Plantar Fasciitis Clinical Practice Guidelines
Plantar Fasciitis Clinical Practice Guidelines Plantar Fasciitis, an overview of the problem:
Plantar Fasciitis (Heel Pain) is a very common problem that seems to be “incurable” to most doctors and physical therapists. I am going to challenge this belief and show you what actually goes on with plantar fasciitis, and why it is fix-able. A lot of common therapies: NSAIDS/Cortisone Shots/Surgery/ Stretches usually never fix the true cause of the plantar fasciitis, and most people with plantar fasciitis stay in pain for MONTHS with no real improvement. Why does this happen?
The Nature of a Normal Injury: Plantar Fasciitis Clinical Practice Guidelines
When you have a normal injury, anywhere in your body, your body responds with inflammation and a whole cascade of events happen (triggered by the chemicals that produce inflammation):
1. The muscles around the injury tighten up. (To force rest)
2. The area becomes hot and inflamed (red and swollen, this is to rush nutrients into the area.).
3. The Fascia (connective tissue around the muscle fibers) also tightens up.
4. Tenderness at the site of the injury occurs. (Pain when touched) Plantar Fasciitis Clinical Practice Guidelines
5. Restricted movement of the joints around the injury due to the tight muscles and fascia we mentioned a second ago.
When this happens, the body is telling the person to rest. Usually, guided by pain, we are forced to rest the area, and in a couple days to weeks, the injury heals and the muscles relax and un-tighten, the swelling goes away, the tenderness subsides, and we regain all of our flexibility back. It may hurt a little bit for awhile, but it’s usually “live-able” pain. We notice it, but it’s not that bad. In a couple months, that pain slowly disappears, and we are all healed up.
What happens with Plantar Fasciitis??
First and foremost, the same events happen that were mentioned above. The tightness/inflammation/swelling/restricted movement all happen when you have pain in your heel. BUT, instead of resting and fixing the problem, people push through the pain and try to ignore it (most people have to go to work/school and have no choice). What this causes is more and more damage. This also causes more and more tightness in the muscles around the heel and tightness in the fascia (connective tissue).
When this person finds that it’s no use, and that the pain is driving them crazy, THEN they finally decide to rest the area. They then wait and wait… sometimes days, sometimes months even (in a cast or walking boot). When they try to walk again, the pain… is still… THERE! How is this possible?!?! Plantar Fasciitis Clinical Practice Guidelines
They go to the doctor and try a cortisone shot. They get great results, but it comes back a couple months or weeks later, and with a vengeance. They are in more pain, and they are more desperate.
They try out “supportive shoes” and “orthotics” and they feel a little improvement! It helps take the edge from the pain, but the pain… is still… THERE!
They go to a physical therapist and try some stretching exercises. It feels a little bit better, but the results are slow. The person sticks with the stretching exercises and gets depressed because the results are still not there.
They search all over the internet and cannot find new treatments to try. There are magnet therapies/acupuncture/laser therapies/ultrasound etc and none of these exotic therapies seems to be proven to consistently beat the heel pain.
How do you get out of this vicious cycle?? Where is the light at the end of the tunnel?? Plantar Fasciitis Clinical Practice Guidelines
So, we have a case of heel pain that won’t go away. Like we talked about before, the muscles and fascia are STILL tight. What this means, and this is the most important thing to know, is that when the heel (plantar fascia) actually does “heal” from rest, the problem is “re-created” because of the tight muscles and tight fascia! (They become tight to restrict movement, and force rest. When you move a tight and restricted joint, it will damage itself and the surrounding structures, especially the plantar fascia)
No matter how much healing power you push into the heel area, if the tight muscles around the heel do not relax/loosen, the area will never heal (quite a tongue twister!). It may get better temporarily, but the problem (the tight muscles and fascia) must be fixed FIRST. These tight muscles and fascia cause problems because they pull constant force on the heel, in an attempt to force you to rest. The body says to your foot “If you move that foot, or put pressure on that heel, I swear I will make it hurt!” when this goes on long enough, the muscles and fascia “get accustomed to” staying tight. This “tightness” is great when you have a new injury, but in a long term “chronic” injury, this tightness is what’s actually causing you most of the pain!! The tight muscles and fascia will cripple the way you walk and move, and shoot pain signals to your heel every time it hits the ground. Plantar Fasciitis Clinical Practice Guidelines
Which muscles are pulling on what? How do these tight muscles/fascia actually perpetuate the heel pain?
