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The 2 biggest myths about heel pain.
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:
- That where you feel your pain is where the problem is.
- 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.
