Foot and ankle pain?
You may wonder what a spine doc is doing talking about feet. In addition to foot pain, we know that poor foot mechanics can lead to back pain, hip pain, etc. so part of every proper spine exam should include a look at how your feet are supporting you. The foot bone’s connected to the…
Figure 1
As a long time sufferer of ankle pain myself, I understand how limiting foot and ankle pain can be on extra-curricular activities and everyday life! The answer to my lifelong question “why do my ankles hurt?” came from a chiropractor after 13 years of doctor’s and therapist’s examinations, unremarkable MRI findings, and multiple pairs of orthotics and exercises. I want to share with you today what saved my active lifestyle: understanding the basic functions of the foot and ankle. This topic should give you a better understanding for just how complicated the foot is, and the multitude of compensations that occur when one part of it doesn’t function correctly.
The foot and ankle has 26 bones and 33 joints. It is designed to change, within each step we take, from a “mobile adaptor” for shock absorption, into a “rigid lever arm” for propulsion and power. Here is an overview of how this complicated process works. The goal isn’t to turn you into a foot biomechanics expert but rather to give you an idea how if this complicated machinery is not working properly, it can mess with the entire rest of the system. After all, depending on who you talk to, we’re built from the ground up!
The Mobile Adaptor:
As your foot strikes the ground, the first job of the foot is to cushion the impact of hitting the ground so the force does not transfer up the body to joints that are not designed to absorb it (such as the back and pelvis). A perfectly functioning foot uses the subtalar joint to accomplish this task.
Figure 2
The Subtalar Joint:
The subtalar joint is located between the calcaneus (heel bone) and the talus (upper ankle bone) (figure 1). This joint allows for movements called supination pronation (figure 2). Stiffness or limited mobility in this joint can result in abnormal stress being transmitted up the leg into the pelvis and lumbar spine, which can lead to all kinds of issues. Some common things we see that can be linked to poor foot mechanics include:
- Back pain
- Hip pain
- Iliotibial band syndrome (IT Band Syndrome)
- Patellofemoral syndrome and runner’s knee
- Bursitis
- Achilles tendinitis
Figure 3
During normal gait, the foot strikes the ground in a supinated position (on the outside part of our heel), and then moves into pronation. This action cushions the impact and allows the muscle in the lower leg time to properly deal with the force (figure 3).
Consequences of poor subtalar function:
- Shin Splints: Excess stress on the shin muscles due to lack of joint absorption.
- ‘Overpronation’ or ‘Fallen Arches’ in the mid foot: The forefoot tries to compensate for the lack of motion in the rear foot by collapsing into pronation to help the body absorb the impact force.
The Rigid Lever:
After the forces are absorbed by the subtalar joint, the foot needs to shift into a rigid lever to effectively transfer your body weight from the rear foot to forefoot when the heel comes off the ground. This is completed by a combination of mechanisms that aim to stiffen the supportive arches of the foot.
The outside of the foot
The joints on the outside of the foot are shaped to form a locking mechanism that stiffen the arch system. OK, so to fully appreciate this locking mechanism, I have to use some fancy biomechanics terms so bear with me and try and visualize how this works:
Figure 4
As the body rotates over the supporting leg, it causes the leg to externally rotate, which leads to the re-supination of the subtalar joint. It is this motion that causes joint between the heel bone (calcaneus) and the cuboid bone on the outside of the foot to lock. Refer back to diagram 1 to see where the cuboid bone is. It is located just before that big bump you can feel on the outside of your mid foot and it forms the cornerstone of all the arches of the foot.
This locking mechanism has been shown to minimize the muscular effort required to walk and run.
Next, as the heel lifts off the ground, the muscles on the outside of your lower leg fire to support this locked arch position and lift the foot. Figure shows the foot from behind, with the tendon of the peroneus longus muscle looping from the outside of the ankle underneath the foot.
Windlass Effect
As the heel lifts off the ground, a phenomenon known as the windlass effect of the plantar fascia also takes place to increase the stability of the foot.
This effect leads to a shortening of the foot and an increase in the height of the arch as you roll onto the ball of the foot.
Figure 5
It is also important for the ankle mortise joint and big toe to be flexible enough to allow for this motion.
Appropriate Range of Motion in the Ankle Mortise Joint and Big Toe
The ankle ‘mortise’ joint (figure 5; red arrow) must be flexible enough to allow the knee to come over the foot (ankle dorsiflexion). If this range of motion is not present, the foot will compensate by pronating through the subtalar joint. But remember – we just learned that this joint should be ‘supinated at this time of the gait cycle for maximum stability’.
