fbpx

Foot pain, plantar fasciopathy (including Plantar Fasciitis), and heel pain affect many people. Our osteopaths work in our specialist physical rehabilitation clinic for Cambridge patients with osteopathic treatment and dynamic exercise physical rehabilitation therapy, for plantar pain (sole of foot pain) and foot control, and other lower limb pain conditions, including foot joints and toe tendons and mid foot conditions. Working with a vast range of Sports Performance abilities, allowing us to have very positive contact with all foot pain symptom sufferers. This is why we provide some of the most up to date Cambridge Sports Injury Treatments.

In fact, foot pain (including plantar fasciitis pain, tendinopathy, mid-tarsal joint pain, ligament sprain, or similar pain syndromes and muscle strains) are common musculoskeletal disorders, and the burden is most likely underestimated, and poorly understood. The ‘physical and personal impact’ of musculoskeletal illnesses are believed to generate some of the highest costs to society. Foot pain and foot mobility seems to have large effects on daily activities, disability levels and quality of life.

For most plantar pain and foot pain suffers, the most cost effective therapy options include exercise therapy and manual therapies, to improve physical function and performance. Additionally, aplying preventative interventions are important and a suggested focus.

Diagnosis

Some of the most commonly ‘diagnosed’ issues leading to an episode (acute), or multiple episodes (chronic), of foot pain, with or without ‘swelling’ (filling of the foot joints and capsule or fluid around the joint area) are:-

Plantar fasciitis (Planar Fasciopathy), Avulsion fracture, Bone spurs, Broken foot, Broken toe, Bunions, Plantar warts, Psoriatic arthritis, Raynaud’s disease, Reactive arthritis, Retrocalcaneal bursitis, Rheumatoid arthritis (inflammatory joint disease), Stress fractures, Tendinitis, Bursitis (joint inflammation), Corns and calluses, Diabetic neuropathy (nerve damage caused by diabetes), Flat feet, Gout (arthritis related to excess uric acid), Haglund’s deformity, Hammertoe and mallet toe, High heels or poorly fitting shoes, Metatarsalgia, Morton’s neuroma, Osteoarthritis (disease causing the breakdown of joints), Paget’s disease of bone, Peripheral neuropathy, Plantar warts, Psoriatic arthritis, Raynaud’s disease, Reactive arthritis, Retrocalcaneal bursitis, Rheumatoid arthritis (inflammatory joint disease), Stress fractures, Tendinitis, Fat pad contusion, calcaneal stress fracture, medial calcaneal nerve entrapment, lateral plantar nerve entrapment (Baxter’s nerve), tarsl tunnel syndrome, talar stress fracture, retrocalcaneal bursitis, osteoid osteoma, complex regional pain syndrome type 1 (after knee or ankle injury), navicular stress fracture, midtarsal joint pain, lisfranc joint injury (sprain), tibialis posterior tendinopathy, plantar fascia strain, cuneiform stress fracture, cuboid stress fracture, stress fracture base second metatarsal, extensor tendinopathy, peroneal tendinopathy, abductor hallucis strain, cuboid syndrome, tarsal coalition, Kohlers disease, accessory navicular bone, lisfranc’s joint injury (fracture or dislocation), osteoid osteoma, referred pain, stress fracture of the neck of metatarsals (I-V), stress fracture of the base of the second metatarsal, fractures of the fifth metatarsal, metatarsal phalangeal Joint Synovitis, first metatarsal phalangeal joint sprain (turf toe), hallux limitus, hallux valgus (bunion), sesamoid injuries including stress fracture, plantar plate tear, morton’s neuroma, corns, calluses, onychocryptosis (ingrown toenail), stress fracture of the great toe, joplin’s neuritis, freiberg’s osteochondritis, toe clawing, subungual haematoma, subungual exostosis…..The list goes on!

The quality of some of these diagnosis concepts, and the actual correlation to your pain, are even more fascinating!

How This May Affect People

When this doesn’t go well, it often leads to a very dissatisfying outcome. This can manifest itself as: deconditioning, disability development, depression, loss of confidence in yourself and your body, which ultimately often leads to a dependency on pain altering medications, and poorer physical health.

So, what are we to do? Are we to:- be immobile?, be mobile?, be active?, or minimally active?, train into pain (‘no pain no gain’)?, or train avoiding pain?, stretch the foot?, or no stretching of the foot?, use medication management?, topical or oral?, use massage?, use mobilisation?, heel lifts?, or no heel lifts?, foot orthotics and arch supports?, or no foot orthotics and no arch supports?, Osteopathy or chiropractic or physiotherapy?, use prescriptive exercise?, regular treatments or minimal treatments?, have imaging or not to have imaging?, surgery?, should we focus on structure or function?, or is it just age?!!!

{

Michael Parr is without a doubt the most skilled and amazing osteopath I have ever met. His clinical and diagnostic skills are second to none. After a very bad fall and seeing 3 osteopaths for most of last year, Michael diagnosed and ‘fixed’ me in one visit! It has taken some more visits to remedy the root cause and set me on the path to health, but I have now completed two walking marathons and contemplating a 10k run, something I would never have entertained at the beginning of last year. His approach is the complete package, with ‘hands on’ work, advice and exercises, as well as gentle, secure and professional attitude. I would wholeheartedly recommend him in a second. Top dude!