The Plantar Fascia starts at the toes, goes to the heel, then it wraps around the heel and becomes the Achilles tendon. The Achilles tendon is attached directly to your calf muscles. They act on your foot like a puppet, when your calf muscles contract (flex), it moves the foot in various ways. Right when the calf muscle contracts (flexes), the power of the muscle pulls up on the Achilles tendon, and this pull continues to the plantar fascia to move the foot. If the calf does not function properly, or is excessively tight, it places a mechanical load/stressor on the plantar fascia. If you have any inflammation in the heel area, you can be sure that the calf muscle will be tight, perpetuating the problem and preventing it to heal.
There are also other muscles under the plantar fascia that are deep in the foot. These cause the toes to move and also support the arch of the foot. The integrity of the heel and a lot of its strength is given to it from the support of the muscles.
The muscles also act as “pumps”, forcing nutrient rich blood into the tendons and heel area. When these nutrient “pumps” become tight (and in turn less able to do their job), they do not “pump” nearly as much nutrients into the injury (which are needed to fix the plantar fasciitis). Plantar Fasciitis Clinical Practice Guidelines
This is all caused by “micro tears” (tiny areas that have been “sprained”) in the plantar fascia from stressing the plantar fascia over time. This is done from over activity (running too far, standing on the feet all day, or from being overweight), from weak muscles in the foot/calf area or from a severe injury to the heel (sports injury etc). Whenever your body fixes those tiny “micro tears” in the plantar fascia, everything should be fine and fixed for good. But! If the muscles/fascia is tight around the heel, they will pull directly on the newly fixed area and rip apart the scar tissue (this is what the body uses to fix these injuries) and you are back to square one, with a severe injury (and LOTS of pain).
Every time the plantar fascia heals, those tight muscles/fascia cause the area to be ripped apart over and over and over again. This makes it seem like the pain will never go away!
OK so they are tight muscles… Why not stretch them?? Plantar Fasciitis Clinical Practice Guidelines
This is a huge mistake. When you have tightness in a muscle/fascia from an injury, it forms “trigger points” in the muscles and “adhesion’s” in the fascia. These do not “relax” with just stretching. When your muscles are tight after a workout, stretching works great to release them. When you have tight muscles from an injury, you must use other techniques to fix/release them. When you do a stretch prescribed by a physical therapist, it causes these “trigger points” to freak out and tighten up EVEN MORE! This is why those stretches can do little to no help (and cause more harm in the long run) with someone who has plantar fasciitis.
How in the world do we fix these “problem causing” tight muscles/fascia??
Soft tissue mobilization therapies, in a specific order, can fix these tight muscles and fascia very fast and easily. Soft tissue mobilization methods, can release these “trigger points” and “adhesions”. These are done through special massages with different tools (including your own hands). Plantar Fasciitis Clinical Practice Guidelines
I always find that plantar fasciitis, in particular, responds better to release of the muscles first, with trigger point therapies (these can be done easily, and at home, with your hands!). Then second, the fascia should be released. Fascia is much easier to release usually when the trigger points are released. This is usually done with “scrapping” the fascia with special tools. This can cause the adhesions that were formed in the fascia to break apart.
If you have pain and inflammation, you will have tight muscles and fascia around the heel, no matter what. When you get rid of the trigger points, you should have ALOT less pain. When you get rid of the adhesions in the fascia, the pain will have less chance of coming back. Next is kinetic chain stretches…
What happens after you fix these trigger points and adhesions??
The next stage of treatment is to do “kinetic chain stretches” that stretch specifically fascia (Stretching the fascia makes it less likely that the trigger points will come back, and also prevents the adhesions in the fascia from forming again). Plantar Fasciitis Clinical Practice Guidelines
Also you should focus on methods that break away from the chronic inflammation cycles (by causing GOOD inflammation. Fighting fire with good fire!). This is usually done with cross friction massage methods that you can do at home with house hold objects. This “good inflammation” can cause the body to fix all the damage that has been done. These methods cause your body to finally get rid of the scar tissue and get rid of the pain for good. When you cause good inflammation, the horrible effects of chronic inflammation can be “un-done”. Good inflammation causes more cells to form in the injury, and also forces the body to further fix the injury.
Usually when you have an injury in the plantar fascia, the scar tissue is laid down in un-uniform patterns. The scar tissue looks like mixed up spaghetti with fibers going in every direction. This is great for short term healing, but it is a weak structure. When you cause “good inflammation”, the scar tissue is forced to be laid in the “direction of force” (which is parallel and uniform with the other fibers around the scar tissue). This makes it possible for the scar tissue to be laid down in a parallel pattern, which is much stronger.