The joint of the big toe (green arrow) must bend (dorsiflex) 65° for normal gait to occur.
Consequences of an insufficient rigid foot:
Inefficient propulsion: occurs when the peroneal muscle can’t support the foot on the big toe during toe off. This leads to a rolling push off on the outside edge of the foot and the dissipation of energy through the small joints of the foot, leading to extra strain on soft tissues (plantar fasciitis, Morton neuromas), and leads to joint restrictions over time in the subtalar joint.
Consequences of a lack of range of motion:
- To compensate for decreased range of motion, the body has to regain mobility by unlocking the joints of the mid foot just as the peak force hits. This messes up the function of the peroneus muscle and the windlass effect, which puts more strain on the soft tissues. Painful conditions, including plantar fasciitis, morton’s neuroma and heel spurs can result.
- Metatarsal stress fractures: Again, lack of mobility in one area has to be compensated by increased stress in another area. In this case, lack of ankle dorsiflexion causes the metatarsal heads to be driven into the ground. Soldiers found this out the hard way as they suffered from stress fractures from all the marching they did in their training.
- Impingement at the front of the ankle: lack of ankle dorsiflexion damages the joint surface as the tibia collides into the talus. This is a vicious circle as bone builds up at the front of the ankle joint which increases the signs of impingement. This condition is exacerbated by fast running, walking up hills, and prolonged squatting.
Treatment: So now that we understand the basic intricacies of proper foot motion for an effective gait, how do we fix it?
When a joint fails to move through its designed range of motion, a fibrotic type of scar tissue forms, preventing the return of full range of motion with gait coaching or exercises alone. These restrictions can occur from simple things like toeing off on the outside of the foot, poor shoe choices, ankle injuries, or old traumas.
Manipulation and mobilizations of the foot and ankle are designed to break down this scar tissue and restore the normal motions necessary for proper gait. This decreases the likelihood of injury, and also decreases foot pain by relieving the extra stress placed on the other foot structures: muscles, ligaments and nerves. It can take months to restore motion to an old fibrotic foot, but often even the slightest increase in movement can spell the difference between pain and complete relief.
Also, due to the chronic nature of gait deficiencies, the muscular system also has to be addressed to target the wear and tear on the muscles and ligaments that were stressed due to gait compensations. These soft tissue injuries respond very well to both Active Release Techniques and Graston Therapy.
Rehabilitation exercises are also essential for full recovery. There are simple and effective take home exercises that can help you retrain your gait so you too can return to your active lifestyle without foot and ankle pain.
Hopefully this article has helped you look at the foot from a functional perspective, and begin to answer a lot of questions of why chronic foot and ankle issues occur so frequently in society today with no apparent source of trauma.
Please feel free to contact Dr. Andrea Sargent with any further questions, or book an appointment to see if you are a candidate for conservative treatment on your feet.
Gearing up for Summer
Pearls for Cyclists
The cycling posture puts the low-back in flexion (convex curve, or reversal of the natural lordosis), the mid-back in flexion (convex curve, or increased kyphosis) and the neck in extension (concave curve, or an increased cervical lordosis).
Pushing the pedals places demands on the calves, quads and glutei (and hamstrings when riding clipless). Stresses through the arms are greatest through the triceps, anterior deltoids and pec muscles while spinning and descending, and create shearing forces through the upper back (upper thoracic spine/thorax). While climbing or sprinting, the muscular demands are greatest through the bicep, posterior deltoid, rotator cuff, lat-dorsi, mid-traps and rhomboids (the muscles between the shoulder blades). Here are some stretching and strengthening tips to get you ready for the road or trails:
Stretching:
Pec stretch: Find an empty corner in the room. With your shoulders and elbows at 90 degrees (the “hands-up” position), place your forearms against the walls and lean into the corner. Sustain the stretch 20-30 seconds; repeat 2-3 times.
Chin-tucks: Lying on your back or standing with your back against the wall, nod your chin down and and gently flatten the back of your neck against the floor/wall. Hold 10 seconds; repeat 5 times. While spinning on longer rides, sit tall in the saddle and nod or tuck your chin in to give the neck extensors a break.
