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Treatment of plantar heel pain requires both patient and provider components. Here are 9 facts about plantar fascia-mediated pain from a recent publication: Pathomechanics of Common Foot Disorders (2021). Staying up to date on current research is essential, but often more difficult is translating this knowledge to our patients. Fortunately, you can use the ChiroUp exercises, stretches, treatments, and patient education materials from this blog to solve these tricky cases. Personally, my favorite is number 4! I hope you will find these tips useful for your next patient with foot pain.

Finding 1

Plantar heel pain is a common disorder of the foot which involves multiple anatomic structures.

In-office treatment should include instrument-assisted manipulation/manipulation/ and mobilization of surrounding tissues to ensure equal distribution of forces across multiple muscles, ligaments, and joints, thereby assisting in your patient’s recovery. Here is one example:

foot

Finding 2

It is widely accepted that inflammation followed by degeneration of the plantar aponeurosis at its attachment to the calcaneus is the most common pathology associated with plantar heel pain.

Educating patients on the degenerative model will improve patient compliance with your treatment plan.  Inflammatory pain (most patients believe is the cause of their foot pain) improves with medication, supplements, and adequate rest.  However, most plantar fascial pain requires promoting a local inflammatory reaction coupled with a progressive loading rehabilitation program. Use the treatment in the previous section and the Plantar Fascia Stretch on a Step to begin a progressive loading program with your patients.

foot

*To view this test, log into your ChiroUp account and check out the clinical evaluation tab! If you don’t already have an account, click HERE for access and less than 20 seconds.

Finding 3

During walking and running, the plantar aponeurosis is subjected to loads which approach the maximal limit of load to failure.

Teaching your patient to walk with a widened stance will decrease the subtalar pronation rate thereby unloading the injured fascia. Proper shoe wear will also help your patient have less pain during their recovery in your office. Here is an infographic you can deliver to patients enabling them to participate in their own recovery.

running

The plantar fascia must absorb up to seven times body weight during the push-off phase of running. Pain often presents following an increase in training demand or change in the running surface.

Finding 4

Entrapment of the inferior calcaneal nerve can be a primary or secondary cause of chronic plantar heel pain.

Be sure to rule out other causes of heel pain.  Here is a quick differential diagnosis algorithm provided by a recent article in American Family Physician (2018).  Spending extra time on your evaluation saves you valuable time by ensuring adequate care for the right diagnosis. 

Finding 5

Increased body mass index and reduced ankle joint dorsiflexion are the two most common risk factors for plantar heel pain.

Increasing ankle dorsiflexion pays quick and lasting dividends in both patient satisfaction and recovery.  Check out this blog highlighting a simple to follow exercise your patients can perform today to help themselves improve ankle dorsiflexion.   

Patients with a BMI greater than 35 are approximately 2.5 times more likely to experience plantar fasciitis than those with BMI’s less than 35.

Finding 6

Deficits in toe flexor strength have been identified in patients with plantar heel pain.

Balance and strength diminish with prolonged shoe wear.  These muscles are necessary to help the plantar fascia store energy and provide the rigid structure required for the gait’s propulsive stage. Consider prescribing the Flexor Digitorum Brevis Strengthening exercise.

foot stretch

Finding 7

Dorsiflexion of the digits increases strain in the plantar aponeurosis by 70%, while Achilles tendon tension increases strain by 30%.

Tenderness to palpation is often exacerbated by simultaneously dorsiflexing the great toe to 65 degrees. The Windlass Test for plantar fasciitis is a reproduction of heel pain during passive dorsiflexion of the toes. Performing this test while the patient is standing/weight-bearing more than doubles sensitivity to almost 33%.

foot 2

To view this test, log into your ChiroUp account and check out the clinical evaluation tab! If you don’t already have an account, click here for access in less than 20 seconds.

Finding 8

Kinematic studies of patients fail to demonstrate a consistent pattern of foot mechanics, which predispose to the development of plantar heel pain.

Maybe it’s not the structure or function that is causing plantar foot pain.  Both of which you are capable of assessing in the officeEvidence-based chiropractors are able to assess MSK structure and function during an office visit. One component you can’t see is what the patient does outside of your office.  Consider the hobbies, habits, and sports your patient participates in daily.  These factors are the cause of dysfunction or limit your patient’s ability to heal quickly. 

Patients with occupations or activities that involve prolonged ambulation have a higher incidence of plantar foot pain.  (teachers, construction workers, cooks, nurses, distance runners, etc.) Runners average 1200 steps per mile at a 6-minute per mile pace, and walkers average 2300 steps at a 20-minute/mile pace. Patients often present following an increase in training demand or change in running surface- i.e., concrete.

Finding 9

Plantar fascia thickening rather than calcaneal spurs is more commonly associated with plantar heel pain.

foot

*Patients with stress fractures of symptomatic heel spurs may note pain at heel strike.

Consider this quote from Snook in 1972:

It is reasonably certain that a condition which has so many different theories of etiology and treatment does not have a valid proof of any one cause.”

Treating plantar fasciitis may become frustrating due to the widely variable results from patient to patient.  Consistent clinical results arise from addressing all factors leading to tissue failure AND modifying the activities limiting each patient’s ability to heal.  Incorporating the ChiroUp condition report for PF with each patient will save you time and patient frustration—ultimately resulting in a more satisfied patient base. 

References
  1. Richie Jr DH. Plantar Heel Pain. Pathomechanics of Common Foot Disorders 2021 (pp. 275-311). Springer, Cham.
  2. Infographic adapted from: Tu P. Heel pain: diagnosis and management. American family physician. 2018 Jan 15;97(2):86-93.

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