Effective Management of Plantar Fascia Foot Pain

Plantar fascia pain (heel pain) is a common foot condition characterised by inflammation in an acute setting and often as a result of poor loading strategies in persistent cases. This condition can cause intense heel pain and discomfort (usually first thing in the morning), impacting daily activities and overall quality of life.

The plantar fasciia is a is a band of tissue connecting your heel bone to the base of your toes. It helps support the arches of the foot (medial and lateral) and helps absorb shock when walking. This condition is often mistakingly attributed to the presence of heel spurs that have been found on xray. Managing plantar fascia pain involves a comprehensive approach that combines lifestyle and activity modifications, targeted exercises and pain management strategies.

What is the cause?

Plantar fascia pain often occurs due to a combination of events such as:

1. increased/decreased loads - more or less training, recent holiday/break from exercise

2. changes in regular physical activity - length of run, different terrain, new shoes etc

3. previous subsequent injury

4. background of altered loading or mechanics

While it is important to address these changes with short term activity modification, identification of factors influencing movement are essential. Muscle strength, tissue tolerance/capacity and biomechanics play a large role in the successful management of plantar fascia pain. A whole body understanding of loading mechanics including the knee, pelvis and trunk make up an often-overlooked part of the rehabilitation process. Your physio should definitely be assessing these areas in chronic cases that have become recurrent in nature.

Strengthening Exercises:

Strengthening the muscles in the foot and calf often are the primary goal of rehabiliation and can contribute to improved stability and support for the plantar fascia. Exercises such as toe curls, marble pickups, and calf raises can be incorporated into a daily routine.

In addition, other areas that should be addressed when managing plantar fascia pain include:

• ankle and knee stiffness

• ability to control movement through the hips and trunk and thorax

• assessing tissue capacity and assist in developing improved loading mechanics

Pain management strategies:

Additionally, massaging the foot with a tennis ball or a frozen water bottle can provide temporary pain relief with acute flare ups. The use of ice can provide a short-term analgesic response and is best used during flare ups or post exercise.

Other treatment options that should be conisdered for acute foot pain are:

• manual therapy to help manage stiff and tight joints and muscles

• use of tape to help unload/reload the foot

• heel raises or off-the-shelf orthotics for temporary support

• use of non-steriodal anti inflammatory (NSAIDs) medications and creams

Effectively managing plantar fascia pain involves a combination of lifestyle adjustments, targeted exercises, and, in some cases, medical interventions. It is essential to consult with a physiotherapist to determine the most appropriate and personalised treatment plan. By incorporating these strategies, individuals suffering from plantar fasciitis can experience significant relief and regain control over their foot health.

Running with Knee Pain

Knee injuries are a common concern for runners due to the repetitive nature of the activity. Two common knee injuries that runners often encounter are patellofemoral pain syndrome (PFPS) and iliotibial band syndrome (ITBS).

Patellofemoral Pain Syndrome (PFPS), commonly known as "runner's knee," refers to pain and discomfort around or behind the patella (kneecap). It is often caused by factors such as overuse, muscle imbalances, improper running mechanics, or a sudden increase in training intensity. Runners with PFPS typically experience a dull, aching pain during or after running, particularly when descending stairs or squatting. The pain may also worsen with prolonged sitting or inactivity. Treatment for PFPS typically involves a combination of resting the affected area and non-steroidal anti-inflammatory drugs (NSAIDs) for pain management.

Physiotherapy can help manage PFPS by providing manual treatment to the joints and muscles affected, taping the knee, providing exercises to help strengthen the quadriceps and hip muscles, and assisting with modifying running techniques or footwear to reduce stress on the knee joint.

Iliotibial Band Syndrome (ITBS) is another common knee injury among runners. The iliotibial band is a thick band of connective tissue that runs along the outer side of the thigh, from the hip to the shin. ITBS occurs when the band becomes irritated or inflamed, resulting in pain on the outer side of the knee. Runners with ITBS typically experience a sharp or burning sensation during activities that involve repetitive bending and straightening of the knee, such as running downhill or on uneven surfaces.

