Last episode we covered Plantar Fasciitis causes, prognosis, symptoms, differential diagnosis and risk factors. It is essential for effective management that a correct diagnosis and compromised structures are identified so please listen to plantar fasciitis 1 if you haven't already done so. Today we discuss treatment by: STEP 1: ways to reduce pain STEP 2: building up load tolerance STEP 3: Maintenance & prevention phase My 5 tips for plantar fasciitis prevention Running considerations for plantar fasciitis 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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Plantar fasciitis II, rehabilitation and prevention. 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 Brodie Sharp. I am the guy to reach out to when you 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. I was going to release Plantar Fasciitis number one a lot earlier, but as in between number one and number two, which is like half an hour, I went to upload Plantar Fasciitis one and turns out I have run out of my monthly storage that I can upload because I've been going nuts and publishing multiple a week. So I have to be patient and release Plantar Fasciitis one when the month... starts up again and I'll publish this one soon after. Last episode we covered common plantar fasciitis characteristics, the clinical presentation, a few tests that can be done, some differential diagnosis. If you haven't listened to Plantar Fasciitis Number 1, please go back and listen to it. There's no point learning about rehab if you're mistaking plantar fasciitis for something else. So... We want to make sure that the common characteristics are there and the presentations there so that your management can be just as effective. This isn't a replacement for a sound individual tailored management plan from a health professional. Everyone's slightly different. We do need to tailor management plans to the individual, but episodes like this will be extremely helpful. So let's get started. Rehabilitation, I want to start with step number one, and that being to reduce pain. This is the hardest one to do, particularly for those who have long-standing fasciitis. In that pain, rest, weakness, downward spiral, some people are really, really far down that spiral and almost everything irritates them. So this first step to reduce pain can sometimes be the hardest, and it really depends on how long this first step takes could take a couple of weeks, a couple of months, but important that we address this. If it's entered this pain dominance phase and not the low dominance phase, it's critical that this be addressed. So during this stage, the aim is for treatment to settle down pain so that we can quickly progress into the low dominant stage. Some First, find what loads you can tolerate during this phase, temporarily reducing your training load, recognising the importance of footwear, both athletic and non-athletic, so what shoes you are running in and what shoes you're spending in throughout the day, recognising which shoes are better for you and substituting the not so good shoes, modifying your activities of daily living. So that could be avoiding hard surfaces, standing still for long periods of time, making sure that you're shifting your weight and walking. Walking can usually be a lot better than standing still. You can use anti-inflammation tablets for the short term and you can also do some taping. If you Google low dye taping, that can be effective for some people. Isometrics, if effective. So like I said, with a... plantar fasciitis presentation, it can act like a insertional tendinopathy. So isometrics can be beneficial and some people will undergo some heavy load isometrics for the plantar fascia and actually feel better afterwards. So it's good to test and retest and if it is beneficial for you, that can help settle down your pain throughout the day. I'm still undecided whether stretching helps or not. I think it will depend on the individual. There's a lot of studies saying stretching is good, some saying stretching not so good. I wouldn't recommend purely stretching as an isolated treatment. If you are doing stretching, do it also in combination with strengthening, and these are the points that I'm listing out. Consider an orthotic device, either custom made or generic, especially if tape offers good support. So... maybe that low diataping can be your first wave of treatment if that's really settling down symptoms, consider an orthotic device. There is a study that I found that's titled Foot Orthoses and Plantar Heal Pain, a systematic review and meta-analysis and they found that there is moderate quality evidence that a foot orthosis is effective at reducing pain in the medium term, however it is uncertain. whether it is clinically important change. So bear that in mind, I really don't like orthotics for the longterm, but if it does get you out of pain and does assist in getting you to that load management phase sooner, then it can be extremely effective. The other thing I like implementing is those gel heal insoles. You can go to a pharmacy or chemist and... just get these generic sort of gel-like insoles that you can slide into any shoe. That could be really nice at distributing the load through the plantar fascia, especially if you have to do a lot of standing. And then you can also consider therapies like shockwave therapy, if the heel pain has been present for more than six months and has been non-responsive to other therapies, is what I would recommend. Then we have step two. So hopefully, We can systematically go through step one, implement some really careful strategies and it might take a while, but gradually you'll see pain symptoms start to reduce and then we can slowly work into step two, which is increasing this load