If this is always true, why can we feel pain when we have not injured ourselves? 

For example, we feel neck or back pain after sitting for a prolonged periods or a trivial action like reaching for a towel causes severe back pain?
How is this possible if pain = damage? This is confusing.

What The Research Shows

The research tells a different story:

One study ( Brinjiki et al) showed a high rate of ‘pathology’ in lower back MRIs in over 3000 subjects without any pain or dysfunction – and this was in people ranging from 20 to 80 years old.

In the shoulder, many studies have painted a very similar picture. One study (Grisih et al) found that a remarkable 96% of subjects who reported no pain or issues had at least one identifiable ‘pathology’ on their ultrasound scan. 

So you can see that tissue damage does not lead to pain in many cases, and pain can arise without  evidence of tissue damage. This is precisely why we constantly remind our patients that ultrasound scans don’t tell the full story.

The general understanding of pain and injury needs to be updated so that people can overcome pain more easily and get back to living their (best) lives.

A New Understanding of Pain

The new understanding of pain is that it is an output signal created by the brain, as a warning sign. It can be out of proportion to the injury. This serves to change behaviour to prevent further damage, which is often required to fix the problem.

The issue is that most people don’t understand this, and remain stuck with a painful condition because they are fearful to move in case it causes more tissue damage. The problem with this is that people are thinking about local structures, not the whole body. There are compensations and protective mechanisms that can develop in other areas of the body that can contribute to your pain…. Where your pain is located is not necessarily where it comes from.

For example, someone can get knee pain because they had a recent back pain episode that affected the way they walked. The back pain improved, but the knee persisted because of secondary protective mechanisms that have not resolved.

A Whole Body Approach

This is why we look at the whole body and how it works together. We want be as thorough as we can and find all the contributors, both local and remote for your pain. This will enable you to get back to the things you love doing without the pain you have been suffering.

We use a 7 step process (the ridgway method) that will find the main drivers of your pain and fix them quickly. It is scientific, objective and based on the latest neuroscience research. 

If you’re not open to a new understanding of pain, you will remain stuck and restricted by your pain and fear of movement. Are you really willing to let your pain dictate your quality of life? 

Or are you looking for a new approach to regain your lifestyle, independence and get on top of your pain long term?

If you’re ready to take control of your life, book an initial consultation with us. We’d love to help you!

References

Brinjikji W et al; Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6. doi: 10.3174/ajnr.A4173. Epub 2014 Nov 27.

Girish G et al; Ultrasound of the shoulder: asymptomatic findings in men. AJR Am J Roentgenol. 2011 Oct;197(4):W713-9. doi: 10.2214/AJR.11.6971

Plantar Fasciitis Symptoms

Most people experience heel pain on the inside of the heel bone or extending into the arch of the foot. The pain is worse in the morning getting out of bed, then usually improves. It can recur during the day after periods of non-weight bearing again initially as you start to walk.
It can be worse after running or playing sport, especially after getting up from sitting afterwards.

Anatomy of The Plantar Fascia

The plantar fascia is a thick band of tissue that runs along the bottom of the foot, connecting the heel bone to the toes. It acts as a shock absorber and helps support the arch of the foot. It also shortens the foot during the propulsive stage of the gait cycle. Plantar fasciitis is essentially a biomechanical overload condition, and while there may be inflammation in the early stages of the condition, the pathology is one of degeneration of the fascia with or without micro tears. This can cause pain and discomfort in the heel or arch of the foot.

Is Plantar Fasciitis Causing Your Foot Pain?

Causes and Contributing Factors of Plantar Fasciitis

There are many factors that can contribute to the onset of plantar fasciitis, including:

1. Excessive loading: Overuse or increased loading of the foot is one of the most common causes of plantar fasciitis. This can happen with activities such as running, jumping, or standing for long periods.
2. Age: As we age, the plantar fascia can become weaker and less flexible, increasing the risk of injury.
3. Foot Mechanics: Abnormal foot mechanics, such as flat feet or high arches, can put extra stress on the plantar fascia. Reduced ankle joint dorsi flexion has also been shown to be associated with plantar fasciitis, as well as weakness in the intrinsic foot muscles which leads to less support of the arch of the foot and plantar fascia.
4. Obesity: Being overweight or obese (BMI > 27) can put extra pressure on the feet, leading to plantar fasciitis.
5. Improper Footwear: Wearing shoes with poor arch support or inadequate cushioning can also contribute to plantar fasciitis.