What about chronic inflammation? Why is it different than normal inflammation?
When you have this horrible cycle for more than 4 months, the body “gives up” on healing the heel, and starts to break the area down. It literally starts eating the area up slowly because it feels that it’s “no use to the body” (scary but true). This is why ESWT works for some people and prolotherapy as well. These therapies cause a concentrated and localized amount of “good” inflammation to fix the area. These therapies cause a specific type of damage to the heel in order to work properly. They force the body out of the chronic inflammation cycle and into a “fast healing” and “good inflammation” cycle to fix the damage fast (but these therapies do not fix the tight muscles/fascia). Cross friction massage is very effective at doing this also, and you can easily do it at home. Fast AND effective relief! Plantar Fasciitis Clinical Practice Guidelines
I like to take vitamins daily, are they helping my heel pain??
I find that most vitamins should be taken WITH a healthy diet. This includes raw foods such as raw vegetables/fruits/seeds/nuts etc. The reason these are so good for inflammation is because they have enzymes.
These enzymes help the body a lot with different functions in the body. This is why my favorite supplement for Plantar Fasciitis is Systemic Enzymes. These cause the body to chemically stop the chronic inflammation. When you have chronic inflammation for a long time, the body has all sorts of chemicals and toxins circulating in the blood stream that are limiting your body’s ability to heal.
When you take systemic enzymes, on an empty stomach, they get absorbed into the blood stream and fix the damage that has been done from the chronic inflammation. One enzyme, called serrapeptase, has an amazing ability to digest scar tissue. It literally goes into your blood, accumulates in the heel area, and breaks up and digests the scar tissue!
What happens if I release the muscles/fascia, take some supplements, and have a good diet?
You should be able to fix the heel pain pretty quickly. I have heard of people having amazing results in less than a week. It all depends on many factors though. What I do know is that plantar fasciitis is NOT an incurable disease, and if dealt with properly, it can be fixed in no time! The hardest part is accepting how bad the injury is, and giving it all the effort you can to fix it fast. Do not ignore the pain or push through it. I know that after months of pain, you will get desperate. If something hurts, do not do it! Plantar Fasciitis Clinical Practice Guidelines
Why do regular treatments SUCK?
Cortisone: This chemical causes no inflammation wherever it is injected. This means “chronic” (bad) inflammation and “good” inflammation all cease to exist in the heel area. When the cortisone leaves the heel over time, the area has not healed at all, and it is now weaker than before. So now the person is back where they started (actually worst off because the heel area is weakened), and in lots of pain!
Orthotics: These are great when you have severe pain, but if you think that it will fix your heel pain, think again. All that orthotics “do” is take pressure off the heel and causes weak foot muscles (instant pain relief, but does not fix the problem). When you wear an orthotic for many months, the pain comes right back again (can be weeks, or months, it simply will return if that is the only method of treatment). Supporting the plantar fascia does not fix the pain, it does help though, and I do believe they should be used, but they will not actually “fix” your pain (they do help IF you wear them while releasing the muscles/fascia, then you must slowly stop using the orthotics when they pain subsides). If you have been wearing orthotics for a long time, your foot muscles are slowly becoming weaker and weaker by the day. This does not help your heel pain. Plantar Fasciitis Clinical Practice Guidelines
Stretching: Stretching a muscle with a trigger point causes the trigger point to become worst (more tightness). If you have pain, you more than likely have some trigger points in your feet and calf. You must release the trigger points first, and then later on you can stretch the muscles so that the trigger points do not come back.
Surgery: Not needed. And when you get the surgery, the muscles/fascia is still tight, so the pain comes back. Some people do get results with surgery, but not many. It is very rare usually.
Icing: Is OK, and relatively safe, but does not do much. If you just hurt your heel recently, it is good for the first few hours, but after that, it does little to nothing.
Taping: Works great if your pain is severe, but it DOES weaken the foot muscles. So it is temporary relief. I find that it’s great to support the plantar fascia so that you can walk a little further and give the area a “break”, but it will not fix the tight muscles/fascia that are causing your pain. Plantar Fasciitis Clinical Practice Guidelines
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Plantar Fasciitis Clinical Practice Guidelines
For more information on how you can treat and prevent plantar fasciitis, click here. You can also find support from other sufferers of this condition by joining Facebook groups. You can find helpful articles on foot structure and biomechanics, stretches, exercises, orthotics and more. You can start taking care of your feet today by doing just that. Take the first step and start walking comfortably again.