Plantar Fasciitis (AKA plantar heel pain & plantar fasciopathy) can be extremely debilitating for runners & is very commonly a chronic condition. But it doesn't have to be! This episode covers crucial information about plantar fasciitis in running much as: common symptoms diagnostic tests & relevant scans how long plantar fasciitis takes to recover other potential causes for your symptoms plantar fasciitis risk factors To follow the podcast joint the facebook group Becoming a smarter runner click on the link: https://www.facebook.com/groups/833137020455347/?ref=group_header To find Brodie on instagram head to: https://www.instagram.com/brodie.sharpe/ To work with Brodie Sharpe at The Running Breakthrough Clinic visit: https://breakthroughrunning.physio/
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antifascitis 1, causes, diagnosis and characteristics. Welcome to the Run Smarter podcast, the podcast helping you overcome your current and future running injuries by educating and transforming you into a healthier, stronger and smarter runner. My name is Brody Sharp. I am the guy to reach out to when you've finally decided enough is enough with your persistent running injuries. I'm a physiotherapist, the owner of the Breakthrough Running Clinic and your podcast host. I'm excited to bring you today's lesson and to add to your ever-growing running knowledge. Let's work together to overcome your running injuries, getting you to that starting line and finishing strong. So let's take it away. Hey, we're starting up again. It's been probably about two weeks since I've actually sat down on my own and started recording an episode. Most of the time has been filled out the last couple of weeks, either being interviewed or interviewing other people or collaborating with other podcast hosts. So I'm excited to sit back down and I've had this plantar fasciitis information collected and on my... word spreadsheet for quite a while now, so I'm excited to get through it. I want to start with why I decided to choose plantar fasciitis a bit earlier in the podcast rather than discussing other diagnoses and producing other little mini-series. I thought I'd do plantar fasciitis because one, it's extremely common, two, it's very I have seen on a lot of Facebook groups people asking for answers and three, it's just a, it can be a really big culprit when it comes to this downward spiral. It could be very long standing, debilitating and people are in search for a lot of answers if they've had it for a very, very long period of time and the amount of things you can do now are less and less and so yeah, I thought I'd put this episode out there to give a helping hand as soon as I can. these resources that I've compiled to put together the facts, mainly coming from Tom Goom's online Running Repairs workshop. Simon Barthold, who is a podiatrist, he has an online course that I've attended. So gathering the evidence and the research from their two courses, the Science for Runners, that book I have mentioned in the past, my clinical experience and expertise, other research articles that I've managed to come across in my time. So I'm compiling a lot of this evidence and this mini-series has taken up a fair bit of my time just to put together all this research. I think it's probably been about 8 or 10 hours of work. So I'm raising my standards and trying to bring just the highest quality podcast I can and I'm seeing a lot of audience growth and a lot of... feedback which I'm really enjoying. So I think that sparks a little bit more passion but also a bit more of a need to make sure that my standards are quite high and that this information that's being delivered is a really good calibre. So I encourage you if you are enjoying the podcast to do me a solid favour for putting in all these hours and compiling this to at least leave a rating and review for the podcast on iTunes or Apple podcast that would really, really help me out. I'm starting to ask this favour to a couple of people in Facebook groups and, um, people that have shown their appreciation for the podcast. So I really want to give a big thanks to those who have done so already, or, um, you can go one step further and just recommend it to your friends or put together a post to say, this podcast is helped me out a lot. This is how it's helped me. Um, if anyone wants to listen, please do so. That'd be a huge favour as well. Let's dive into it. Like most of these topics, I want to discuss like the definition first because there is a few different terminologies that a lot of people like to use. Plantar fasciitis is probably the most common one, which is why I used it in my title and what I'm going to be referring to mainly throughout this podcast. But I guess the most accurate terminology would actually be plantar heel pain. And that sort of covers an umbrella. term that puts together like a whole bunch of terminologies but um, plantar fasciopathy is another one, runner's heel, I haven't heard of before but when I was doing my research people were calling it runner's heel, um, and plantar heel pain. All these can refer to very similar presentations and they're kind of interwoven, jumbled into one diagnosis you could say. And when it comes down to it, it's actually very similar to a tendinopathy. regarding its pathology and what's actually happening to the tissues, and in particular more of an insertional tendinopathy. So you can actually start treating this like a tendon, and you can refer back to the tendinopathy miniseries that I've done, because a lot of these same principles apply to a insertional tendinopathy. But if you have listened to those tendon... episodes, just a bit of a recap of why people develop these sort of things and this relates much to the plantar fasciitis side of things. One being overload. So I see a lot of