Plantar Fasciitis Treatments

There are many treatments available for plantar fasciitis. Some of these are considered Plantar Fasciitis treatment at home and can be quite effective.

Most of these treatments have been shown to have some impact on the pain:

1. Rest: Resting the foot and avoiding activities that aggravate the condition can help relieve symptoms in the short term. To achieve long-term gains short periods of rest,or modified loading, need to be interspersed with higher loading and strengthening exercises.
2. Ice: Applying ice to the affected area can help reduce inflammation and pain in the early stages
3. Stretching: Stretching exercises have been shown to improve outcomes in this group of patients but outcomes have been improved with the addition of strengthening exercises.
4. Footwear: Wearing shoes with good arch support and cushioning can help reduce stress on the plantar fascia.
5. Orthotics: Custom-made orthotics can be used to correct abnormal foot mechanics and provide additional support to the arch. Compared to sham orthotics, one study found an improvement in pain and function with custom-made and prefabricated orthotics.
6. Medications: Over-the-counter pain medications, such as ibuprofen or acetaminophen, can help relieve pain and reduce inflammation in the short term but do not address the causes of the condition.
7. Corticosteroid Injections: Corticosteroid injections may be used to reduce inflammation and pain in severe cases of plantar fasciitis, but there is limited evidence to support long-term results. Other risks associated with this procedure include rupture of the PF or fat pad atrophy.
8. Autologous blood injections (including Platelet-rich plasma injections) have been shown to have an 80% success rate at 3 months in one study.
9. Shockwave therapy: this procedure has gained more popularity recently and uses acoustic sound waves to penetrate the tissues and create more blood flow, and introduction of growth factors to stimulate healing. Several good-quality studies have shown that SWT can reduce pain and improve function in people with PF when compared to control groups.
   You can learn more about Shockwave Wave Therapy here.

Surgery is rarely necessary for plantar fasciitis and is only considered in severe cases that do not respond to other treatments.

Plantar Fasciitis Treatment At Home

Plantar Fasciitis Treatment- Our Physiotherapy Approach

Good physiotherapy management of PF will involve a careful and thorough assessment of all factors that may contribute to the onset of the condition, including biomechanical , social and any limiting beliefs the patient may have around pain. Once the key contributors are identified, treatment is aimed at addressing all of these, which can involve many of the options listed above, in a measured and coordinated manner.
At NWPG, we know that pain is a protective output from the brain, and where you feel your pain may not be where the main driver of the pain is. We look beyond the foot and leg to assess any dysfunctional muscle or joint in any region of the body that may also have an input to the pain.

Read here about a success story which involved remote contributors to a case of PF.

We also have a SWT unit and can administer this treatment if we determine that it is indicated for a particular person’s condition.

Plantar Fasciitis At Home Summary

Plantar fasciitis is a common condition that can cause pain and discomfort in the heel or arch of the foot. It is more common in middle-aged individuals and women. There are many causes of plantar fasciitis, including overuse, age, foot mechanics, obesity, and improper footwear. The best treatments involve through assessment of all the contributors, and a coordinated approach involving any of the treatments detailed above.

It can be a chronic condition, but responds to the right treatment, which is individual specific. Surgery is rarely necessary and is only considered in severe cases that do not respond to conservative management over a long period.
If you’ve had this condition and it has not responded to previous treatments or plantar fasciitis treatment at home, get in touch with us at the clinic and we’d be happy to discuss your case and how our approach can help you get back on your feet again!

Plantar Fasciitis References

Trojian T, Tucker AK. Plantar Fasciitis. Am Fam Physician. 2019;99(12): 744-750.

Landorf KB, Keenan AM, Herbert RD. Effectiveness of foot orthoses to treat plantar fasciitis: a randomized trial. Arch Intern Med. 2006;166(12):1305-1310.

Rathleff MS, Mølgaard CM, Fredberg U, et al. High-load strength training improves outcome in patients with plantar fasciitis: a randomized controlled trial with 12-month follow-up. Scand J Med Sci Sports. 2015;25(3):e292-e300

Vahdatpour B, Kianimehr L, Ahrar MH. Autologous platelet-rich plasma compared with whole blood for the treatment of chronic plantar fasciitis; a comparative clinical trial. Adv Biomed Res. 2016;5:84.

Lou J, Wang S, Liu S, Xing G. Effectiveness of extracorporeal shock wave therapy without local anesthesia in patients with recalcitrant plantar fasciitis: a meta-analysis of randomized controlled trials. Am J Phys Med Rehabil. 2017;96(8):529-534.

