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At Physio.co.uk we receive a wide range of musculoskeletal patients who present with an even wider range of conditions.

It is now spring – the sun is shining (honestly!), the running trainers have been dusted down and people are back plodding the pavements. Running season is officially back in full swing.

As a result, we begin to see a definite increase in patients walking, or most likely limping, into our clinics with a host of lower limb injuries.

This blog will focus on one of our most commonly observed conditions at this time of year, the runner’s unwanted friend – plantar heel pain.  

plantar heel painWhat is it?

Plantar heel pain is a term that is given to pain that is experienced on the inferior aspect of the calcaneous (the underside of the heel). PHP is a broader term that may be used to encompass related pathologies which may be difficult to accurately define as the definite the source of pain (ie plantar fasciopathy, heel spur syndrome, potential fat pad irritation etc).

PHP has remained a contentious pathology for a number of years, with debate existing regarding the aetiology of the condition, as well as its treatment (Porter, 2016).

Previously believed that bony spurs were major contributors to sources of pain, however, it is unclear whether bony deformities are to be attributed to this or are as a result of sustained altered loading of the plantar fascia (Agyekum, 2015), as non-symptomatic individuals can also demonstrate this.

It is also fair to say that developments in theories of tendon-related pathologies over last decade may have changed some perspectives and therefore treatments and management within this condition (ie Cook & Purdem’s work, Rio, Malliaras etc).

Who gets it?

  • Women > men (although the evidence varies…)
  • Between 11 – 16% of population (Western)
  • Average age 40-60
  • Average episode 6 months+
  • Increased BMI
  • Repetitive loading/unexpected changes to training loads
  • Alterations to foot posture – Pes planus/cavus deformities

foot anatomy - plantar heel painWhat will they present like?

  • Point tenderness – generally anterior-medial calcaneous but can also be mid plantar fascia
  • Recent altered loading – change in activities of daily living, altered training frequency or intensity, changes in footwear etc
  • Painful upon weight bearing – especially following periods of immobilisation (ie when rising from bed), this may be increased with hard surfaces
  • Reduced DF
  • Positive Windlass Test

(Martin et al, 2014)

  • Pain pattern (low SIN = pain post exercise, high SIN = during and after exercise)
  • Altered foot posture/biomechanics – alterations to mechanics (ie more proximally up the kinetic chain) can cause altered loading of the area

sports massage and physiotherapy - plantar heel painWhat else could it be?

  • L5/S1 Radiculopathy:

– Positive neural tension testing

– Nil pain on palpation plantar heel region

– Windlass Test negative (if performed in none neural tensioning positions!)  

  • Tib post tendinopathy:

– Alternative pain location,

– Similar aggs and eases (also biomechanics and foot posture…)

– Negative Windlass Test

  • Tarsal tunnel syndrome:

– Positive dorsiflex-eversion test (which may also provoke pain in plantar fasciopathy)                     

– Alternative aggs and eases

– Positive Tinnels Sign

  • Spring ligament strain:

– Alternative MOI (likely!)

– Alternative aggs and eases

– Alternative location of pain upon palpationphysiotherapy - plantar heel painHow do we fix them?

Physiotherapy management of PHP remains a primary way to treat the pathology.

While there is debate regarding the best methods of treatments to apply to achieve resolution, management may be loosely based around:

  • Offloading the tissue

         Avoidance of aggravating factors/activity modifications

         Use of adjuncts (ie heel inserts, footwear consideration, taping etc)

         Training load management

  • Tissue loading

–      Begin carefully structured loading (isometric contractions for pain relief)

–      Prolonged stretching (within pain limits)

  • Progression of loading

          Increase load (concentric WITH eccentric- within pain parameters),

          Eventually plyometric loading or controlled landing programme (if/when required)

  • Addressing biomechanics

         Posture

         Dynamic stability

         Kinetic chain (ie length/strength/activation/endurance)

  • Return to function

         Gradual, graded return to activity

         Load management

         Specific sport/activity preparation  sports massage - plantar heel pain

What outcomes should be expected?

Physiotherapy treatment remains effective for many patients with 80%+ reaching a successful resolution of symptoms within 12 months.  (Ageyekum, 2015).

Surgery is sometimes considered if conservative management is unsuccessful in patients with long lasting symptoms, however, there remain no randomised studies that demonstrate any assurances of their benefits or superiority over physiotherapy treatments (CSP, 2015).

Due to the numerous factors that can cause PHP, along with the difficulties that come with managing the symptoms and effectively returning to full function, rehabilitation can often be a lengthy process.

Patient compliance with the rehab plan is therefore hugely important to allow full resolution of symptoms and prevent re-injury. This places an emphasis upon the patient fully understanding the cause of the pathology, as well as the steps that are required to allow return to full function.

References:      

  1.       Porter, K. (2016). ‘Plantar Heel Pain’ in Baheti, N & Jamati, K.- Physical therapy: Treatment of Common Orthopaedic Conditions. Jaypee Brothers Medical Publishing: USA
  2.       Agyekum, E. et al (2015). Heel Pain: A Systematic Review. The Chinese Journal of Traumology. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/26643244
  3.       Martin, R. (2014). Heel Pain: Plantar Fasciitis. Journal of Orthopaedic & Sports Physical Therapy. Volume 44, Issue 11. Doi: 10.2519/jospt.2014.0303
  4.       CSP (2017). Plantar Fasciitis: The Evidence. Viewed: 27/06/17. Retrieved from: www.csp.org.uk/sites/files/csp/Plantar%20Fasciitis%20Evidence.doc 

 

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