Treatment for ITBS includes rest, ice, and anti-inflammatory medication to reduce pain and inflammation. Physiotherapy can help by focusing on advice with stretching and strengthening exercises for the hip muscles (TFL and Glute Max) and quadriceps. Modifying running routes to avoid downhill running, improving glute activation patterns and using proper footwear can help prevent ITBS from recurring.

Preventing knee injuries in runners involves maintaining a balanced training program, gradually increasing running distance, incorporating strength and flexibility exercises, and addressing any muscle imbalances or biomechanical issues. It is essential for runners to listen to their bodies, pay attention to any early signs of discomfort, and seek appropriate attention from their physio. Working with a physio familar with running injuries can help runners develop strategies to prevent and manage knee injuries, allowing them to continue their running journey with reduced risk.

Burmese Foot Massage

I was recently in Myanmar, an inspiring country for the soul. There, I had three delightful experiences with the traditional Burmese techniques which is why I have decided to bring them to you. In the picture below you can see me with two Burmese masseuses after having a healing treatment 

I offer you two new types of massage of 45 minutes each ($70):  

1. Burmese Foot Massage

The soles of the feet are where tension in the body builds up. Our feet work hard for us every day. That is why foot massage will benefit you in many ways such as improving circulation, promoting better sleep, stimulating the muscles around your feet and reducing pain in the ankles and heels.

I will be using an exquisite Thai balm with a cold effect and Burmese strokes with mild pressure.

2. Neck, shoulders and head massage

Most complaints from my clients relate to these areas.  This is the reason to offer this massage targeting the neck, shoulders and head. The main benefits from having a massage are to improve mobility of neck and shoulders, reduce tension, dissolve knots, ease pain or tiredness, improve mood, and help in relaxation.

I will be using a Thai balm with a warm effect, my usual Chiro-massage and remedial massage techniques and some shiatsu techniques.

Last thing! Remember that you can purchase a massage voucher at the Physio Lab with these two new services or the regular ones (30 min, 60 min or 90 min Chiro-massage or/and Remedial massage). Nothing better than spreading love for well-being during Christmas!! 

Claudia Turró

Massage Therapist

Time to throw out the ice baths?

There has been a lot of information recently suggesting that ice slows healing, causing us to question whether cryotherapy still plays a role in initial injury management. It was the topic of discussion in a recent SMH article about why inflammation might beter better for you that you think. The articles discusses whether icing and injury (or during recovery) was suppressing insulin growth factor 1 and hence altering the bodies hormonal response to healing.

“Pain kicks that hormone off - thats how the body knows - so when you suppress pain you stop that healing”

— Laird Hamilton - Elite Athlete Trainer

All health professionals have been taught the RICER (rest, ice compression, elevation, referral) principle at some point in their careers. Is it still relevant? One such study (1) has shown that there is little to no effect of the RICE principle on acute injuries. So our practice is still largely based on THEORY.

Regarding cryotherapy, there are two main theories:

• Reducing swelling and inflammation improves function and therefore hastens recovery

• Reducing inflammation limits tissue healing and the natural response of the body, therefore prolonging recovery

It is not clear if intermittent icing on an acute injury actually impedes or slows healing. One particular study (2) showed that “icing attenuated or delayed the infiltration of inflammatory cells… and change in vessel volume in muscle following injury. However, these effects were not sufficient to reduce capillary density or prevent effective muscle regeneration.” That is to say, ice slowed initial inflammatory responses but had no effect on muscle tissue healing in the medium to long term.

Another recent study (3) backs up this sentiment, noting that whilst initial icing reduced inflammatory markers, it did not affect tissue remodeling.

It should be noted that both of these studies were looking at muscle tissue injuries. Take, for example, one of the most commonly iced injuries: an ankle sprains. Well, surprisingly or not, there’s not much evidence at all. A few studies compared different icing techniques, and others included too many confounding treatments such as exercise. A systematic review (4) from 2004 found that ice plus exercise was the most effective treatment for acute lateral ankle sprains. It should be noted that no studies found showed a harmful effect of icing on ankle sprains.

Bottom line:

If icing your injury reduces pain, allows you to move better, and do more exercise, then the minor (and short-term) reductions in inflammation seem to negligible, and certainly not harmful – ice away!

References

1. Van den Bekerom MP, Struijs PA, Blankevoort L, Welling L, van Dijk CN, Kerkhoffs GM. What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults? J Athl Train. 2012;47:435–443. doi: 10.4085/1062-6050-47.4.14. 

