Foot Pain OUCH!
You leap out of bed in the morning and you get stabbing pains in your heels or the arches of your feet. You hobble a few steps, and then hobble a few more until the pain reduces. Most of the day your feet feel OK …except when you tackle stairs or when you have been sitting for a while when the pain makes a reappearance.
Pain in your heel or the bottom of your foot is most commonly caused by Plantar Fasciitis. Your Plantar Fascia is the ligament that goes from the underneath of your heel to your toes. If you strain it, micro tears can form, which leads to swelling and sharp pain.
While most people experience the pain in their heel, some also get pain through to the arch of their foot. In about 70% of cases, the pain is in both feet, making walking a very painful experience.
You most commonly notice the pain first thing in the morning when you get out of bed and it reduces as your feet warm up with movement. It can reappear during the day after periods of rest or sitting, if you have been standing for a while, or when climbing stairs or ladders.
Plantar Fasciitis is more common in middle-aged people, although it can also affect younger people who use their feet a lot like joggers, dancers, or soldiers. That’s why it is also often called Joggers Heel.
Causes of Plantar Fasciitis
While the actual causes of plantar fasciitis are not known, there are risk factors that will increase the likelihood of you getting plantar fasciitis.
Overuse – excessive running, walking or dancing, or changing your training pattern so you dramatically increase hill running (for example).
Standing on hard surfaces
Flat feet or high foot arches (this is one time when average is better!)
Tight Achilles tendons or calf muscles
Your feet roll in when you walk or run
Ill-fitting shoes, worn out or unsupportive footwear such as thongs/slides
Walking barefoot on hard surfaces
First aid for Plantar Fasciitis
Generally, plantar fasciitis is gradual onset, which means it gradually increases in severity over time. If you ignore it and try to run through the pain, then the symptoms can get worse, ultimately leading to you changing your gait, limiting your activity or triggering the growth of heel spurs.
For initial symptoms, you need to rest, apply ice packs (15 minutes at a time every 2-3 hours), and take anti-inflammatory painkillers such as ibuprofen.
You don’t need a referral from a doctor to see a physiotherapist. If the pain is moderate then you can seek treatment with your Physiotherapist immediately as the sooner you begin treatment, the sooner you will experience relief.
Occasionally your plantar fascia can snap and you could hear a clicking or snapping sound, accompanied by swelling, intense pain and significant swelling. You need to see a doctor urgently if this occurs.
Physiotherapy & Treatment Options
Your physiotherapist will assess the extent of your injury, and will explore the causes of your injury.
Depending on your symptoms, you may have the soles of your feet taped or strapped to support your feet and reduce pain. You may also need to wear a plantar fasciitis brace or heel cups in the initial stages of healing.
Your physiotherapist will take you through a number of gentle stretching exercises for your feet, as well as exercises to address any tight Achilles tendons or calf muscles.
We will combine these with pain reduction techniques that you can do at home such as rolling your foot on a frozen water bottle or frozen golf ball to help ice your injury site.
Massage, joint mobilisation techniques, dry needling and ultrasound therapy will also be used to reduce swelling and restore movement.
For your footwear, we recommend you replace your joggers every 650km of use, and only wear shoes that support your feet while healing. Definitely no thongs or slides!
It also helps to put your shoes on first thing in the morning, before you take your first steps. Avoid barefoot walking on tiles or hard surfaces while you heal.
If the cause of your injury is your feet shape or foot pronation, you may need special orthotics. If this is indicated, we would conduct a walk/run assessment on you and have your technique analysed.
To maintain your fitness during your treatment, we recommend swimming and cycling. Don’t return to running until you have been pain free for at least one week, and then only run on soft surfaces until you rebuild your strength and stamina. If pain is felt at any time, then go back to swimming and cycling rather than running.
Unfortunately, Plantar Fasciitis is a long-term injury, and may take a number of months to fully heal even with the most aggressive treatments.
Things to Remember
Plantar Fasciitis is the most common cause of heel and arch pain, and is caused by micro tears to the plantar fascia.
It is a gradual onset injury and causes sharp pain when taking the first few steps in the morning or after rest.
Physiotherapy can treat plantar fasciitis, while reducing pain and increasing movement during healing.
Your physiotherapist may advise you of techniques for the improvement of your walk/running style, or provide you with solutions for arch support, to help prevent further reoccurrence.
Healing may take many months for full recovery.
A New England Journal of Medicine (NEJM) study showing that physical therapy is just as effective as surgery in patients with meniscal tears and arthritis of the knee should encourage many health care providers to reconsider their practices in the management of this common injury, according to the American Physical Therapy Association (APTA).
The study, published March 19, showed no significant differences in functional improvement after 6 months between patients who underwent surgery with postoperative physical therapy and those who received standardized physical therapy alone.
“This study demonstrates what physical therapists have long known,” explained APTA President Paul A. Rockar Jr, PT, DPT, MS. “Surgery may not always be the best first course of action. A physical therapist, in many cases, can help patients avoid the often unnecessary risks and expenses of surgery. This study should help change practice in the management of symptomatic meniscal tears in patients with knee osteoarthritis.”