people who might go on a long hike, longer than what they're used to, standing for long periods of time like at work, that puts a lot of load through that plantar fascia. Occasionally trauma, a rapid increase in training loads. That's a very common theme that comes up throughout the podcast. And wearing new or unsustainable footwear. So thongs, jandals, whatever you want to call them, barefoot walking is an avenue to increase the load through the plantar fascia because it has less support. So that's reason number one. Reason number two could actually be compression and that could lead to barefoot standing as well. If you were walking and standing, striking your heel onto say concrete, that compression Or if you're standing, I guess, if you're standing on concrete, just that compression itself could start to stir up a few issues. Reducing your heel drop, say in your shoe, if you go from a 2cm rise in your heel for your runner, and then you transition to a 0mm heel drop, that can cause a lot more compression. standing on hard surfaces I just mentioned, and running on hard terrain also, a change is also a change that you can make in your training which can put more compression on that plantar fascia. And also another reason I've just put here, reduced capacity. So I see plantar fasciopathy and plantar fasciitis a lot in my clinic when summer just starts and a lot of people throughout winter they encase their feet a lot, they wear supportive shoes throughout the day, and when they get home they put on their slippers or stay in their shoes, and it doesn't give that plantafascia a lot of freedom to maintain their strength. And as soon as you go into summer and people are walking around in bare feet a lot more, they're walking around in thongs, they're walking on the beach, all these have serious demands through the foot. And throughout winter, if that capacity and that strength of the plantar fascia is decreased, and then you're required to do these intense amounts of load, which, you know, just walking around in bare feet might not seem like a lot, but for a weak structure it is, that can be one of the leading causes, which is why I do see a lot of plantar fasciitis coming into those summer months. Okay, so there's some of the reasons. So you've got overload, you've got compression and that reduced capacity based on the time of the year or your own individual routine and circumstances. The next thing I want to talk about was prognosis. And I was just messaging this guy named Dave on my Facebook group just this morning and he was raising the question how long until it takes for plantar fasciitis to come good. He's had it for, I think he said about 12 months and a lot of people have had a lot longer. A lot of people have overcome plantar fasciitis a lot sooner. So the plantar fasciitis is a self-limiting condition and the length of symptoms will depend on the actual patient. And within the literature it does suggest it can resolve in three to six months. However, the patients who can't avoid those aggravating factors, the plantar fascia will just be susceptible to prolonged strain and if you continue overloading it, it might not ever get better if you don't put the right management into place and can take several years to overcome if you're really not identifying those aggravating factors and addressing those and building up strength and any impairments you have which we'll talk about later in the episode. So the shorter answer is we don't know. It just it depends on you. It depends on how quickly you pick it up and what you do in those early stages for your management plan. makes a huge difference in terms of prognosis and how long it takes to overcome. The other thing I wanted to touch on before we get into some common characteristics was just briefly mentioning the anatomy and function of the plantar fascia and this term that they called the windlass mechanism. And you need your plantar fascia for propulsion and when you run or when you walk, if you can imagine, just say if you're in bare feet and you slowly start taking a step, your toes go into extension and as your toes go into extension, the plantar fascia tends to wind up and become taut and when it becomes taut it can act more as a lever and so as your toes extend the plantar fascia undergoes more and more and more tension and it's then within the gait cycle that you need to push off and so that structure needs to be hold its own when you forcefully push off and enter that propulsion phase of the gate cycle or your running cycle. So that's the windlass mechanism and the big toe plays a really important role in loading up that plantar fascia and increased range of movement or decreased range of movement of that big toe when you're walking and when you're running could lead to the plantar fascia being loaded up way too much too early. if there is a decreased range of movement or the plantar fascia could be really flimsy when it comes to that push off phase if there's increased range of movement through that big toe. So I hope that makes sense because that will tie in really well when I talk about a couple of tests that we can do further in the episode. If there is one thing you want to take away from this episode, if you do suffer from plantar heel pain, it is an accurate you seek the right advice, get the right health professional to make an accurate diagnosis and understanding some common characteristics of plantar fasciitis is a huge step into making that accurate diagnosis. So the common characteristic number one I want to talk about is it will usually, not in all cases, but usually have an insidious but gradual onset and it could start with just some very mild symptoms. And then just progressively get worse over time and sometimes as an example someone will say, oh look I've had it for about Three months