Sports Injuries

One of the most likely causes of foot/heel pain is inflamed plantar fascia, which causes plantar fasciitis. It can be a painful and common injury from overuse of the ligaments in the foot. When this pain presents, it can make an individual not want to walk or place any type of pressure on the feet, as the pain worsens with pressure or impact on the foot.

Chiropractic care doesn’t just treat the spine but can help with various other musculoskeletal issues throughout the body. With chiropractic adjustments, rest, icing, and exercises, the ligaments, and tissues of the feet are worked out, massaged, and stretched back to their normal range.

Plantar Fascia

There is a ligament called the plantar fascia. It runs along the bottom of the foot and connects the toes to the heel. The plantar fascia absorbs shock and helps support the feet when walking. However, ligament tension can begin to increase, specifically when standing for long periods. When the tension reaches its limit, small tears can begin to form along with inflammation causing pain.

The pain occurs when walking, standing, or immediately after waking up. The condition can happen to anyone but is more likely to become an issue for those who stand or walk as a regular part of their job, home activity, etc. Side effects from the foot pain often cause individuals to adjust their walking gait to avoid feeling discomfort, that stresses the rest of the body like the muscles, ligaments, joints that can lead to various types of injury/s.

Chiropractic Treatment

Individuals with an inflamed plantar fascia often experience a shooting/stabbing pain that worsens in the morning or after standing or sitting for an extended time. Repetitive impact on the feet and poor arch support from shoes cause small tears to happen over time from the continued stress. If it has just started the pain can be treated with ice and rest, but they are not for solving the root cause. Chiropractic can help bring pain relief that lasts along with recurrence prevention. Here are some a few ways a chiropractor can help:

Ankle Re-alignment

• Ankle misalignment can contribute to plantar fasciitis at the plantar fascia has to work harder to move the foot without the ankle's support. Manipulation and realignment of the ankle will improve foot function.

Massage

• A chiropractor along with a physical therapy team can be utilized for soft tissue massage and trigger point therapy to release tension.

Exercises and Stretches

• Various stretching and exercising techniques can be implemented to help speed up the healing process. A chiropractor will work the individual through exercises and stretches designed to relieve inflammation and stretch out the tissue. Specific exercises will also be taught to help strengthen the lower leg muscles to stabilize the heel and help prevent pain.

Posture

• A chiropractor will correct any improper posture/s that has contributed to the foot pain or has become a way of being able to function as a result of the pain. This will return the individual to a normal gait when walking and running. Pressure on the feet and plantar fascia will be alleviated.

Spinal/Hip Re-alignment

• Individuals learn to avoid pain by walking/moving in a different way than how the body is supposed to. This results in pain in the hips and back, as the body is being pulled in various ways. Manipulation and mobilization will be used to realign the body to its proper form.

Footwear/Orthotics

• A chiropractor will make adjustments to the feet, ankles, and spine to reduce pain and relieve the pressure on the plantar fascia. Supportive footwear and orthotics could be recommended for extended/preventative care. Once diagnosed with a foot problem wearing proper shoes that support the feet is essential.
• Orthotics can also help prevent injury to the back, joints, and muscles that were stretched or over-worked from an abnormal gait. When the pressure is relieved, the ligament starts to heal. This can take a few weeks. The result is a healthier heel/foot with proper function. Chiropractic can accelerate the healing process combined with home care. If pain is presenting in the heel, do not delay and focus on healing the foot.

Walking Incorrectly

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References

Goff, James D, and Robert Crawford. “Diagnosis and treatment of plantar fasciitis.” American family physician vol. 84,6 (2011): 676-82.

Science based chiropractor, Dr. Alexander Jimenez looks at frequent mechanical causes of heel pain -- and how they can be seen and treated.

Plantar heel pain is a frequent presentation to sports clinicians and might be result of mechanical, neurologic, traumatic or other systemic illnesses(9). Plantar fasciitis is undoubtedly the most common pathology in this area seen by cliniciansnonetheless, other causes of heel pain has to be considered when assessing a customer with heel pain. Up to two million Americans report heel discomfort each year at a price estimated to be up to $400million(5). Despite this, little is known about the pathophysiology and etiology of plantar heel pain. This article will discuss plantar fasciitis in addition to other frequent mechanical causes of heel pain such as plantar fascia tears/rupture, heel pain of neurological source, calcaneal stress fracture and atrophy of the heel pad. The anatomy of each of those illnesses will be discussed as well as diagnostic criteria and potential treatment choices will be summarized.