tolerance. In the load dominant stage, symptoms remain stable unless the tissues are overloaded. During this stage, the aim of treatment is to increase the capacity of the tissues. through a gradual loading program. And you can start with daily lighter exercises to calm down symptoms, treating it like a tendon. And then we can transition to heavy slow exercises, that being like calf raise, single leg calf raise, weighted calf raises, and doing like a three second up onto the heels, three second down onto the heels. and we can easily just progress this by just adding more and more weight. I personally like to use this exercise called foot yoga. If someone's foot coordination or foot intrinsic muscles are lacking, that being a nice simple exercise where you can place your bare feet on the ground in sitting, and you can try and raise your big toe up off the floor with keeping all the other toes just comfortably resting on the floor. drop that big toe back down to the ground, and then you try and raise all other toes, keeping that big toe down on the ground. And we're not trying to scrunch any toes in this process, but we're just gradually lifting the big toe down, all other toes, and then back down. And then just cycling through that, and you can spend a minute, 30 seconds, two minutes, depending what you can tolerate, but should start to elicit a burn or like a fatigue kind of feeling through the foot itself and getting those foot intrinsic muscles fired up. The other one that is quite common is getting a towel and trying to scrunch or pick up the towel in your toes that can be quite strenuous, but if you can tolerate it, then it can be a very nice exercise. Another one that was recommended by, I think it was Ebony Rio when I was attending one of her lectures, is barefoot on the ground and you get a theraband, those exercise stretchy bands that are in a loop. You place one around the big foot, around the big toe and while you're in sitting and that band is around the big toe, apply load just by pulling on the band and trying to resist that band by keeping the big toe placed on the ground and that can help stress that plantar fascia and you can apply quite a light load so it can be quite nice in those initial stages but you can also increase the tension of that band quite a lot to progress through. Big toe being the main attachment for this, but you can also work the other toes as less of a priority, but if you do wanna progress through those, you can. When it comes to the evidence side of things, there is a very nice study that looked at, I'll just name the title, it's called, heavy load strength training improves outcome in patients with plantar fasciitis, a randomized control trial with 12 month followup. And they looked at. high load versus stretches. So they had one group that received education about plantar fasciitis. They put them in those gel heel insoles and then got them to do 10 lots of 10 seconds of passive stretches in sitting. So this could be like the stretch group. They received education insoles and instructions on how to stretch. The second group received the same education, And instead of doing stretches, they did single leg calf raises on a towel. So the towel folded up being placed underneath the toes. So the toes are up in extension. And then they were to proceed doing single leg calf raises with those toes into extension. So it loads up the plantar fascia a bit more. And they did a 12 rep max, three seconds on the up phase, a two second hold at the top, and then a three second down phase. three sets of 12 every second day and they did that for three months. But as the three months progressed, they slowly progressed the exercises from a 12 rep max to an 8 rep max. And then by, so by the end of this 12 months they were actually doing five sets of eight instead of three sets of 12. So you're getting quite a lot of load through that plantar fascia and really... progressing along. If someone was to do an 8 rep max, what that is holding enough weight so that you were to do 8 single leg calf raises with really good form, but then it's so heavy that you couldn't possibly do a 9th or a 10th. That's the definition of a 8 rep max. So keep that in mind. It's quite heavy. And so looking at the foot functional scale, they needed 7 points of improvement on that scale. in order for the intervention to be significant and they found a 22 point improvement on average with the strength group and only a 16 point improvement with the stretch group. So both of them ended up doing quite well. Like 16 points on average in the stretch group is still quite good but the study shows that strength comes out on top with this one. Possibly combining the two might be nice. stretching can be beneficial for some. I think it might just depend on the range of movement of the big toe and what the response is like to the fascia. I have some experts that I follow say that stretching it will just irritate it. Others say it's quite good. So I think it might just be on an individual basis. So there's some nice practical tips for you to work on that load management phase or step two, increasing the load tolerance. So step one, reducing that pain. Step two, increasing that load tolerance. Step three I've put here is the maintenance phase. And once you have built up a level of tolerance and you're slowly starting to get back to running, get back to more running or walking, standing throughout the day, and you're strong enough for those tissues of the plantar fascia to start tolerating that load, we need to start addressing the maintenance. We don't wanna fall off the wagon again and start heading down that spiral. We want to keep working, building our way back up that spiral. And so the first thing I could think of was addressing the whole kinetic chain. So the