started off with just a bit of tightness didn't worry about it that tightness persisted for about two or three weeks And I just it was too mild so I just ignored it And then that tightness just got more and more severe and then my heel started getting a little bit sore And then my first few steps in the morning started getting a bit worse and now running is aggravating it and later on in the day or the next day after I run it's actually quite painful now and so I decided to see a physio. A very common history, it's just very gradual and very insidious you could say. So that's one common characteristic. The second one I want to talk about is pain in the morning or rising from rest and this is one of the hallmark features of plantar fasciitis, a patient will report severe pain in the first few steps of the morning or if they rise up from long periods of sitting or say if they've been on the train or public transport for a long period of time or a long drive and then they get out and then they start moving around and they have a lot of that sharpish pain in the plantar fascia and then the pain will, especially in the early stages, inevitably settle down once you're up and walking around. And so when you see a physio, they'll ask, okay, is it worse with the first few steps in the morning? How long until it settles? And it could be one minute, it could be 10 minutes, it could be half an hour, depending on the level of severity. But again, is a hallmark feature for plantar fasciitis. The third common characteristic I want to talk about is the very well localized pain, like where it's generated from. And it's relatively uncommon that the pain can spread and become a bit more diffuse. And so this localized pain is usually towards the heel. So if you were to roll your finger through the top arch of your foot towards the heel and you slide it towards the heel and it makes its attachment onto the inside of the heel, that is where it's usually the worst. You usually just feel the heel bone just off that heel bone as it attaches and it's usually on the inside of the foot rather than the outside of the foot. That is the most common localized spot for pain when it comes to plantar fasciitis. There may be some nerve involvement which can make things a bit more complicated but I'll talk about that later in the episode. The fourth common characteristic is there's usually, the individuals usually have weight bearing occupations where they have to not only walk, but stand, and stand still is usually a common characteristic. And so a nurse, or I see a lot of people like a chef who have to just stand there for hours and hours are very susceptible to increased load in the fascia. And they could be a runner and most runners would then go to work and sit for most periods of time and that plantar fascia can heal but a runner who has to stand all day as well accumulates that overload just doesn't really give it a lot of time to settle. The fifth common characteristic is just like that warm up time if someone starts running and they feel plantar fasciitis, they feel that plantar fascia pain at the start of their run, it can warm up in the early stages if that irritated, it can warm up and have that kind of tendon numbing effect like we've talked about in the tendon mini-series. And if it's really, really irritating, it gets to those severe kind of symptoms. Standing up for prolonged sitting and also aggravated by long walks can also start to irritate it. The sixth and final one I want to mention with common characteristics is that history... taking of that downward spiral, that pain, rest, weakness downward spiral, very common with plantar fasciitis. Those who are unaware of the pain, rest, weakness downward spiral refer to the Season 1 and people with plantar fasciitis usually nod their head when they talk about, when I talk about this concept and very common, say you have a 10k runner who starts to develop this issue and They can still manage 10Ks but it's a little bit stiff or a little bit sore the next morning. That gets worse and worse, so they're back off their running. And then, like, 5Ks is totally fine. But they don't address any impairments. Then after a while, 5Ks becomes an issue, 3Ks becomes an issue. And then, spending a long day walking can start to become an issue. And then, you can just see throughout their history as they're taking it, the further... that condition develops, the less and less load it can tolerate. Very, very common. So be mindful of that. So if you're listening to this and you look through those common characteristics you like and you say, yep, tick, this is starting to fit the pattern that I'm experiencing. What are some tests we can do? So as a physio, we do palpation. We feel around that tender area, see if there's any other structures that might be impacted. We have a look at this windlass test. So we get you in standing. bring that big toe up into extension if that produces pain. Usually positive if it's more of those severe cases, but that can start to indicate, okay, the plantar fascia has been impacted. There's a fair bit of evidence around ankle stiffness and doing like big toe range of movement exercises and other ankle range of movement exercises to see if there are any impairments with that. If there is a very, very rigid ankle, that could be an impairment that needs to be addressed. We can look at functional strength and functional-like coordination of the foot to see if there's any impairments there. And Tim Branston earlier in the podcast, can't remember what episode number he was, I wanna say 13, 14, talks about it really well. Looking at maybe calf capacity, so how many single leg calf raises you can do. and compare that to the opposite side to see if there is a strength deficit. And another key crucial thing that we can do is