Upper traps: Sit in a chair and hold the bottom of the chair with one hand to anchor that shoulder down. Take the opposite ear to the opposite shoulder and your nose towards your underarm. Hold 20-30 seconds; repeat 2-3 times.
Quads and the Iliotibial Band (ITB): Anterior knee pain such as Patellofemoral Pain or ITB friction syndrome can often be managed with quad and Iliotibial band streteches.
Strengthening:
Thoracolumbar extensors: There are lots of options to strengthen these muslces. I typically prescribe “core exercises” prone on a theraball.
Deep neck flexors: These muscles are typically long and weak in cyclists. Strengthening exercises can be prescribed by a Physiotherapist, or other health-care professional.
Chest and arms: Strong pecs, shoulders and triceps allow mountain bikers to absorb the bumps and drops while descending. Dumbbell bench press and tricep extension exercises are recommended.
Shoulder retractors and the rotator cuff : Key muscles for climbing hills effectively and preventing postural pain in the shoulder blade or upper thorax. Seated row and front-side lat-pull are two easy and effective ways to strengthen the posterior deltoid, mid and lower traps, lats, and rhomboids.
Final Notes:
These are just a few, basic exercises cyclists may find helpful to stave-off aches and pains. If you need further guidance or have a more complicated presentation of pain or dysfunction, the professionals at National Spine Care are here to help.
Happy Trails…
Treatment speeds soft tissue healing times
Soft tissue injuries refer to injuries involving the muscles, ligaments and tendons (any tissue except bone). They are very common and often can be quite stubborn to resolve. You may be familiar with a few of these including:
- Tennis elbow
- Golfer’s elbow
- Patellofemoral syndrome (anterior knee pain)
- Achilles tendinitis
- Rotator cuff tendinitis (impingement)
Over approximately the past 10 years, research started to evolve our treatment techniques. In sport medicine, there was significant motivation to promote faster healing times to enable the athlete to return to competition sooner. This knowledge and treatment has moved outside of the sport medicine arena and is now available in clinics that everyone can benefit from.
One of the treatment techniques I’ll discuss is Instrument Assisted Soft Tissue Therapy. There are many different soft tissue instruments that are available and in use by clinicians One of the more popular types is Graston.
Histology research beginning approximately 10 years ago demonstrated the positive influence certain soft tissue treatments can have on collagen synthesis (repair).
I have included some pictures of what different tissues look like under the microscope to try and illustrate how the various soft tissue cells respond when different treatments are applied.
This histology slide shows a dose-response relationship of instrument-assisted soft tissue treatment on fibroblast formation. Fibroblasts are the cells responsible for creating new tissue and are critical in wound healing.
As mentioned, this is a dose-response experiment so the picture on the far left had the least amount of pressure and treatment, the middle picture had a moderate amount and the picture on the right had the greatest amount of pressure and treatment. You can see that the concentration of cells increased depending on how firm the graston tool assisted massage was performed: more pressure = higher density of cells.
Another interesting study came out of the University of Indiana in 2006 by Dr. Loghmani and associates. Their team in the department of anatomy and cell biology looked at healing times in knee ligaments in an animal model.
They took 20 rats and cut the inside knee ligaments (MCL) on both back legs. One leg was allowed to heal normally, while the other side was treated with Graston instrument cross friction massage. They were treated 3 times per week for three weeks and then the ligaments were analyzed under a microscope to compare how the tissue healed.
They found that the treated ligaments healed 31% stronger and 34% stiffer than the untreated ligaments at the 4-week mark. There was no difference in strength at the end of healing. Essentially, the treatment sped up the healing by approximately 1/3. You can check out the pictures of what the ligaments looked like under the microscope. Again, the dark circles are the fibroblast cells (cells that are creating the new ligament tissue).
No treatment
Graston treatment
The first illustration shows the untreated ligament, demonstrating irregularly oriented and diminished quantity of fibroblasts. The second picture shows the treated ligament, which appears to have increased cellularity and more regularly oriented and elongated fibroblasts.
Now, if you can stand a little more science, the plot thickens. Again, those people in white coats staring into microscopes found out some more interesting things about how soft tissue heals.
This study looked at the how introducing tensile load onto tissue promotes chondrocyte alignment and density during the repair process.
The picture only demonstrates the cartilage cells (chondrocytes), however the study also showed that the tensile load resulted in an increase in other important components of the soft tissue healing process, including proteoglycan synthesis and collagen synthesis in the extra cellular matrix (sorry, had to throw in some fancy biology terms to gain some street cred).