Heel pain or plantar fascitis, can be a real nuisance, stopping you from putting your best foot forward! In our experience, the 2 biggest myths around this condition are:

1. That where you feel your pain is where the problem is.
2. That the degree of damage on your scan results will determine your ability to recover.

Through a thorough assessment, we often find other areas in the body that contribute to heel pain.

Research shows that scan results are not consistent with your functional restrictions and are not an accurate predictor of recovery.

This case study is a good example of this.

History

Miss C is a 30 year old nurse who presented to our rooms on 28/3/18 with a 5 month history of right heel pain and plantar pain. This had began while overseas and walking a lot in high heel shoes. It had slowly worsened and the plantar foot pain had started in January 2018.

Miss C was a keen runner and this pain had stopped her from running. As the pain worsened, she found walking difficult and would often limp after an exercise class or walking a lot. She had seen a podiatrist, had 3 bouts of shockwave therapy, dry needling and had seen a specialist who had ordered a cortisone injection.

All this had not helped and Miss C was becoming increasingly frustrated and down about not being able to walk properly let alone run.

Scan Results

An MRI of the foot had confirmed plantar fascitis with a small split tear in the plantar fascia, as well as significant degeneration (osteoarthritis) of the sub talar joint (heel joint).

Assessment findings

We used whole body systematic problem solving approach to treat Miss C and get her back to running as soon as was possible.
On examination we found a poor gait pattern with a significant limp and reluctance to take weight through the heel. She was unable to perform a heel raise, and knee to wall lunge was 4cm on right and 6cm on left.  The the sub talar joint was “locked”, ie it was not able to be moved side to side. This movement is referred to as a passive accessory glide of the joint, and all healthy joints in the body should have a certain amount of “passive glide” when tested. The cuboid joint in the foot was also very stiff, as well as the deep calf muscle(tibialis posterior).

Remote assessment revealed Miss C held a lot of tension in her neck and shoulders, especially the left shoulder, which had reduced internal rotation (hand behind back). There were also stiff joints in the thoracic and lumbar spines.

Treatment

Through a process of trial treatments and elimination, we found that release of the left shoulder (subscapularis muscle) was making significant changes to the assessment signs around Miss C’s right foot. Treatment here improved the knee to wall lunge range and heel raise, as well as the mobility of foot joints, when retested immediately after release of the muscle.

Local release was also performed, and as Miss C’s pain and movement signs improved we gradually increased her walking and load bearing exercises. Within 4 sessions, Miss C’s knee to wall lunge had improved to 12cm and she could heel raise without pain x10 on the right leg.

At this point, Miss C started to increase the load on the foot by alternating walking with short periods of running. We progressed the running intervals and reduced the walking intervals over a few weeks until she was running continuously for 30min. We then added faster pace interval sessions to her training.

Miss C emailed us after approximately 2 months telling us that she had just completed a 10km charity race, coming 6th in the field of women! Her foot had held up well, and she was not sore afterwards! As you could imagine, we were absolutely amazed and impressed with her recovery.

We posted her result on our Facebook page.

How do we explain this?

To understand this we need to think about pain in a different way. Modern neuroscience research tells us that pain is an output signal created by the brain to warn the individual and protect them from further damage.

Pain is not in the “tissues” of the body. These tissues have receptors in them that pick up excessive strain or inflammation, but it is the brain that decides whether this is important enough to warn the individual. If the brain is receiving lots of nerve impulses from other tissues in the body, which may be remote from the site of pain, these add to overall level of “danger” signals the brain is receiving. If the sum of these signals exceeds what the brain determines as a safe threshold, then it will create the warning of pain. The brain then allocates an area for the pain based on what is most likely to change the behaviour of the individual, so that they will either take a rest or seek treatment that will restore the body’s balance.

This is why working on other primary areas of the body that are under strain can lower the overall level of  input signals to the brain, and hence reduce the output signal of pain and the associated protective responses in the body.

More information is available at Why do Whole Body Assessment.

We can break the elements of correct running biomechanics and posture into key areas:

1. Head straight and shoulders relaxed

While this may seem obvious, we see many people running with their head down and their shoulders tense.  This increases effort and energy expenditure with moving the body forward. Keeping your head upright and your shoulders relaxed also keeps the muscles in your back relaxed, which helps with running efficiency.