entire foot, the entire ankle for strength, but then working on the hip and knee for running, looking at plyometrics and speed, and just integrating that whole kinetic chain to address a really sound maintenance program. The other thing you need to consider barefoot function of the foot, starting to do more and more things in bare feet if it's tolerated. If you can recall Tim Branston when he was on and talking about what he does with his foot function, he does a lot of his gym sessions in bare feet and just really maintains a high level of load through that plantar fascia and a high level of function through that foot. So that's another point in the maintenance phase. Another thing I can think of is just education around training errors. and this is a big one that's gonna pop up in the future of the podcast and it's popped up a couple of times in the past. Just understanding and having the education of what these training areas might be and what your response is going to be like, what the tissues in the body are going to be like. For example, if you decide to start running barefoot or running on the sand, it's... recognizing that's just a huge, huge load. So if you were to do that, make sure it's gradual. So you can see if you can start tolerating running once the AM symptoms and stiffness and long walks are tolerated. You can begin a walk to run program to slowly building in more and more running. Make sure you monitor symptoms and make sure you progress based on the pain during, pain afterwards and pain the next day, similar to a tendon. want to make sure all of those are settled, you tick all those boxes before progressing, doing more running, more speed, more hills, etc. It's also worth noting the expectations of these. Like I said last episode with Dave messaging me and being like, how long does it take to get over plantar fasciitis? Laying down these expectations is critical and it depends on your level of severity but also depending on if you're addressing those aggravating factors. appropriately otherwise it might never settle down and Tom Goon makes a good point of implementing something to reduce pain and then you need to pay attention to it over one to two weeks. It's not going to be a couple of days. You need to pay attention to morning symptoms and just very patiently documenting the symptoms and see if this is working or if it's not working because if symptoms are remaining the same over the course of a couple of weeks we need to address it in some other way. And like this study shows, once it's stable, it takes three months of strengthening and heavy load strengthening in order to receive that benefit. So we need to know where your starting level is and slowly build up from there because it might actually take a couple more weeks for you to build up to that three sets of 12 rep max. Being able to tolerate that load might even take a couple of months to start and then it's three months after that where you start to see the benefits. So really having laying down these expectations. So step one, reducing pain. Step two, increasing that load tolerance. And step three, building a maintenance phase, building a maintenance plan once you are starting to tolerate a lot of those loads. To make things a little bit more concise and a little bit easier, I've put in three, ah, sorry not three, five, five tips for prevention and maintenance. I know a lot of people like... talking about injury prevention or wanting to know a lot about injury prevention. So I thought I'd just add a couple of points. One, recognize load through the plantar fascia when increasing your load, standing still, doing barefoot work, shoe change, and just transition into more of a minimalist shoe. Just like I mentioned before, just having that education of what it's going to be doing to the plantar fascia. winter to warmer weather. I mentioned this a bit last episode, but certain types of the year, certain phases of the year, people like to encase their feet in a lot of supportive shoes and they do that for a long period of time. And the plantar fascia is expected to decrease in its load capacity to actually become weaker because it's no longer reliant on suspending itself. And then that transition into warmer weather and people start demanding more load or requirements through that plantar fascia is a high risk level throughout that phase of the year. So just be careful with that. Number three, maintain a good level of strength and function and coordination even when things are feeling really good. So these are five tips for prevention and maintenance. So once you're feeling really good, making sure you keep up with those levels of functioning and strength and coordination, make sure you can do a lot of things in bare feet. keep strong, keep functional. All of these are gonna help that maximum capacity line for those tissues just to be through the roof, just be so high that you couldn't possibly reach it. If you were to say, just go for a run or do a gym session. So keep that in mind. A lot of people just get over or overcome their plantar fasciitis and then just back off all their exercises. And so they are usually the ones that are at risk of developing it again. Number four, just make sensible decisions if minor symptoms arise. So we're trying to catch it early. And like I said last episode, these symptoms are just very gradual onsets. And if you ask Dungton, it's a little bit of stiffness here and there. When you first wake up, the heels are a little bit tender or the plantar fascia feels a little bit tight, making sensible decisions then and there and not waiting for it to exacerbate. And then it's until it's painful running and then you see a physio. So you wanna stay at the top of that downward spiral as high up in that downward spiral as you can in