Recurring theme, I know, but the picture on the right, which is the tissue that had the loads applied to it shows a large increase in the density of the cells. The importance of introducing specific movements that properly load the tissues to promote effective repair is illustrated here.
So what does all of this heady research mean to you?
A new modification of the Instrument-assisted soft tissue techniques was built around the research that demonstrated appropriate loading can stimulate faster healing reactions in the cells of the soft tissue. This treatment is called FAKTR-PM, which stands for Functional and Kinetic Treatment and Rehabilitation utilizing Provocative Movement. Quite a handle but it works!
Essentially, it combines the concept of using the Instruments to promote the healing times of the soft tissue cells, while at the same time, having the person move in a fashion that introduces load into the injured area. Based on the research and pictures I showed you previously, these combined approaches enhance the body’s normal soft tissue healing mechanisms so the tissues heal up much faster.
So if you are experiencing a soft tissue injury that continues to nag at you, this treatment might be the ticket!
Stay tuned for an upcoming blog where I get into some exciting new research in the world of fascia. We used to think of the fascia as some sort of undifferentiated connective tissue that just kind of hung around supporting the more important soft tissues like the muscles and internal organs. We now know that the fascia is more like a sensory organ and plays a very large role in chronic soft tissue pain syndromes. I’ll touch on some of this research as well as some treatment techniques that have been developed to help speed up soft tissue healing in my future blog posts.
Intramuscular Stimulation (IMS) for IT Band
IT band issues are always a common injury on my treatment table. And there seems to be a pattern: weak gluts, tight hip muscles and knee pain? Yes, often, this little combo of problems creates ongoing irritation of the iliotibial band. The iliotibial band is connective tissue attached to the tensor fasciae latae muscle (TFL). The TFL is a muscle of the pelvis attaching to the IT band. Therefore when this little muscle becomes tight or shortened, usually from excessive use (think running) our bodies start to compensate. Lengthening of the gluteus medius can occur and this causes the muscle to become incapable of firing correctly. As a result, the relationship between the pelvic muscles is out of whack. So how come the knee hurts with IT band syndrome? Well, the IT band attaches on the lateral part (outside) of the knee so the constant pulling from the TFL creates this friction.
So what can we do about all this? Strengthen the weak muscles- gluts. Clam shells and bridging are good ones. And stretch the tight muscles. Now that can be a feat on your own if you have been dealing with this problem for a while. This is where IMS comes into play.
IMS (intramuscular stimulation) is a great technique to help release tight muscles. It involves using acupuncture needles but that is the only similarity between these 2 techniques. IMS has been around for many years (it was created in the 70’s) although most people have still never heard of it. It was created by a doctor in Vancouver, Dr. Chan Gunn. Click here for further information on Dr.Gunn and his clinic.
The whole idea of IMS is to basically “fish” around in the tight muscle with the acupuncture needle. This thin needle is not injecting you with any substance: it is basically a tool to feel inside the muscle. When the muscle is contracted or shortened, it reacts to the needle by contracting. This feels like a jump or a cramp to the patient. The practitioner also feels this tension and may also see the muscle physically jump. The result is now the muscle has lengthened, the body is sending blood flow to the area to help it heal and the nerve to the muscle starts to function more normally. The patient usually feels a bit sore the day of treatment, maybe a bit longer for some, but obvious changes in range of motion are apparent immediately.
This is not a quick fix problem that will be gone in 3 weeks. It takes time, commitment to the rehab program, compliance to avoid certain activities (think running uphill and sprints) for a while and regular treatment until the muscle balance is restored in the pelvis.
Nicole Zacharias BMRPT, BPE CGIMS, CAFCI
Tension Headaches
Hope everyone enjoyed the long weekend! This week’s blog post is a continuation of the blog series about headaches. And today’s topic – TENSION HEADACHES.
Tension Headaches are one of the most common forms of headaches and are listed as one of the “Primary Headaches” in the International Headache Society’s classification system, along with Migraine and Cluster headaches. They are defined as pain in the head, neck or scalp which is associated with muscular tightness. These headaches can be in response to physical exertion, an injury to the head or neck, bruxism, prolonged static postures and/or stress. In the classic case of a tension headache, the patient will feel a “band” or pressure around the head. Although not specifically addressed by the International Headache Society’s classification system, I would argue that “trigger point headaches” should be a sub-category of the Tension Headache Category. For more information about Trigger Point Headaches, please read Dr. Gord McMorland’s previous blog “Got Headaches?”.