2. Singh DP, Barani Lonbani Z, Woodruff MA, Parker TJ, Steck R, Peake JM. Effects of topical icing on inflammation, angiogenesis, revascularization, and myofiber regeneration in skeletal muscle following contusion injury. Front Physiol. 2017;8:93. doi: 10.3389/fphys.2017.00093.)

3. Vieira Ramos, G., et al., Cryotherapy Reduces Inflammatory Response Without Altering Muscle Regeneration Process and Extracellular Matrix Remodeling of Rat Muscle.Sci Rep, 2016. 6: p. 18525.

4. Bleakley C, McDonough S, MacAuley D (2004) The use of ice in the treatment of acute soft- tissue injury: a systematic review of randomized controlled trials. Am J Sports Med 32:251–261

Wrist Injuries in Golf

“Understanding how a wrist moves in golf can prevent an injury from occurring at all.”

The wrist provides the penultimate link in the kinetic chain of the golf swing. The professional game of golf has become increasingly focused on the bodies ability to generate power and club head speed to gain an advantage. During the swing the lead side of the body is the predominate generator of this power. It is no wonder then that the lead wrist is the second most common site of injury in professional golfers (behind the lumbar spine) with an incidence as high as 30%. In this population they are commonly injured by either overuse or impact related mechanisms and occur more frequently in younger golfers with lower handicaps. This is in comparison to low back injuries which are more frequent in older players with higher handicaps. The lead wrist is where the majority of injuries occur (29-67% of all problems) and the site of injury will mostly be ulnar sided.

Worth pointing out is that in amateur, non-professional, golfers the lead elbow is the second most common injury. The causes for wrist injuries in amateurs will be a bit different to those mentioned below. Most wrist studies have been done on professional golfers and ones in amateurs are awaited.

Clinical Picture

For a great overview on clinical assessment the wrist, check out this great video “Examining the wrist: A guide for sports physicians and physiotherapists” https://www.youtube.com/watch?v=GRxY6ghU3eg

The help localise wrist pain we can generally group symptoms into 3 distinct locations; Ulnar-sided (along the little finger side), Radial-sided (along the thumb side) and Dorsal (back of the wrist) pain. Common conditions seen at these sites include:

• Ulnar wrist pain:

  • Extensor carpi-ulnaris (ECU) subluxation or instability

  • ECU tenosynovitis

  • Triangular fibrocartilage complex (TFCC) injury

  • ‘Fat shot’ pain

• Radial wrist pain:

  • De-Quervains tenosynovitis

  • Intersection syndrome

  • 1st Carpometacarpal (CMC) joint injury

  • Hamate fractures

  • Carpal Tunnel syndrome (CTS)

• Dorsal wrist pain:

  • Ganglia

  • Extensor synovitis

Dorsal view of wrist showing TFCC in green

Palmar view of wrist showing Hammate in green

(image courtesy of 3D4 Medical Images: Essential Anatomy)

Wrist Biomechanics DURING the golf swing

During the swing the lead wrist will begin in an ulna-deviated position and move into maximal radial deviation at the top of the back swing. As the swing commences the wrist rapidly moved back into ulna-deviation by impact. One explanation for why a lower-handicapped golfer will experience lead wrist pain more commonly is through the process of "playing through the ball" (Hawkes et al, 2013). The trail wrist follows a completely different motion, beginning in neutral and moving into maximal extension at the top of the back swing and returning to neutral at impact.

Understanding the different wrist movements can help understand injury patterns in golfers and the mechanisms that can help manage them.  

Causes of wrist pain

Can be both acute or chronic in nature. Injuries are often the result of:

• Hitting off hard surfaces (such as mats or hard grounds) can create an inflammatory reaction within the tendons, commonly ECU

• ‘Fat shot’ (where too much of the turf is taken while playing a shot) will increase compression of the TFCC and can result in injury

• Hitting immovable objects such as tree roots or rocks. This is the most common way to sublux the ECU tendon from its sheath in the lead wrist and generally requires surgical management

• Biomechanics:

  • Extreme wrist angles at top of back swing and again at impact can be overload tendons and ligaments resulting in inflammation or injury

  • Kinetic chain problems. The presence of swing faults (such as those listed below) can often lead to an overload and/or excessive motion at the wrist that can result in chronic or overuse symptoms

• Grip - strong (closed) vs neutral vs weak (open). A good swing will start with a good grip so it is best to discuss your grip technique with you golf coach as different grips will serve different purposes. A rule of thumb (pun intended!) is that a weaker grip will result in more injuries to the wrist due to the excessive motion that is associated with it.