2. Elbows bent between 60-90 degrees, kept by your side, with arms moving forward and back

A common biomechanical deficiency seen with runners is the arms moving across the body and/or elbows bent beyond 90 degrees. This creates more rotation force, placing increased pressure through the spine and also decreases the efficiency of moving the body forward.  In addition, holding the arms away from the body further encourages an arm swing across the mid-line and increases tension through the neck and shoulders.  It is important you keep your arms compact, by your side, bent between 60-90 degrees and moving straight back and forth to maximise efficiency.

3. Pelvis in neutral

While a slight forward tilt of the pelvis may help to facilitate a forward lean from the ankles, assisting with forward propulsion, it is best from our experience to keep the pelvis in neutral to maximise efficiency and optimal length/tension relationships for all muscles working off the pelvis. Conversely, the pelvis tilted backwards flattens out the spine and shortens the hamstrings, resulting in increased tension and effort to move forwards. While the pelvis is in neutral, it is easier for the trunk to remain upright, with the forward lean coming from the ankles.
Individual variations of the above guidelines may be required for specific runners with specific issues. For example, if you have a spondylolisthesis ( forward slip of one lumbar vertebra on another) it is more desirable to run with a slight posterior tilt to reduce the load on the vertebral segments. It is best to consult with a health professional to get the best personal recommendations about pelvic posture while running.

4. Footstrike – ideally should occur between rear and midfoot.

It is widely accepted that landing with a heel strike creates increased braking forces and places significantly increased load through the knee.  The majority of runners (80-85%) will land predominantly on their rearfoot, but it is important that this is occurring closer to the midfoot as opposed to the back of the heel.  The key measure for correct foot-strike is that the ankle should sit directly below the knee, with the tibia (lower leg) vertical at footstrike.

5. Optimise knee spring/stiffness in stance phase to approximately 25 degrees of knee flexion

It is important that we achieve a good balance between ‘spring’ and ‘stiffness’ in the knee during the initial part of stance.  This ensures we get good shock absorption, force distribution and support through the lower limb joints throughout this phase. Too much spring / knee flexion is indication of weakness through the lower limb muscles (quads especially) therefore increasing the force through the joints, particularly the knee.  Too much stiffness/reduced knee flexion will decrease the force distribution through the leg and places increased load through the ankle and calf.

6. The foot should land underneath you, with a quick pull back as you land

In line with the ankle sitting below the knee at the onset of stance phase, your foot should also not land too far in front of your pelvis – ie. Your foot should land underneath you, not in front you. At the least, your rearfoot should sit in line with the front of your pelvis as you land – as shown in the photo below.   A common biomechanical issue seen with running is the foot landing in front of the knee and hip/pelvis, which is termed over-striding. This is associated with significantly increased force and loading through the knee.

A quick pull back of the leg as you land engages the gluts and hamstrings effectively, helping to propel you forward.  This also assists in achieving enough knee flexion during swing, which is an important element to prepare the leg effectively for the next stance phase. 

Further information on these key elements can also be found at the following link:  http://www.nwpg.com.au/video-gallery/the-5-elements-of-good-running-posture

>We hope this provides you with some useful information to help guide you in achieving optimal running posture and biomechanics.

If you are unsure whether or not you are achieving some of these key elements, a running assessment with one of our physiotherapists can greatly assist with this.

This will include a comprehensive running analysis and functional screening tests to determine whether there are any factors that may impede your running. A detailed report with recommendations will be emailed to you to clearly identify the steps required for you to run with confidence.

Time for assessment is 1hr and a further 1hr is allocated for compilation of the report.

If you are interested in a running assessment, please contact us at the clinic to make an appointment.

If you would like to discuss further, please email graham@nwpg.com.au.

In our assessment with Mrs S, we looked for biomechanical factors within her musculoskeletal system that could possibly contribute to her heel pain.We found a whole host of imbalances including altered neurodynamics, lumbar, thoracic and cervical tension R>L, depression of the navicular bone in the R midfoot as well as hypomobility in the cuboid joint of the same foot. She also had trigger points and muscle guarding in the R subscapularis, tib posterior and glut medius. Mrs S could not heel raise on the R without pain in her heel and foot.

After normalising her neurodynamics, and through various treatment directed tests (treatment trials), we found that releasing her subscapularis virtually eliminated her pain when she heel raised. This also changed some of the other objective findings.

Treatment progressed to address other areas of imbalance and to improve her general strength and conditioning. Mrs S reported an 80% improvement in her symptoms before the 4th session and we were confident in gaining further improvement over the next 2-3 sessions. She started running again in that time.

This case highlights the fact that symptoms may not be triggered from local causes and can be caused by a build up of various imbalances throughout  the body.