Treatment Options
Firstly, it is important to treat the cause, not the symptoms. This can be a bit tricky when it comes to tension type headaches because you would assume that the primary symptom is the actual headache and the cause is muscular tension. Instead, think of it this way:
- The symptom is the headache
- The secondary cause is the muscular tension
- The primary cause is the stress, bruxism, physical exertion, prolonged static posture, etc.
Therefore, begin your journey to a healthier, headache free life by visiting your physiotherapist or chiropractor who will outline an effective treatment plan addressing the primary and secondary causes of the tension type headache. Using a headache journal may be beneficial in finding out what the primary cause/causes are. Therapies such as Acupuncture, Intramuscular Stimulation, Active Release Therapy, Trigger Point Therapy, Graston and therapeutic massage can be beneficial in treating the secondary causes – the muscular tension. In addition, active exercise rehabilitation prescribed by your health care practitioner will help maintain the effects of treatment, and give your tools for self-management of your headache.
Muscle or Joint?
Is the problem the muscle or the joint?
I find myself answering this question quite often when a patient comes into the office with pain after a weekend of activities like gardening, house work or recreational sports.
The answer in majority of cases is BOTH!
This question reminds me of that song that we all knew growing up “the ankle bone connected to the leg bone…” The fact of the matter is the joints and the muscles work together to allow us to function and with injury sometimes seem to work against each other.
For the purpose of this discussion let’s take acute mechanical low back pain (LPB) for example.
First let’s be clear about what acute low back pain refers to. It is described by the length of time symptoms persist:
- Acute LBP lasts less than 6 weeks.
- Subacute LBP lasts between 6 and 12 weeks.
- Chronic LBP persists for more than 12 weeks.
Low back pain is also classified according to the origin of pain (etiology). Mechanical or nonspecific low back pain has no serious underlying pathology or nerve root compromise. Mechanical pain is often provoked by an episode of increased stress on the structures of the spine in this case. The structures have a hard time dealing with an unusual load (ie. bending to garden) and essentially “buckle” under the pressure. The injured tissues wake up the pain receptors in the area and alert you to the fact that you have hurt yourself. The result simply is PAIN. Mechanical pain is easily reproduced in an examination with movements and test that are designed to either increase or decrease stress on specific structures like the joints and surrounding soft tissues to determine which are contributing to the pain.
So when a patient comes in to the clinic with acute mechanical low back pain after gardening over the weekend what’s at fault? And how do we fix it?
Like I said in most cases it’s a combination of both the joint and the muscle. If a joint in your low back is injured or inflamed the surrounding muscles will tighten up to try and protect the injured area. If you look at the anatomy, many of the muscles and joints in and around the spine are connected to one another, meaning that it would be very hard for one structure to work independently from the rest. So you can see how it’s difficult to point the finger at one joint or one muscle.
So how do we fix it?
Well step one in “fixing” the problem is reducing the pain by restoring the normal function of the joints and muscles. Of course as I’m sure many of you have experienced when a joint in the spine gets stuck and inflamed it can respond really well to mobilizing or moving it with a technique called a manipulation or an adjustment. The interesting thing to note here is that when we adjust a joint more than just the joint is affected. When the joint is moved quickly with an adjustment the connected soft tissues also undergo a quick release, which helps to reduce the tension. Additionally, we can address or treat the muscles directly to help further coax them out of that protective mode. The result typically is increased mobility, reduction in spasm or guarding and a significant improvement in your range of motion. There are some great options to address the muscles directly namely advanced soft tissue techniques such as Active Release Technique (A.R.T), Graston, or IMS. An important thing to keep in mind is that these techniques can also be very effective in treating soft tissues even beyond the acute phase of injury.
Another great question to ask yourself is what can you do after the pain is gone to prevent this acute episode of mechanical low back pain in the future. This is an important topic and deserves it’s own blog post…
The bottom line is if you are in pain a proper assessment, diagnosis and treatment plan will help you get the muscles and the joints working together and get you back to your normal activities without pain.
Stay tuned next month, I will be providing more information on Active Release Technique, what it is and how it can help you with acute, subacute and chronic pain! Find out how the muscles respond differently depending on how long you’ve been injured and the type of tissue injury that has occurred.
Dr. Gillian Smith, DC, BKin, Certified ART provider.