What SWING FAULTS cause the wrist to be the site of injury?

• TFCC injuries from excessive ulnar deviation can be the result of early extension and the golf club becoming more vertical during the down swing. Excessive ulnar deviation can also occur from having a weak grip

• Fractured hamate can arise from club position and having an increased palmar grip. In combination with hitting an immovable object or fat shot the hamate is vulnerable to fracture through the neck

• Scooping, Casting and Chicken Winging all increase wrist stress through creating excessive, unwanted, radial and ulnar deviated motion

• 1st CMC degeneration and radial tendon injuries can arise from having a long thumb position (along the club) combined with a weak grip. This can place increased tension on the EPL and APB tendons resulting in De Quervains or Intersection syndromes and/or increased joint stress.

Treating wrist pain

Seeking an opinion from a Sports Physiotherapist or Sports Physician is a good first place to start. These specialists can assess the anatomy and movements of your wrist to determine what is causing the pain. MRI, xray and ultrasound imaging may be requested to determine the extent of injury that has occurred and to confirm a diagnosis.

Once the problem has been identified physiotherapy management may address joint and soft tissue mobility issues with some manual treatment (soft tissues releases and joint mobilisation) and taping (to limit unwanted movements). This is followed by prescribing an appropriate strengthening exercise program that can improve grip and general upper limb strength. Exercises can be varied (and should be specific to the injury) but the following youtube link demonstrates some simple strengthening exercises using resistance bands and a golf club for weight are a good place to start.

Several training aides exist that can be useful to help manage wrist related injuries. It is important to note that these aides should be used under guidance from your physio, doctor or golf coach as incorrect or excessive use can cause further damage and injury.

• Specific splints include:

  • A dorsal blocking splint can be used during training to prevent excessive wrist extension (such as SKLZ Smart Glove).

  • A wrist widget is a very useful and effective splint that can alleviate ulna sided wrist pain due to excessive ulnar deviation or TFCC injury. These can be worn whilst playing and are generally used until symptoms have resolved.

  • A swing correction tool can be used to help set the correct hinge position at the top of the back swing. While not useful during a round of golf, it can be incorporated into range sessions to gain a feel for where excessive unwanted movement occurs during the swing. This then can train and prevent certain movement patterns at the wrist that result in injury.

Wrist injuries can be serious and are devastating to a golfer and their game. As most of these injuries are overuse in nature prevention is the best cure. If you begin to feel symptoms of pain, swelling or weakness get it assessed early and you will limit your time spent off the course.

Hawkes R, O'Connor P, Campbell D. The prevalence, variety and impact of wrist problems in elite professional golfers on the European Tour. BJSM 2013;47:1075-1079.

Campbell D, Campbell R, O'Connor P, et al. Sports-related extensor carpi ulnaris pathology: a review of functional anatomy, sports injury and management. BJSM 2013;47:1105-1111.

O'Connor PJ, Campbell R, Bharath AK, et al. Pictorial review of wrist injuries in the elite golfer. BJSM Sep 2016, 50 (17) 1053-1063.

Joint and Muscle Flossing

Have you heard of this relatively new treatment technique commonly called "flossing"? 

The rise in popularity of floss bands (or compression band therapy, CBT) can be largely due to interest from the Cross Fit world where it is a popular mobility tool for athletes pre competition and training. The idea and frequency of use in a clinical physiotherapy setting post injury or surgery is limited with a lack of good clinical trials currently available. Potentially, common injuries such as sprained ankles, torn muscles and post-operative surgery stiffness can benefit from such techniques.