order to implement some one or two things and then you overcome it quite quickly. Number five, be careful with long-term orthotic use. And this isn't really much about the evidence, it's more of what I've seen in clinics. you could be heading that downward spiral without even knowing because if you are wearing a lot of supportive shoes and long term orthotics, the orthotics can play the role of the plantafascia so they don't need to work as hard because they've got all that built in support. And I do hear a story a lot where someone will get a bit of plantafasciitis and just say when they play tennis and someone suggested them to get orthotics, so then they get the orthotics, they play tennis, they feel a lot better, happy days. But then they're always playing tennis in those orthotics and the plantar fasciitis, and the plantar fascia isn't working as hard or maintaining its strength. So then when they go for a long hike or a long walk, their symptoms return and they're like, oh, okay, now I need to wear my orthotics when I go for long walks. So they're wearing the orthotics when they play tennis and then when they go for long walks, happy days. But then after a while, standing for long periods of time or standing at work starts to produce symptoms. Oh, now I need to wear orthotics when I work. And gets to the point where they're wearing the orthotics the entire day and they can't function without the orthotics. What do you think's happening there? The plantar fascia is getting weaker and weaker and unable to tolerate activities of daily living. Be very careful that you're not heading down that spiral. So that's number five, be careful of long-term orthotic use. And I don't say don't wear orthotics, I say just be careful, just be aware of what might be happening because you could easily go play tennis without orthotics, play tennis with the orthotics, symptoms are at bay, but you're also doing some foot strengthening on the side just to build up that function and then you can return without orthotics, even happier days. The last topic I wanted to talk about was perhaps some running considerations. And... something you might be able to implement that might impact the planar fascia. So I did find a study that was titled increasing preferred step rate during running reduces planar pressures and pretty much like the title suggests the results show that when you increase your step rate or increase your cadence by 10% it reduces the rear foot and mid-foot planar structures. So keep in mind if someone had plantar fasciitis with running and was flared up with running and then I look at their cadence and it's quite low, I would look at increasing that by about 10%. The other point was shoe transition or shoe swapping. Sometimes having multiple shoes and swapping some out. I know a lot of people have a bit of a strategy with swapping out shoes. That can be quite helpful. Just make sure if you do have minimalist shoes or some lighter... less supportive shoes, your body's used to doing that and not being overloaded too much if you decide to transition into those minimalist shoes too quickly or just doing a high volume that they're not used to. So just be careful with that. Some other considerations, foot strike. So if someone wants to transition from like a heel strike to more of a mid-foot or even a forefoot strike, just bear in mind that the load through the Achilles, the load through the plantar fascia, pretty much everything below the knee. needs to work just so much harder. So just keep in mind with that. And lastly, any crossover or narrow step width need to be mindful. This is with like ankles and Achilles as well, but planifascia. It's when you are running, you should have a slight width when you're stepping. So if you were to run along a straight line, if you're pretty much running on a line, over that line with your foot. So if you're contacting the ground with your right foot, you don't want to cross that midline over to the left side of that line. Otherwise when it comes to that push off phase, it's putting an incredible amount of unnecessary stress through the plantar fascia. So there are a couple of running considerations. That's the cadence, increasing your cadence if it's low. Be careful when you're transitioning your shoes and swapping out your shoes. Be careful with your foot strike if you're transitioning to more of a forefoot. and just be careful if you are eliciting a crossover pattern when it comes to your running. That's all for today. I hope I answered a lot of your questions. Like I said, management should be tailored to the individual based on your individual circumstances, what you're doing throughout the day, what your running loads are like, what you're training for, etc. A tailored effective management plan is the most effective way to go, but hopefully this has answered some of your questions. And if you do have any other further questions, you can always ask the forum or you can send me a direct message, I'll be more than happy to help you out. They are our two Plantafascia episodes. I hope you enjoyed. I'm excited to share these episodes out to people who are on other Facebook groups and have a whole bunch of questions. I can send them the link. And hopefully it helps a lot of you runners out there. So until next time, take care. Thanks for listening to another episode of the Running Smarter Podcast. I hope you can see the impact this content will have on your future running. If you want to continue expanding your knowledge, please subscribe to the podcast and keep listening. If you want to learn quicker, jump into the Facebook group titled Become a Smarter Runner. If you want tailored education and physio rehab, you can personally work with me at brea Thank you so much once again, and remember, knowledge is power.