Plantar Fasciitis

The plantar fascia will help to encourage the lateral longitudinal arch and acts as a shock absorber(3). Support of the lateral longitudinal arch is reached via both passive tensioning of the plantar fascia (the Windlass mechanism) as well as lively tension of the plantar intrinsic foot muscles (includes flexor hallicus brevis, adductor hallicus and plantar interossei) and the tibialis posterior. As strength testing of those muscles is very difficult, Chang used volume estimations of their intrinsic foot muscles and tibialis posterior muscles to find out whether there was a gap in quantity of those muscles in individuals with knee pain. He found no difference in muscle mass of tibialis posterior and just 5% difference in the forefoot volume of the intrinsic foot muscles as well as the asymptomatic foot(5 pounds). Further studies will need to be done to determine whether that is of clinical importance and whether strengthening of those intrinsic foot muscles decreases load onto the plantar fascia.

Assessment & Diagnosis

Patients presenting with plantar fasciitis most often complain of pain on the first few steps in the morning when getting out of bed or after prolonged rest(2). This has been termed "post- static dyskinesia"(2). Maximal tenderness is over the origin of the plantar fascia on the medial calcaneal tuberosity(2). Jack’s test, which involves passive extension of the first MTP joint, tests the integrity of the plantar fascia and the Windlass mechanism (see Figure 2).

It has been shown that reduced dorsiflexion ROM, improved BMI and bad biomechanics are risk factors for plantar fasciitis(4).

This could include but should not be limited to:

Generally diagnosis is completed via ultrasound although weight-bearing radiographs may be useful to determine the existence or absence of calcaneal spur in addition to the elevation of this calceneal fat pad(10). In the case of plantar fasciitis, ultrasound guided examination of the plantar fascia at its proximal insertion shows:

An infra-calcaneal spur might be present but these also have been observed in asymptomatic individuals also, and elimination of the spur doesn't appear to add to the achievement of plantar heel pain surgery(10).

Treatment

The Heel Pain Committee of the American College of Foot and Ankle surgeons, based on available evidence in 2010, determined three tiers of treatment modalities for plantar fasciitis(10).

They said that Tier 1 treatment options must be trialled first, which include:

If no response was noted after six months with these modalities afterward Tier 2-based treatments should commence whilst continuing Tier 1 remedies. Tier 2 choices included:

• night splints
• further injections
• immobilization
• prescription orthotics.

The combination of using foot orthotics and dorsiflexion night splints was shown to be more effective than use of orthotics alone(12). Following these recommendations, they reported that 85-90 percent of patients will respond to treatment within 8-12weeks and have full resolution at the same year. The Tier 3 treatment option they explained was operation, which should only be considered in those patients who neglect Tier 1 and two treatment pathways.

Traditionally corticosteroid has been the injection of choice with respect to plantar fasciitis; however, some evidence points to short-term relief only. As well as poor long-term effects, other risk factors related to corticosteroid injection (CSI) such as fat pad atrophy, osteomyleitis of the calcaneus and iatrongenic rupture have all been reported(2). Platelet rich plasma (PRP), which is a concentration of platelets derived from the plasma part of autologous blood (like growth factors), has also been trialled as a treatment option for plantar fasciitis. Aksahin compared CSI and PRP and reported comparable results at three months and six months (approx 50% drop in VAS scores) also claimed that contemplating the risk factors related to CSI PRP might be a better alternative option(1). Diaz-Llopis compared botulinum toxin type A (botox) with CSI and revealed that the botox group was slightly better at one month but considerably better than the CSI team at both six and twelve months(7,8). Additional research has to be conducted on which injection modality gets the best results over both the short and long term.

Plantar Fascia Tears/Rupture

Intense strains of the plantar fascia occur quite frequently and normally, should they happen in isolation, react relatively quickly to treatment. They may be associated with plantar fasciitis, particularly if a CSI was trialled. Clients with an acute tear describe a sudden beginning heel pain and may have localized tenderness over the plantar fascia, along with a palpable lump might be present in case a partial or total rupture is present(4). In the case of significant tears that they are going to have pain on weight bearing. Treatment is symptomatic and involves initially a non-weight posture boot and innovative weight bearing with inviting taping and/or orthotics as pain allows.

Heel Pain Of Neural Origin

Up to 15-20 percent of individuals with plantar heel pain is brought on by entrapment of branches of the tibial nerve(2). This nerve can get entrapped in the possible sites:

The second most frequent cause of heel pain of neural origin is entrapment of the medial calcaneal nerve which innervates the heel fat pad and superficial tissues overlying the inferior calcaneum(two). Most branches of the nerve lie superficial to the intrinsic muscles of the foot so it is less likely to be compressed within these muscles, but might be compressed or irritated following heel pad atrophy(2).

Assessment & Diagnosis

Much like plantar fasciitis, their pain is most often worse after intervals of rest but might also occur at rest and at non-weight bearing positions. Although paraesthesia or anesthesia is infrequent, it may be reported around the medial or plantar surfaces of the heel(2).