The proposed benefits include:

• increasing joint range of motion (ROM)
• improved muscle mobility
• decreasing pain levels
• potentially speed up recovery through effect on myofascial release, occlusion and reactive hyperemia

Application

The practical use is generally limited to the joints and muslces of the periphery (the legs and arms for ease of application) though other areas have been "flossed". Stiff joints and/or tight muscles can be the target. Once shown this technique, floss bands can be self-administered as part of a warm up for training and competition to help tissue mobility. The process involves:

1. Firmly overlap wrap the floss tape (2.5-7.5cm wide latex rubber band) around the limb (muscle or joint) from proximal to distal (although direction has not been scrutinized)
2. Keep on for 2-4 minutes for treatment
3. The joint or muscle is moved through active or passive ROM (such as a squat/lunge/calf raise) (Figure 1)

An video example for floss application for a knee can be seen here

note: Neurovascular precautions should be observed during application to avoid numbness, pins and needles or excessive changes to blood flow

Figure 1. Ankle application and ROM

Research

Research into use of floss bands is limited, with scientific explanation of mechanisms and reliable research outcomes generally lacking. Bohlen et al. (2014) examined the effect of knee CBT on blood flow occlusion of the lower leg and found, while there was some improvement in strength, that reactive hyperaemic arterial blood flow showed no change. This would suggest that CBT does not alter blood flow significantly, though quality of this study was poor with a small sample tested (n=5). A search of several databases for clinical studies using floss bands or CBT revealed:

• RCT on shoulder ROM (Kiefer, Lemarr, Enriquez, & Tivener, 2017) 
• Case report on Achilles tendinopathy (Borda & Selhorst, 2017) 
• Crossover study on ankle ROM and jump performance (Driller & Overmayer, 2017) -  1.8cm improvement in ankle dorsiflexion ROM post application

The primary theory of CBT is credited to fascial shearing or re-perfusion of blood to muscle (though as mentioned above the latter is less likely). The role of fascia is varied and can act to restrain motion, as a connective structure for skin or provide lubrication or gliding movement (Guimberteau, Delage, McGrouther, & Wong, 2010). The same group of researchers looked at fascial sliding in the hand during surgery with a visual description seen in Figure 2. Perceivably, with peripheral joints lacking bulky overlying tissue, this sliding of the superficial fascia is possible with CBT but yet to be researched. Another purported mechanism has suggested some psychological benefits following application of CBT to the shoulder (Kiefer et al., 2017).

Figure 2. Three-dimensional model of continuity between the skin and tendon provided by the sliding system (Guimberteau et al., 2010)

Conclusion?

At this stage any conclusions are merely anecdotal. Application of CBT/floss bands can potentially be a useful adjunct to current treatment techniques for acute joint sprain stiffness and restoring ROM. In my experience there seems to be a consistent effectiveness with ankle and knee ROM in the short term. Further review for the effectiveness with knee ROM post-surgery is warranted due to the increased presence of knee stiffness that is often seen. More studies are still needed though to get a better understanding of the proposed mechanisms of floss band treatment.

For more information or to give it a try ask one of your physiotherapists next time you see them!

References

Bohlen, J., Arsenault, M., Deane, B., Miller, P., Guadagno, M., & Dobrosielski, D. A. (2014). Effects of applying floss bands on regional blood flow. International Journal of Exercise Science, Conference Proceedings, 9(2). 

Borda, J., & Selhorst, M. (2017). The use of compression tack and flossing along with lacrosse ball massage to treat chronic Achilles tendinopathy in an adolescent athlete: a case report. Journal of Manual & Manipulative Therapy, 25(1), 57-61. doi:10.1080/10669817.2016.1159403

Driller, M. W., & Overmayer, R. G. (2017). The effects of tissue flossing on ankle range of motion and jump performance. Physical Therapy in Sport, 25, 20-24. doi:10.1016/j.ptsp.2016.12.004

Guimberteau, J. C., Delage, J. P., McGrouther, D. A., & Wong, J. K. F. (2010). The microvacuolar system: how connective tissue sliding works. The Journal of hand surgery, European volume, 35(8), 614. doi:10.1177/1753193410374412

Kiefer, B. N., Lemarr, K. E., Enriquez, C. C., & Tivener, K. A. (2017). A Pilot Study: Psychological Effects of the Voodoo Floss Band on Glenohumeral Flexibility. International Journal of Athletic Therapy and Training, 1-16. doi:10.1123/ijatt.2016-0093