Investigations

Our knowledge and understanding of the body, and mechanical anatomy of the foot, its associated structures and the muscles used for stability and injury prevention, are still being updated and evolving. Allowing for constantly changing assessments, treatment and rehabilitation techniques.

Imaging

Sometimes additional investigations are needed. However, for ‘non-specific foot pain’, they are rarely needed as a primary input into your assessment and treatment.

Imaging was originally seen by most, as a tool to rule out pathology or disease states, and less to diagnose specific musculoskeletal causes. Often this was due to a poor correlation of images and symptoms. New imaging approaches have developed, and our dependency on them has increased!
However, recent studies show that by performing a thorough clinical case history and physical examination you can often, very effectively decide if MRI or additional imaging or other investigations are needed.

General Imaging

Magnetic resonance imaging is advantageous for assessing soft tissue structures around the ankle and foot, such as tendons, ligaments, nerves, masses and occult osseus lesions.

Bone Scan’s and Single Photon Emission Computed Tomography (SPECT), have uses, and can be used in combination, as SPECT/CT, a hybrid imaging method incorporating SPECT and computed tomography (CT). These SPECT/CT images are comparable diagnostic performance to MRI images for symptomatic lesions in ankle and foot pain patients. ‘SPECT/CT and MRI exhibit different diagnostic specificity in different lesion types. SPECT/CT may be used as a complementary imaging method to MRI for enhancing diagnostic specificity.’

Plantar Fasciitis

Most cases of plantar pain are not plantar fasciitis. Clinicians are normally able to differentiated what is the cause of pain without imaging. However imaging may help people be assured of this.

Contrast-enhanced ultrasound (CEUS), is used to visualize the microvascularization in a variety of tissues. The microvascularization in ‘the plantar fascia and plantar fat pad can be measured reliably using CEUS, suggesting that it is a reproducible method to examine patients with plantar fasciitis.’

Bone Stress Injuries (BSIs)

MRI grading classification for BSI has been proposed and may guide return to play.

Ligamentous Lisfranc Injuries

Ligamentous injuries to the midfoot, Weight-bearing anteroposterior and lateral radiographic examination of both feet focusing on the midfoot is essential, allowing comparison between the injured and uninjured extremity. ‘Diastasis between the proximal first and second metatarsal is a classic radiographic finding, but proximal extension between the cuneiforms can also be present. A more severe injury shows loss of the longitudinal arch or subluxation of the midfoot that is identified on a lateral radiograph. A tear or an avulsion of Lisfranc ligament along with other midfoot ligaments is the underlying pathology. Advanced imaging modalities including computed tomography and magnetic resonance imaging are useful in these more subtle injuries or when more specific anatomical detail is required.’

Morton’s Interdigital Neuroma

Imaging studies such as standing X-rays, MRI Scans, and Ultrasound, all aid in the differential diagnosis process.

 

Physical Assessment

Physical assessment by a clinician is vital in all cases of foot pain, plantar pain and heel pain. This should include an appreciation of all the lower extremity injury risk factors.

Plantar Fasciitis

Clinicians have concise guidelines for diagnostics of plantar fasciopathy.

People with unilateral (one sided) plantar fasciitis demonstrated weaker toe flexors, also findings indicated that the toe flexors for the involved feet were significantly weaker than the uninvolved feet. Additionally, and very importantly, passive extension range of motion of the first metatarsophalangeal joint was not significantly different between the involved and the uninvolved feet. They state ‘indicate that the extensibility of soft tissues influencing extension of the first metatarsophalangeal joint was not related to the presence of plantar fasciitis’,

This perhaps indicates that stretching tissues will not change the outcome, and how full range of motion is already present.

Bone Stress Injuries (BSIs)

Bone stress fractures are more common in women, and more common still in slender individuals, who have calorie constrictions, and are training regularly.

Morton’s Interdigital Neuroma

Clinical presentations and examination, alongside correct case history, usually reveals the clinical diagnosis.

 

Does This Apply To You?

This affects active and sedentary individuals alike.
All Athletes and all relatively inactive people, could be affected by foot trauma and non-traumatic foot pain.
This risk of foot pain and Plantar Heel Pain including lower extremity tendinopathy is a common sports injury, however, it can also affect non-athletes. Having an effect on people’s ability to work, move as they desire, physically express themselves, perform, and their general quality of life.

What Can Help

For lower extremity injury, ‘Prevention of injury remains an important goal for clinicians and researchers’.
 

Taping

When assessing the effect kinesiotaping (KT) versus sham, on pronated foot postures and walking plantar pressures. They note ‘there was no effect of KT’, and that ‘the sham KT technique had a greater effect’.

