The sedentary population will provide information on their health intake form , including medications ( e . g ., statins , BP meds ), diabetes Type I or Type II , and increased waist-hip ratio , which can usually be observed . These are factors that will need review and help from their GPs . The key point to understand here is that progress may be less responsive when compared to that of active populations .
Finding tissue tolerance and baseline functional capacity is a good starting point in the clinic , using static and dynamic hop tests . First , observe single leg calf raise in both straight and bent knee positions , asking for pain response ( usually this is negative except in acute cases ). In acute cases this will be your starting point . Progressing through to a hop ( double then single ) is all that is necessary to elicit a pain response and dysfunction – identified as loss of spring . The clinician will usually hear the thud on landing as the patient cannot store and release the energy using the plantar fascia .
Differential Diagnoses Before we start a treatment protocol , we need to be confident we are dealing with plantar heel pain . There is a range of differential diagnoses that present in this region that may call for different approaches . The following sources of plantar heel pain should be ruled out :
• Neural irritation ( medial calcaneal nerve )
• Calcaneal stress fracture
• Spondyloarthropathies ( rare )
Treatment - a soft tissue approach Treatment should always be based on your clinical findings . Consequently , it is not possible to be entirely prescriptive . What follows are suggestions that have been found to be helpful .
Moderate activities that provoke pain . Active populations usually need to find an alternative to running for cardiovascular exercise such as elliptical trainers , bike riding , rowing and swimming . These modes of training are generally non-provocative to plantar heel pain . In a case where these activities still irritate the condition revisit your assessment . Mild cases may be able to continue running with modifications like reduced intensity , reduced hill running and volume moderation .
Complete unloading is not always advised . Trial and error will help the patient find a baseline , for example , VAS may be stable at 2 / 10 pain after reducing training load by 30-40 %. Stable pain levels should be achieved over several days and weeks .
Specific plantar fascia loading has been demonstrated in small studies and cohorts ( 14 ). Taking a lead from this research and other evidence on structures such as the Achilles tendon , we can move into concentric / eccentric slow calf raises with the plantar fascia on stretch . Moving further , clinical practice using isometrics shows variable effects in other lower limb tendinopathies ( 15 , 16 ). While the evidence for isometrics for plantar heel pain is not strong ( 13 ), the time spent and the low risk may be worth considering if pain reduction has not been achieved by other means . Further increased stiffness in the plantar fascia and Achilles tendon has also been found in asymptomatic patients , compared to symptomatic ones ( 17 ). Increased connective tissue stiffness is an important factor when considering efficiency and ability to store and release energy . We know that strength improves mechanical stiffness of tendinous structures , which in turn improves function . It seems a logical choice for rehabilitation , particularly in the active population .
Tight calves are often labelled as a factor in plantar heel pain ( 11 ). Further evidence disagrees ( 18 ). Clinically , we can be guided by the assessment process to some extent , while appreciating that reduced dorsiflexion may be from a joint component or a soft tissue component ; hence , apply manual therapy and / or stretching based on the findings . Joint mobilisation or myofascial techniques can yield quick results and help to restore reduced dorsiflexion . This has the added benefit of addressing any excessive pronation issues . It is important to understand that pronation is necessary to allow the plantar fascia to spread load across the foot structures during the gait cycle . We are more interested in excessive pronation .
To address kinetic chain issues , we can use the reflexive nature of reciprocal inhibition practices : for example , as gluteus medius is inhibited , antagonists such as adductors and anterior hip structures often upregulate to take the additional load . Applying sustained myofascial tension to these areas allows the overactive structures to reduce in tone and hence restore function . Following up with some simple activation exercises ( local and remote ) will help close the loop . Trigger point therapy and dry needling can be useful in cases of thickened , atrophied tissue as can be found in chronic issues . Apply as assessment informs .
When to progress ? Progress when response to loads is favourable . If stable pain levels have not been achieved , reduce the load again . Once these have been achieved over several sessions , a small increase in load ( position , weight , repetition ) should be trialled and the response monitored . Addressing the findings in the assessment can be used as a guide , but ultimately it will be the patient response to applied loads that will be the driving factor . Continuing soft tissue therapy to help reduce pain and improve muscle function is an important part of the process .
Timelines Where we expect recovery in weeks with some injuries , we should expect it to take months with a plantar heel pain condition . Early on , pain control needs to be controlled to progress a load issue . In metabolic tendons it is an overall health issue combined with load modification . A wait and see approach usually proves to occupy about a 12 month wait . Patients , whether active or not , are looking for a quicker return to activity and life .
18 | vol30 | no1 | JATMS