According to lead physical therapist for the trial and American Physical Therapy Association (APTA) member Clare Safran-Norton, PT, PhD, OCS, “our findings suggest that a course of physical therapy in this patient population may be a good first choice since there were no group differences at 6 months and 12 months in this trial. These findings should help surgeons, physicians, physical therapists, and patients in decision-making regarding their treatment options.”
Researchers at 7 major universities and orthopedic surgery centers around the country studied 351 patients aged 45 years or older who had a meniscal tear and mild-to-moderate osteoarthritis of the knee. Patients were randomly assigned to groups who received either surgery and postoperative physical therapy or standardized physical therapy. Within 6-12 months, patients who had physical therapy alone showed similar improvement in functional status and pain as those who had undergone arthroscopic partial meniscectomy surgery.
Patients who were given standardized physical therapy — individualized treatment and a progressive home exercise program — had the option of “crossing over” to surgery if substantial improvements were not achieved. Thirty percent of patients crossed over to surgery during the first 6 months. At 12 months these patients reported similar outcomes as those who initially had surgery. Seventy percent of patients remained with standardized physical therapy.
According to an accompanying editorial in NEJM,”millions of people are being exposed to potential risks associated with a treatment [surgery] that may or may not offer specific benefit, and the costs are substantial.” Physical therapist and APTA member Mary Ann Wilmarth, PT, DPT, MS, OCS, MTC, Cert MDT, chief of physical therapy at Harvard University, said, “Physical therapists are experts in improving mobility and restoring motion. The individualized treatment approach is very important in the early phases of rehabilitation in order to achieve desired functional outcomes and avoid setbacks or complications.”
Jeffrey N. Katz, Robert H. Brophy, Christine E. Chaisson, Leigh de Chaves, Brian J. Cole, Diane L. Dahm, Laurel A. Donnell-Fink, Ali Guermazi, Amanda K. Haas, Morgan H. Jones, Bruce A. Levy, Lisa A. Mandl, Scott D. Martin, Robert G. Marx, Anthony Miniaci, Matthew J. Matava, Joseph Palmisano, Emily K. Reinke, Brian E. Richardson, Benjamin N. Rome, Clare E. Safran-Norton, Debra J. Skoniecki, Daniel H. Solomon, Matthew V. Smith, Kurt P. Spindler, Michael J. Stuart, John Wright, Rick W. Wright, Elena Losina. Surgery versus Physical Therapy for a Meniscal Tear and Osteoarthritis. New England Journal of Medicine, 2013; 130318220107009 DOI: 10.1056/NEJMoa1301408
Our spinal columns are made of twenty four vertebrae stacked one above another on the pelvis. They are joined together at the front by discs and at the back by facet joints. When we bend forward, the vertebra above tilts and slides forward, compressing the disc and stretching the facet joints at the back of the vertebrae. When we bend backward, the disc compression is reduced at the front and the facet joints are compressed at the back. In the upper neck and thoracic areas we tend to have more facet joint strains and in the lower cervical spine and lumbar spine areas, disc injuries are more frequent. This is because our upper spine joints allow us to turn our heads to see, hear and smell, so they need mobility but do not support much weight. Our lumbar spine bears around half our body weight and as we move and sit, there are huge, sustained, compressive loads on our discs.
CAUSES OF BACK PAIN
Disc injuries are the most common cause of low back pain and can range in severity from a mild intermittent ache, to a severe pain where people cannot move. Disc injuries occur mainly during sudden loading such as when lifting, or during repetitive or prolonged bending forces such as when slouching, rowing, hockey and while cycling. They are often aggravated by coughing and running. A flexed posture during slouching, bending or lifting is a frequent cause of disc damage because of the huge leverage and compression forces caused by gravity pulling down on the mass of the upper body.
It is important to understand that damage from small disc injuries is cumulative if discs are damaged at a faster rate than they can heal and the damage will eventually increase until it becomes painful. Pain sensing nerves are only on the outside of the disc, so by the time there is even small pain of disc origin, the disc is already significantly damaged internally where there are no nerve endings to feel pain with.
There may be a previous history of pain coming and going as the damaged area has become inflamed, perhaps was rested or treated, settled for a while but as the underlying problem was not fixed, the pain has flared up repeatedly since. This type of disc injury responds very well to Physiotherapy treatment.
A marked disc injury causes the outer disc to bulge, stretching the outer disc nerves. In a more serious injury, the central disc gel known as the nucleus, can break through the outer disc and is known as a disc bulge, prolapse or extrusion.
Spinal muscles are often blamed as the cause of spinal pain but this is rarely the cause of the pain. Muscle pain may develop as the muscles contract to prevent further damage as they protect the primary underlying painful structures. This muscle pain is secondary to the underlying pathology and when the muscles are massaged, given acupuncture etc, there is temporary relief but the pain will often come back, as the muscles resume their protective bracing. Treatment must improve the structure and function in the tissues which the muscles are trying to protect. The most common sources of primary pain are the discs, facet joints and their ligaments.
There are four facet joints at the back of each verteba, two attaching to the vertebra above and two attaching to the vertebra below. A facet joint strain is much like an ankle sprain and the joints can be strained by excessive stretching or compressive forces. The joint ligaments, joint lining and even the joint surfaces can be damaged and will then produce pain.