On physical examination, nerve entrapment should be suspected if the site of maximum tenderness is over the nerve.

Neurodynamic testing may play a part in the identification of nerve involvement of plantar heel pain. Altered straight-leg increase testing that additional dorsiflexion, eversion and toe extension increased strain on the tibial nerve and LPN and when hip flexion was inserted no additional load on the plantar fascia has been noted(2). Differentiation of the plantar fascia as well as the tibial nerve may be carried out with the addition of hip flexion. Figure 3 shows the modified SLR for the tibial nerve and its branches.

Treatment

Despite its various pathophysiology and etiology, current study suggests the treatment of plantar heel pain of neurological source should be similar to that for plantar fasciitis. This absence of specific treatment options for your differing presentations may be among the reasons why plantar heel pain may be so recalcitrant. It could be suggested, like nerve entrapments in different parts of the body, "port" function and nerve gliding or sliding exercises may be useful to cure and prevent ongoing entrapment. Further studies need to be done in order to determine the most effective treatment for all these neural entrapment syndromes of the foot.

Fat Pad Atrophy/Contusion

The calacaneal fat mat comprised of elastic fibrous tissue and carefully packed fat cells that act as a shock absorber on heel strike(4). This problem is often related to plantar fasciitis but can be an isolated thing. Patients with fat pad atrophy may report pain aggravated with walking particularly in hard shoes or on hard surfaces(4). Commonly due to the heel strike pattern, pain is felt more over the lateral aspect of the heel that helps to differentiate it from plantar fasciitis.

Stress fractures of the calcaneum are quite common and mainly occur at the upper posterior margin of the os calcis or adjacent to the medial calcaneal tuberosity(4). Patients with a calcaneal stress fracture will report insidious onset heel pain which unlike other plantar fasciitis worsens with activity(4). On palpation they'll be tender over the lateral or lateral aspect of the calcaneum and pain will be replicated by the squeeze test (see Figure 4). Plain X-ray or MRI could be used to validate the diagnosis.

Remedy of calcaneal stress fractures involves a period of non-weight bearing rest until the pain disappears; walking and then gradual return of activity can occur after using soft heel pads and coaching to improve biomechanics.

Conclusion

This article has outlined several pathologies that needs to be considered when assessing clients with heel pain. Treatment modalities should be aimed at preventing pain and fixing potential predisposing factors.

References
1. Aksahin E et al (2012) The comparison of the effect of corticosteroids and platelet rich plasma (PRP) for the treatment of plantar fasciitis. Archives of Orthopaedic Trauma and Surgery. Vol 132 781-785.
2. Alsahmi A, Souvlis T, Coppieters M (2008) A review of plantar heel pain of neural origin: Differential diagnosis and management. Manual therapy vol 13 103-111.
3. Anderson J, Stanek J (2013) Effect of foot orthoses as treatment for plantar fasciitis or heel pain. Journal of Sport Rehabilitation Vol 22 130-136.
4. BruknerP and Khan K (2012) Clinical Sports Medicine 4th edition McGraw Hill.
5. Chang R, Kent Bruan J, Hamill J (2012) Use of MRI for volume estimation of tibialis posterior and plantar intrinsic foot muscles in healthy and chronic plantar fasciitis limbs. Clinical Biomechanics. Vol 27 500-505.
6. Chen C, Lew H Chu N (2012) Ultrasound guided diagnosis and treatment of plantar fasciitis. American Journal of Physical and medical Rehabilitation, Vol 91 (2) 182-184.
7. Diaz-Llopis I et al (2011) Randomised controlled study of the efficacy of the injection of botulinum toxin type A versus
corticosteroids in chronic plantar fasciitis: results at one and six months. Clinical Rehabilitation Vol 26 (7) 594-606.
8. Diaz-Llopis et al (2013) Botulinum toxin type A in chronic plantar fasciitis:clinical effects one year after the injection. Clinicla Rehabilitation Vol 27 (8) 681-685.
9. Dizon J et al (2013) Effectiveness of extracorporeal shock wave therapy in chronic plantar fasciitis: A meta-analysis. American Journal of Physical Medicine and Rehabilitation Vol 92 no7 606-620.
10. Thomas J et al (2010) the diagnosis and treatment of heel pain: A clinical practice guideline-revision 2010. The Journal of Foot and Ankle Surgery. Vol 49 S1-S19.
11. Wearing S et al (2010) Plantar enthesopathy: thickening of the enthesis is correlated with energy dissipation of the plantar fat pad during walking. The American Journal of Sports Medicine Vol 38 (12) 2522-2527.
12. Winson L, Wong W, Kung E, Leung A (2012) Effectiveness of adjustable dorsiflexion night splint in combination with accommodative foot orthosis on plantar fasciitis Vol 49 (10) 1557-1564.