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1st Sep

2009

Orthopedic Manual Therapy for Plantar Heel Pain

Plantar heel pain, often referred to as “plantar fasciitis” is a very common wear and tear, or overuse condition, reportedly affecting 1 in 10 individuals in a lifetime, and nearly 2 million Americans every year.

The pain is typically located in the arch of the foot, extending to the heel, and is often the worst when taking the first steps early in the morning, and after prolonged sitting. These problems can lead to long lasting pain and disability, if left untreated. Plantar heel pain is commonly treated in physical therapy.

MANUAL PHYSICAL THERAPY AND EXERCISE FOUND EFFECTIVE

Although treatment with modalities such as iontophoresis, to electrically move pain relieving medications to the painful area, combined with foot and calf stretching has been found to produce short-term pain relief for these conditions, studies have shown that the pain typically returns in less than three months after treatment.

A newly published well designed randomized study showed that manual physical therapy (orthopedic manual therapy) consisting of deep soft tissue mobilization to the arch/heel and calf, and joint mobilization stretch to the rear foot, combined with arch and calf stretching, produces significantly greater improvement in pain and function both short term and long term, as compared to treatment with ultrasound, iontophoresis, stretching and ice.

Previous studies have also shown strong evidence that foot orthotics can help these conditions, and there is moderate evidence that night splints, to put the calf and possibly arch on stretch, can be helpful as well. However no studies have compared such treatment to orthopedic manual therapy with exercise.

PLANTAR FASCIITIS USUALLY A WEAR AND TEAR CONDITION

Plantar fasciitis has been shown to be a degenerative rather than inflammatory condition of the plantar fascia. It may be caused by overuse, although quite frequently it is associated with abnormal foot mechanics. Therefore, for plantar heel pain to be treated effectively, a thorough biomechanical foot evaluation has to be performed by a competent clinician.

OVER PRONATION COMMONLY SEEN

Plantar heel pain is typically caused by excessive stretch to the plantar fascia. During a normal gait cycle, the arch of the foot should temporarily fall during the middle phase of walking, while the foot is planted. However, the arch should not fall already when the heel first comes in contact with the ground, nor should it be flattened as we start to push off with the foot.

Some people already stand with their heels tilted, causing the arch to fall or flatten immediately. This starts to stretch the plantar fascia. If this flattening, or pronation, continues through a majority, or worse the entirety of the gait cycle, this plantar fascia stretch continues with full body weight applied to it, potentially causing strain and wear and tear of the plantar fascia.

Other people have restricted upward motion (extension) of the big toe, which also prevents the arch of the foot from being restored at push-off.

It should be pointed out, that this scenario does not necessarily apply to people with congenitally flat feet even when not putting weight on the foot, where the plantar fascia has adapted to its lengthened resting position, which does not change very much when they get up on their feet.

COMPREHENSIVE ORTHOPEDIC MANUAL THERAPY

According to our orthopedic manual therapy training (through the Ola Grimsby Institute) and based on recent research, to attain optimal results when treating plantar heel pain, you need to combine procedures aimed at restoring more normal foot mechanics, initially reduce stretch forces on the plantar fascia while walking, apply manual techniques to inhibit the pain and normalize soft tissue and joint mobility in the foot and lower leg, and subsequently apply and progress precisely measured forces through exercise to the plantar fascia, in order to increase its tolerance to strain.

Deep soft tissue mobilization to the plantar fascia is an integral part of the treatment approach, and we also teach our patients to perform daily self mobilization to the fascia either manually, or by using a ball, can, or similar objects.

EARLY PROTECTIVE PHASE

Since the plantar fascia initially cannot handle much stretch, it is usually helpful to add a heel lift, and at all times use good shoes with a supporting heel counter (such as a good running shoe), and to never walk barefooted. Most people would benefit from a foot orthotic, either an over the counter support such as “Super feet”, or by fitting the patient with a custom foot orthotic, if there are more pronounced biomechanical abnormalities.

Daily activities, including walking and workouts must initially be modified, in order to reduce the plantar fascia irritation.

RECONDITIONING PHASE

Specific exercise is the main means by which we can increase a tissue’s tolerance to strain, performed while the patient gradually increases his or her activities and exercise. We also specifically include exercise for foot and lower leg muscles which are capable of increasing the arch of the foot, and thereby decrease the strain on the plantar fascia.

We may use a resistive pulley apparatus in the clinic, and at home, and over time progress weightbearing exercise as well. We always encourage our patients to continue with exercise at home, well after having finished their treatment program in the physical therapy clinic.

With best wishes for continued good health,

Gunnar

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