Facet joint sprains can occur during excessive bending but typically occur with backward, lifting or twisting movements. Trauma such as during a car accident or during repetitive or prolonged forces such as when slouching or throwing.
There are many other sources of back pain including arthritis, crush fractures and various disease processes. Your Physiotherapist will examine your back and advise you should further investigation be necessary.
SYMPTOMS OF BACK PAIN
Symptoms of structural back pain are always affected by movement. This is important to understand. Symptoms, usually pain but perhaps tingling and pins and needles, are often intense and may be sudden in onset but also may be mild and of gradual onset. There are other conditions which can produce back pain such as abdominal problems, ovarian cysts and intestinal issues. If you have symptoms in these areas which are not affected by movement, you must consult with your doctor. If you have chest, jaw or upper limb pain which is unaffected by movement, you must attend your doctor or hospital immediately.
Facet joints, discs, muscles and other structures are affected by our positions and movements. More minor problems produce central low back pain. With more damage, the pain may spread to both sides and with nerve irritation, the pain may spread down into the thigh or leg. As a general rule, disc pain is worse with bending, lifting and slouching and facet joint strains are worse twisting and bending backward or sideways. A severe disc problem is often worse with coughing or sneezing and on waking in the morning.
DIAGNOSIS OF BACK PAIN
Diagnosis of back injuries is complex and requires a full understanding of the onset history and a comprehensive physical examination. It is important for your Physiotherapist to establish a specific and accurate diagnosis to direct the choice of treatment. In some cases, the pain may arise from several tissues known as co-existing pathologies and each of these are treated as they are identified. Where the Physiotherapist requires further information or the management may require injections or surgery, the appropriate x-rays, scans and a referral will be arranged.
UPPER BACK AND LOWER BACK PAIN RELIEF
Lower Back pain treatment.
Eighty percent of adults will experience severe spinal pain at some time in their life. Much of this pain is called non-specific low back pain and is treated with generic non-specific treatment. This type of treatment often fails to provide lasting relief. However, Musculoskeletal Physiotherapists have developed specific diagnostic skills and specific treatment techniques, targeted to specific structures. We identify the structure and cause of the pain producing damage and develop specific advice and strategies to prevent further damage and promote healing.
Specific techniques are chosen to correct the structural and mechanical problems. Among many choices, treatment may include joint mobilisation, stretching, ice, strengthening and education. As normal tissue structure and function returns, there is a reduction in the inflammation and the pain will subside.
When normal movement has been achieved, the inflammation has settled and the structures have healed, your new strategies will reduce the possibility of the problem recurring. We use this specific approach to reduce or stop chronic pain.
While we have the choice to manipulate, adjust or click joints, patients with ongoing pain will seldom benefit from repeating these techniques. This is because our tissues are elastic and the benefit of the quick stretch of manipulation is lost, as the elastic tissues tighten and shorten again. Adjustments of this type have little long term benefit and often lead to an unhealthy dependence on the provider. Your Physiotherapist will choose a safer and more appropriate treatment for you.
Living and working in this century will have seen us spending more and more time sitting at the computer, whether it is part of our work, studying or even leisure time. An unfortunate consequence of spending long periods of time doing this is that it can cause pain in a number of areas including the neck, shoulders, arms and lower back.
Sitting at a desk for long periods means it is often difficult to maintain good posture for long periods of time. Many people will have a tendency to lean forward or slouch their shoulders which will put unnecessary stress on the spine leading to pain and fatigue. Repetitive movements such as typing /filing can also contribute to pain by placing your body in awkward positions and increasing the risk of muscle strain.
Simple tips how we can avoid this situation developing and causing pain.
Get up every 20 minutes, stretch and walk around
Specific stretches to the neck, chest, shoulders and mid and lower back.
Strengthening exercises to improve the strength of the deep neck muscles, shoulder blade muscles and the deep abdominals that stabilise the lower back.
Ergonomic assessment. The set up of your desk will have a big influence on the stresses and strains on your muscles and joints. A few adjustments could make a huge difference to your pain and also prevent future problems developing, for example adjusting your computer screen height. Many workplaces offer these assessments. Your physiotherapist will be able to advice you on simple adjustments or even visit your workplace to perform an assessment.
Already have pain from sitting at your desk?
If you are in the unfortunate situation of already having pain it is recommended that you address all the above steps immediately. It is also advised that you take some painkillers and/or anti-inflammatory medication. Consider using heat packs to soothe tightness and soreness in muscles. Most importantly, physiotherapy or your preferred form of musculoskeletal treatment should be sought. Everyone is different, so a physiotherapist will be able to specifically assess your painful area and look at the causes of your pain. Following this he /she will be able to advise what you can do yourself. This may include specific stretches and strengthening exercises, adjustments to your desk and correction of your posture.
The physiotherapist will also provide you with some hands on treatment which may include soft tissue massage, joint mobilisation and dry needling to help settle the pain. Early intervention is the key to ensuring your pain is managed effectively and will normally mean less physiotherapy treatment is required.