just rule out any other potential diagnosis that it could be. So doing some nerve tests, doing other resistance tests of the ankle to test out other tendons, and other tests that we can do for like say back pain or a stress fracture, those tests to rule out something else that it could be. And that brings me into the next topic, which is what are other differential diagnoses? I've talked about this a little bit, but I'll go into a bit more detail. Number one, it could be something to do with nerve entrapment and Baxter's nerve entrapment is probably the most common and it will have more of a radiating symptom. Can be associated with pins and needles or numbness or just this really vague radiating. type of symptoms so that might indicate that there's some nerve that's been involved. Bony stress or stress fractures of the navicular or calcaneus like your heel bone that's usually presented with like diffuse pain, night pain, background pain, that sort of stuff and potentially some swelling at these end stages of stress fractures. a lot of swelling like this golf ball type swelling but can usually be more towards the back of the heel. Spondyloarthritis or like any other inflammatory issues could be an issue. Fat pad atrophy so the fat pad is more of a spongy tissue around the heel and sometimes that can waste away and start to produce heel pain. A calcaneal spur if anyone knows of any bone spurs. Tarsal tunnel syndrome, I won't go into that too much. S1 radiculopathy so that's more of like a nerve irritation from originating from the spine from the lower back that can refer into the foot and heel. And some of these, particularly the nerve issues like the Baxus nerve entrapment, can often be coexisting with plantar fasciitis. So it's good that you get an accurate diagnosis from a qualified professional to make sure that there aren't any other structures. that have been impacted because that will help while that will change your management. I found an interesting review of, it was titled, a review of plantar heel pain of neural origin, differential diagnosis and management. And it mentions that the first branch of the lateral plantar nerve was present in 15 to 20% of patients with chronic heel pain and whether that is... having plantar fasciitis originally and just stirred it up quite a lot and then the nerve starts getting involved or whether the nerve was involved from the start, hard to say, but 15 to 20 percent of chronic plantar fasciitis patients is quite significant and the management will change depending on that. And it mentions in this study that differentiating the symptoms, it's usually present with burning, sharp, shocking, shooting, electric kind of symptoms. localized or radiating either towards the heel or more distally, sort of towards the toes. And the tests you can do to help with the diagnosis is understanding the nature of the pain, doing some palpation, doing these neurodynamic tests that health professionals are very good with doing. They load up the nerves to see if that produces any pain. And sensory testing can also be effective. They also mentioned high resolution ultrasound can also help to confirm a diagnosis and thought I'd dive into a few more studies when it comes to scans and found that an ultrasound for detecting plantar fasciitis is very accurate. They have a specificity of 90% or a sensitivity of 91%. So if it's positive, if the scans show that you do have plantar fasciitis, it's most likely that you do. And if the scans show that you don't have plantar fasciitis, it's very likely that you don't have it. So there's no false negatives in there and 90 and 91% is quite high for that. And they're also great for revealing any other things that might be impacted and they commented on edema, bone marrow edema and any sort of swelling of the peritendons. So yeah, thought I'd add that. I found that quite interesting. If you listened to my interview with Peter Maliaris, we mentioned the role of getting scans and whether it's necessary or not. And this plantar fasciitis topic has very similar points of view. So imaging is indicated in patients who are not responding to a really well managed treatment plan. and or have other symptoms that don't fit with the plantar fasciitis symptoms. Further investigations is indicated in patients who present with symptoms of bone stress or other signs and symptoms that might involve some nerves or constant unremitting pain. Stuff that doesn't make sense will be sent for scans but if you're responding to a really well managed treatment plan there's not a lot of likelihood or there's no reason to go get scans. So I thought I would add that. As we come towards the end of this episode I thought I'd finish with a couple things, one being some risk factors. So the evidence shows that training variables like changing up your running training can be a big risk factor but also high BMI which is your body mass index, pretty much how heavy you are based on your body type and your height. there was a study that looked at risk factors for plantar fasciitis and the title was Higher Body Mass Index is associated with plantar fasciitis, a systematic review and meta-analysis of various clinical and imaging risk factors. And this review represents a comprehensive appraisal, can't really talk today, don't know why, a comprehensive appraisal of the evidence for clinical and imaging factors in plantar fasciitis and they had about 51 papers and they came out with 12 variables that were considered to be associated with plantar fasciitis. There wasn't a lot of strong evidence for those 12 variables, but one of the strongest was the association of high BMI and they said that the evidence supporting Associations of ankle and toe range of movement, muscle strength, kinematics, kinetics, so rate of force, foot posture and physical