Shoulder Injuries
Ouch…
Shoulder pain and shoulder dysfunction can be debilitating and disheartening. Simple movements like tucking in a shirt or reaching into the refrigerator can give a disproportionate shot of pain. Movement can be severely restricted. For some individuals the shoulder aches all night and sleep is disrupted. For others, there is a cramplike burning in or around the shoulder blade, often radiating down the mid-back or up into the neck.
What’s to blame?
There are a number of structures in the shoulder that will cause pain or dysfunction when injured. These include articular structures such as bone, cartilage and the surrounding ligaments; the labrum (soft-cartilaginous rim around the socket); muscle (most commononly the rotator cuff muscles or the long head of the biceps brachii); a bursa (a fluid-filled pouch that reduces friction); and the joint capsule (the bag-like tissue that surrounds, lubricates, and nourishes the joint). To further complicate things, the shoulder is actually comprised of two joints: the glenohumeral joint (upper arm/ball in socket) and the scapulothoracic joint (shoulder blade on rib cage). There may be trigger points in the muscular origins of the rotator cuff on the shoulder blade, or in the periscapular muscles (those which coordinate movement of the shoulder blade on the rib cage).
Common problems
Some injuries are the direct result of a forceful trauma. But often there is no ”injury” – no fall, no tug, no incident to point to. Many problems develop over time with repetitition or micro-trauma. Listed are some common injuries or problems and a brief description of each:
- rotator cuff tears – traumatic or degenerative tearing of the small muscles originating on the shoulder blade and attaching to the head of the humerus (“the ball”)
- labral tears – a fissure or tear in the softer rim around the socket
- impingement syndrome – irritation of the rotator cuff under the subacromial arch (the collarbone and local ligaments); this condition can lead to calcification and degenerative tears of the rotator cuff
- dislocation and instability - the “ball” pops out of the socket or has too much freedom of movement
- separation – the ligaments that attach the collar bone to the shoulder blade are partially or completely torn
- subacromial bursitis – inflammation of the bursa that reduces friction on the rotator cuff tendons
- “frozen shoulder” – a very stiff and painful condition that severely restricts motion
Managing shoulder injuries and shoulder dysfunction
Managing the problem is more important than diagnosing what structure is injured. Don’t get hung up on diagnosis. Imaging such as a Diagnostic Ultrasound or and MRI can be helpful when developing a treatment plan, but are often unnecessary. An experienced therapist (someone who sees a lot of shoulder injuries) can help you and your Physician develop a plan to manage your pain, set the stage for repair, maintain or restore movement, and restore strength and function. An experienced therapist will help you set reasonable expectations for your recovery. Some shoulder injuries take a long time to heal (months, not weeks). While many require more frequent treatment in the early stages, others can be managed with a progressive, home-based exercise program. The vast majority of shoulder injuries do not require surgery.
Let your therapist take the guesswork out of it – see someone early to ensure you’re doing all that you can to heal and prevent further damage or complications.
Rob Ruddick, BScPT, BHKin, FCAMT
Plantar Fasciitis
“I noticed my heel was bothering me at work. I am a nurse so I spend long hours on my feet standing on hard hospital floors. I also like to run 2-3 times per week. But then last week, when I got out of bed and stepped down onto the floor, it felt like the something at the bottom of my foot was tearing right off! I had an unbelievably sharp, stabbing pain and I could hardly walk! The pain seemed to lessen after I had a shower and got moving a little bit. But by the end of the day my foot feels so achy and sore. What’s going on???”
Sound familiar? Plantar fasciitis is the most common cause of heel pain. Most cases develop gradually, are unilateral, and feel like a sharp, stab at the bottom of the foot especially upon rising out of bed. Factors that may increase the risk of developing plantar fasciitis are:
- Age: This condition commonly occurs between the ages of 40-60
- Gender: Females are more likely to suffer from plantar fasciitis
- Exercise: Certain types of exercise such as long distance running can place excessive tension on the plantar fascia
- Improper Foot Mechanics: Abnormal gait patterns due to structural conditions of the foot (such as having high arches or flat feet), and/or functional compensatory mechanisms (such as decreased flexibility of the calf muscle) can place increased loading of the plantar fascia
- Increased Weight: Obesity and pregnancy weight gain put increased stress on the plantar fascia
- Occupation: Employees that are required to stand for long periods of time on hard surfaces such as nurses and factory workers
- Unsupportive Footwear: People who wear high heels, shoes with limited arch support and/or heel padding are more likely to develop plantar fasciitis
Under normal circumstances, the plantar fascia acts like a rubber band. It creates tension in order to maintain the arch of the foot. Throughout the gait cycle, the hindfoot impacts the ground and causes the plantar fascia to stretch out, lengthening the foot. When the heel lifts from the ground and weight shifts to the forefoot, all of your weight is directed through the plantar fascia. Repetitive and excessive loading of this tissue can cause small, micro-tears which leads to inflammation and pain. In the acute stages of plantar fasciitis, the process is indeed inflammatory. Without proper attention, the condition will become chronic and thus, degenerative in nature. This will hinder you from regular activities and can lead to problems “up the chain” in the ankle, knee, hip and low back.
