest, where the foot and ankle are relaxed (with the toes pointed downward), the plantar fascia and muscles of the calf are on slack.  The sudden stretch imposed by putting the foot on the floor and walking can trigger significant pain.  The same might occur after sitting for an extended period.  In very mild cases, after walking a bit and warming up the tissues, pain subsides. Taj Gibson, another Chicago Bull suffering from plantar fasciitis has been receiving treatment but has been able to play through it, an obvious sign that his condition is not as severe as Joakim Noah’s.

Prolonged walking and especially running, which requires a more forceful push-off, are likely to increase the pain and inflammation associated with fasciitis.  Jumping will do likewise.  Not the best scenario for Joakim Noah who, when he began his medical leave, was the NBA’s second leading rebounder.

TREATMENT
Treatment of plantar fasciitis requires a multifaceted approach to reduce inflammation, stimulate healing, stretch tight tissues, strengthen weak musculature and minimize additional stresses.  Here are some tried and true methods of care as well as some of the emerging techniques:

Rest – time off from offending activities is an important part of treatment.

Night Splint – wearing a night boot to keep the ankle at a 90-degree angle maintains some stretch of the calf and fascia and significantly reduces early morning pain.  By helping to lightly stretch tight structures over a prolonged period, resolution of plantar fasciitis is accelerated.

Deep tissue massage – performed manually and also by rolling the foot on massagers or things such as a tennis ball or frozen can of soda can be very helpful.  Deep massage with the ankle held at 90 degrees and the big toe held gently in a backwards-bent position can help to ease fascial pain and tightness.

Stretching – tight calf muscles and fascia must become more flexible to limit recurrence.

Range of motion – treatment to restore motion where it is limited may be necessary to allow for more flexibility of the attached structures.

Cushioned heel lifts – by slightly elevating the heel, stress on the tight structures is minimized during walking or prolonged standing, and the increased shock absorption of a heel lift also decreases the stress from impact.  Choice of footwear factors in here as well (notice that many surgeons and chefs wear clogs).

Ice and electric stimulation – both help to reduce inflammation and swelling

Iontophoreses – another very helpful tool used in physical therapy.  For plantar fasciitis, “ionto” involves the use of a corticosteroid medication that is driven through the skin in the region of the inflammation with a transistor size electric stimulator.  It is painfree, entails only localized use of the drug and does not entail an injection.

Taping – even after returning to competition, taping techniques are used to support the arch.  Taping can be very helpful and enable a player to compete without aggravating a condition as well as reduce the chance for recurrence after a problem resolves.

Strengthening weak muscles throughout the lower body and especially those of the calf and foot is crucial, as is building muscular endurance.  For example weak toe flexors (muscles that let you grip with your toes) are a common problem resulting in fatigue in the foot and strain on the fascia due to poor push-off.  Even the toes must be strengthened when treating foot and ankle conditions.

Balance training is vital as well, working to stabilize while standing on one foot and challenged to reach or bend.  Balance training should be progressed from stable to unstable surfaces to increase the difficulty of the tasks.

Arch supports – if flattened or high arches or other malalignment issues are part of the problem, over-the- counter or custom orthotics (shoe inserts) may be recommended.  It is generally suggested to wait until you have increased your flexibility (if it is one of the causative factors) before getting a custom orthotic because the resting position of the foot may change once greater flexibility is achieved.

Prolotherapy – Prolotherapy treatment involves injecting a sugar water solution into the involved ligament or tendon where it attaches to the bone. This is intended to cause a localized inflammation in these affected areas in order to then increase the blood supply and flow of nutrients.  It is thought to stimulate the tissue to repair itself.  I’m not sold.

Plasma Rich Platelet Therapy (PRP)– Joakim Noah recently underwent PRP and shock wave treatments. Both are relatively new.  Some recent studies on PRP were not as favorable as the original clinical impressions, showing that it was no more effective than injecting saline. Platelets are one of the four components of blood.  The others are red and white blood cells and plasma. The procedure involves taking a patient’s own blood, spinning it down to the platelets, which are said to release proteins called growth factors, then injecting that back into the injured area.  The treatment is thought to accelerate tissue and wound healing.

Shock Wave Therapy – Another emerging treatment, shock waves are said to work by inducing microtrauma to the affected tissue, which then stimulates a healing response. This healing response causes a repair process during which small blood vessels form to increase delivery of nutrients to the affected area.

Injections – Not on my go-to list of treatments for plantar fasciitis, they are still in the arsenal so are included here.  The cortisone injection is occasionally needed to jump start the rehab process by reducing inflammation and pain sufficiently so that the active treatments (such as stretching and strengthening) can be progressed without exacerbating symptoms.  With the potential side effects of injection always at issue, it should not be a first line of defense or used repeatedly in one area of the body.  Nor should cortisone be the entire treatment even if it brings relief.  That is dangerous because it gives a false sense of order when in fact the underlying causes of the problem have yet to be addressed.  Cortisone by injection at the foot is even riskier because of the more fragile nature of the tendons there and their predisposition to rupture.

Surgery – A very last and infrequently relied upon resort, surgery to lengthen the fascia is sometimes the final step when all else has failed