activity levels were either inconsistent or inconclusive. So they didn't find a great enough change or any change to be significant with a common risk factor. But BMI was high up there on the relevance. So if you can think of someone who had an off season or just got quite lazy with exercise and put on 5-10 kilos and then decided, I've put on a bit of weight here, I need to start running in order to lose some weight, that can put you at risk of a lot of tension through that plantar fascia. Some risk factors they didn't identify but I've found in, just as a clinical opinion in my work is changing. in shoes like a shoe transition from just like to a minimalist shoe or a barefoot shoe if someone does that too quickly puts the plantar fascia at a lot of strain. Changing in foot strike if you go from a heel strike to more of a forefoot strike the load through your calf achilles plantar fascia just goes through the roof. Walking on firm surfaces a change in job description like I mentioned before if someone um changes their job description to have to stand for long periods of time or have to walk when they're used to sitting. That can just be a change that stirs up and like just reduces that amount of heel time. Heel being recovery time, not heel as in your foot. But yeah, so they're the risk factors. And what's interesting is that there's no associated risk factors for like foot pronation if your foot rolls in or if you've got flat feet or your foot tends to not be a really solid risk factor. So keep that in mind as well. In my experience, I have developed plantar fasciitis slowly twice. One of them was about four years ago and I changed my work shoes. This is a bit of a different presentation, but these work shoes, I was walking around and started developing a little bit of heel pain like over the course of a couple of weeks. So like I said, that really gradual onset, I didn't identify the work shoes as being a factor. I thought it was my running, so I was doing a fair bit of running as well. And it wasn't until about six to eight weeks down the track, I actually took my work shoes off and had a feel around the heel part. And there was actually like a little like bolt, it might have been like a manufacturing error or something, but it was actually compressing my plantar fascia, like right where the plantar fasciitis originates from, there was a heel, there was a bolt there that was like a really hard metal pressing into it and it was subtle enough that I didn't notice it, but significant enough that it would slowly flare it up. Once I identified that, changed my shoes straight away and that plantar fasciitis had already undergone about two months of being stirred up and so it was really hard to overcome and it was... not like the change in shoes wasn't just the cure. I still had to deal with a weak, tender, irritated plantar fascia and that took a long time to settle down. The other instance is very recent. It's probably the last four, five months, four months or so. Going through work throughout December, I had two of my colleagues, physio colleagues go on holidays over Christmas break. and I was just flat out at work and instead of sitting to do notes and take breaks in between patients like I'd sometimes have, that luxury was gone and I was flat out day after day and doing a lot of standing and started to notice after a while my heels were starting to get a little bit sore and the plantar fascia was getting a little bit tight and a little bit of pain every morning. And started to... I swapped out. my shoes with something a little bit more supportive, did some strengthening, and it wasn't until the last couple of months when my routine is a little bit more predictable now and I get a little bit more of a break to sit down and starting to slowly see improvements with those morning symptoms and that just takes a really, really long time just to settle and just recognising those factors can be really important. I did implement a few treatment strategies in there as well, which I'll discuss next episode. But that's it for today, so let me recap. We have, let me scroll up through my Word document. We talked about the diagnosis, we talked about reasons why you develop this sort of thing. One being overload, two being compression, three being that reduced capacity. Common characteristics is that just really gradual onset, very common. very localized tenderness to the inside of the heel, very much associated with occupations with standing. You can get that warm-up time when you go for a run. It can warm up and start to feel a lot better, similar to a tendon. Keep in mind that an accurate diagnosis is very, very important with an effective management plan. So making sure they're is or isn't some nerve irritation, bony stress, bursitis, fat pad irritation. Very important that you get checked out by a really methodical qualified health professional. And yeah, just some risk factors being training variables, high BMI, transition in shoes, transition in your foot strike, and just changes in your daily routine like I had with my work. And yeah, I think that covers enough when we're... talking about this topic of causes, diagnosis and characteristics, I hope that helped out a lot. Hopefully this has helped with identifying that you do have a plantar fasciae, so it's helped strengthen that belief and perhaps you need to go see a physio or see someone to get it more accurately diagnosed. Next time, we're going to be discussing strategies in how to reduce your pain, how to increase that low tolerance, how to build strength and prevent slash... maintain your running and running considerations, all that sort of stuff. So I'm excited to bring you that in the next couple of days and thanks for taking the time to tune in and listen to this episode. Enjoy your running, bye for now.