So now what? Treatment of plantar fasciitis is not nearly as simple as the diagnosis. The frequency and duration of treatment corresponds directly to what stage the condition is in. For example, if it is detected early not as much treatment is required to decrease symptoms quickly. However, if you’ve ignored the pain and refused to modify your activities, the accumulation of microtrauma will be more significant and require more treatment.
Conservative Management of Plantar Fasciitis
- Soft tissue therapies such as Myofascial release therapy (MRT), Active Release Therapy (ART), Graston, FAKTR-PM, Intramuscular Stimulation (IMS) and assisted stretching can all be used to break down adhesions within the plantar fascia and address any soft tissue conditions within the lower extremity, hip and low back.
- Joint Mobilization/Manipulation can address restricted joints that may be contributing to aberrant gait patterns and increased muscular tension.
- Kinesiotaping and Athletic Taping can provide support and increased kinesthetic awareness in the area to help promote proper foot mechanics
- Heat and Ice Therapy can help promote the healing cascade and decrease inflammation.
- Active Exercise Rehabilitation is the most important aspect of treatment. It includes stretching, strengthening and balance exercises.
Home care strategies and lifestyle/activity modification
When the pain is severe, rest is your best friend. Stay off your feet as much as possible and allow the inflammation to subside. Replace aggravating activities with low to no impact activities such as swimming, cycling, and elliptical training.
I recommend my patients perform daily self directed soft tissue therapy by:
- Heating the foot for 5 minutes
- Follow with rolling the foot on a golf ball for 2-3 minutes
- Apply pressure to the painful plantar fascia with your thumb while slowly dorsiflexing the great toe (pulling it back). Repeat several times.
- Stretch calf muscles
- Finish with rolling the foot on a frozen soup can for 5 minutes
Your health care practitioner may also suggest:
- Night Splint: Throughout the night, the plantar fascia is in a shortened position and the inflammatory process causes adhesions to form in this position. Therefore, when you take that first step in the morning and stretch the plantar fascia in a weight bearing position, this can be extremely painful. The night splint is designed to hold the foot in dorsiflexion which puts the plantar fascia in its lengthened state. This can decrease morning pain and promote tissue healing.
- Orthotics: Custom designed orthotics can increase shock absorption and help correct improper gait mechanics that may be the cause of plantar fasciitis.
If you are not responding favorably to the least invasive conservative treatment options as outlined by your health care practitioner the next steps are:
- Nonsteroidal Anti-inflammatory drugs (NSAIDS): These medications can ease the pain however the will not treat the underlying cause of the condition.
- Corticosteroids
- Iontophoresis: The corticosteroid solution is applied to the skin over the painful area and the medication is absorbed with the aid of a non-painful electric current
- Injection: The corticosteroid is injected directly into the plantar fascia (sometimes with ultrasound guidance). This can reduce pain however will not treat the underlying cause, therefore the condition can reoccur. Multiple injections are not recommended as they can weaken the plantar fascia and lead to more problems down the road.
And, as with most conditions, the most effective treatment is prevention.
- Listen to your body. If you feel foot pain, you need to modify your activities. If you are a long distance runner who is training for an upcoming race this may be difficult. But if you continue to put on the miles you may find yourself sitting on the sidelines.
- Choose function over fashion. Replace those high heels and flip flops for a shoe that offers arch support and shock absorbency. Avoid going barefoot when you are in your home, especially on hard surfaces such as tiled floors.
- Replace “Miled-Out” Running Shoes! Although there is no golden rule on how often to replace running shoes, an accepted guideline is between 300-500 miles.
Hope that helps! Be good to your feet!
The Infamous Migraine Headache
A migraine headache is a debilitating condition which has considerable impact on the quality of life of sufferers and their families. Attacks can be completely disabling, forcing the sufferer to abandon all activities of daily living for up to three days. And throughout symptom free periods, migraine sufferers often live in fear of triggering another attack.
In North America, more than 1 in 10 people suffer from migraine headaches. These headaches usually appear between the ages of 10 and 40. There is a wide range of symptoms associated with migraine headaches. Most commonly people complain of intense, throbbing pain usually on one side of the head, behind the eye or at the base of the skull. This is often aggravated by activity and can be accompanied by increased sensitivity to light (photophobia), sound (phonophobia) and/or smells (osmophobia) which causes the sufferer to seek relief by lying down in a dark, quiet room.
A migraine headache is generally vascular in nature. The brain may become hyperactive in response to certain environmental factors such as lights or smells which causes an enlargement of blood vessels in the neck and head. This enlargement causes the release of chemicals from nerve fibers that coil around the large arteries of the brain. The chemicals cause inflammation, pain, and further enlargement of the arteries. The increasing enlargement of the arteries magnifies the pain.
Migraine attacks also effect the nervous system, more specifically, the sympathetic nervous system. This system controls primitive response to stress and pain, the so-called “fight or flight” response. Thus, migraine headaches are often associated with nausea, vomiting and diarrhea. Interestingly, sympathetic activity also delays emptying of the stomach into the small intestine and thereby prevents oral medications from entering the intestine and being absorbed. The impaired absorption of oral medications is a common reason for the ineffectiveness of medications taken to treat migraine headaches.
Women are more likely than men to suffer from migraine headaches as it is often in association with fluctuation in hormone levels as seen throughout the menstrual cycle. In fact, the number one trigger for a migraine is hormonal changes. Migraines in women are usually worse during puberty and can disappear around menopause.
About 1 in 5 patients will experience visual disturbances such as flashes of light, lines of color, and blurred/double vision. These symptoms, known as an “aura” begin about 15 to 30 minutes prior to the onset of the headache. Other people may have a “prodrome” of symptoms 24 to 48 hours prior to the onset of the headache. These symptoms include appetite changes (including cravings), difficulty concentrating, excitability, irritability, fatigue, frequent urination, weakness, increased yawning and/or stretching. Family members may be the first to notice these symptoms.
As mentioned above, migraine headaches are often “triggered” by exposure to environmental factors. Some common triggers include:
- Alcohol (especially red wine or beer)
- Stress
- Perfumes/Odors
- Loud noises
- Bright lights
- Smoking or exposure to smoke
- Caffeine
- Caffeine Withdrawal
- Fluctuations in Hormone Levels
- Changes in Sleep Patterns
- Exercise or Physical Stress
- Missed meals
- Foods
- Chocolate
- Aged cheeses
- Food containing monosodium glutamate (MSG)
- Fermented, pickled or marinated foods
- Aspartame
The most effective method of treating a migraine headache is prevention. Avoiding the triggers is often the first step. This can be accomplished by using a “Headache Journal” to track your symptoms and discover any patterns. For the 80% of migraine sufferers that experience a prodrome of symptoms, taking action prior to the onset of the intense, throbbing pain is key. Other common lifestyle recommendations include avoiding sleep deprivation and undue stress, maintaining a regular exercise program and ensuring proper and adequate nutrition. Incorporating yoga, meditation, and biofeedback techniques can also be helpful in decreasing the frequency of the attacks.
Migraine headaches are usually managed with prescription medications. The medications fall into two categories: 1) Abortive medications and 2) Prophylactic medications. Abortive medications are used to control the pain of an existing headache whereas prophylactic medications are taken to prevent the onset of the headache. The choice of treatment depends on the intensity, frequency and duration of the headaches, concurrent medical conditions, and any contraindications with other medications.
Although most migraines are managed with medications, some patients do not tolerate the medications due to side effects or they prefer to avoid pharmacological interventions. Conservative care such as physiotherapy, massage, and chiropractic treatment are non-pharmacological treatment alternatives. In a recent systematic review of randomized clinic trials regarding the effectiveness of manual therapies for treating migraine headaches, it was found that massage therapy, physiotherapy, relaxation and chiropractic spinal manipulative therapy may be equally as effective as propanolol and topiramate in the prophylactic management of migraines. Promising news for migraine sufferers!