Orthotics

To systemically review and analyse the data, for the efficacy of foot orthoses for the treatment of plantar heel pain. Studies looked at the effects of different orthoses on pain, function and self-reported recovery in patients with Plantar Heel Pain and compare them with other conservative interventions.

No difference was found between sham orthoses and custom orthoses for pain at short term, nor was there a difference between prefabricated orthoses and custom orthoses for pain at short term.

Concluding, that ‘foot orthoses are not superior for improving pain and function compared with sham or other conservative treatment in patients with Plantar Heel Pain’.

Naturally certain conditions require additional support, and orthotics are likely a usefull method to do this.
 

Plantar Fasciitis

Often now called ‘plantar heel pain’. Some ‘trials have found that the effectiveness of these interventions differs over time, with corticosteroid injections being more effective in the short-term (i.e. 0–4 weeks) and foot orthoses more effective in the longer-term (i.e. 5–12 weeks).’

However, ‘patients may not notice a clinically worthwhile difference between the interventions’.

Therefore, more needs to be understood for a positive outcome. Ultrasonography-verified plantar fasciitis sufferers, used shoe inserts and daily plantar-specific stretching, or compared, shoe inserts and high-load progressive strength training, performed every second day. They found, ‘a simple progressive exercise protocol, performed every second day, resulted in superior self-reported outcome after 3 months compared with plantar-specific stretching. High-load strength training may aid in a quicker reduction in pain and improvements in function’. After 1 year, those who trained the feet, still had a better outcome than those who performed stretches of the foot.

This is also in line with other systematic reviews, which look at the Strength training for plantar fasciitis and the intrinsic foot musculature (training approaches to treating plantar fasciitis and improving intrinsic strength), which found research to indicate foot exercises and toe flexion against resistance, may contribute to improved intrinsic foot musculature function, with reduction of pain and improvements in function.

The strong evidence on the benefits of physical exercise therapies, and manual therapy are clear

Pronation

Pronation of the foot, often termed ‘flat footed’, is a normal function, and complex motion of multiple planes of movement, to assist with shock absorption, and allows for grounding, when walking and performing other activities.
Many people have an incorrectly fitting shoe for their feet, leading to increased demand on certain tissues, and more ‘pronation’ occurring and less functional fluctuation of the foot shape.

Sometimes simple toe spacers work very effectively, to guide restoration of the foot.
At other times, specialised exercises are required to achieve this restoration of foot shape and function.
The foots ‘core system’, and the understanding of intrinsic foot muscle functions, role in static posture and dynamic activities. Movement and stability of the arch’s of the foot are ‘controlled by intrinsic and extrinsic muscles’.

The muscle stretch reflex action (‘H-Reflex’) of the abductor hallucis muscle in the foot, is lower in people with ‘flexible flatfoot’. Interestingly those with flexible flatfoot are also found to have higher muscle activity. Showing that, ‘increased postural demand’, meant that ‘flexible flatfoot individuals maintained their postural stability by recruiting greater foot muscle activities than through automatic stretch reflex’. Therefore compensating for the flexible mid foot with muscle activity, not foot supports.

Exercise training with abductor hallucis strengthening exercises, increased muscle activity, and significantly increased muscle activity during toe-off. Helping correct the pronated foot, and reducing navicular drop, and is an ‘effective method for achieving normal gait’.

Heel Pain

For runners, there seems to be some logical fallacies in the running shoe debate. Shoe design may not be linked in the prevention or improved of outcomes .  There is no evidence to say either way.  The authors mention, ‘there remains a lack of conclusive evidence to support traditional shoe prescription to prevent running-related injuries (RRI)’.

Morton’s Interdigital Neuroma

Guidance for the management of a Morton’s Neuroma, includes correct physical rehabilitation, and modification of activities, alongside nutritional supplmeentation.

They suggest that we must consider the bigger picture which should include calf muscle tightness, hind-foot or fore-foot derformity and long lesser metatarsals.

 

Whole Body Integration

Then we can start to look at more global motor patterns, and treatment plan.

There is a link between foot posture and lower extremity pain, indicating that foot posture and foot shape, and may have an effect on the ankle or knee. The association between foot posture and function, and lower extremity pain. Planus foot postures, are ‘associated with greater risk of knee and widespread lower extremity pain, while cavus foot posture is associated with ankle joint pain’.

Correct alignment of the lower limb should be maintained, in order to introduce optimal calf muscle elongation, without strain to the plantar fascia, in the treatment of plantar fasciopathy.

Concurrent foot pain is common in people with knee osteoarthritis and impacts health and functional status. Foot pain is associated with knee osteoarthritis. Foot and ankle issues may boost risk of clinical and radiographic knee Osteoarthritis (OA). The relationship between foot and ankle symptoms and risk of developing knee osteoarthritis has been better understood in recent years, until it is now stated ‘In individuals at-risk of knee osteoarthritis, the presence of contralateral foot/ankle symptoms in particular increases risk of developing both knee symptoms and symptomatic radiographic knee OA’.

Dynamic Exercise Therapy is very useful for foot pain. This includes plantar heel pain exercises, which can be good for general foot health.

Incidence of secondary overuse musculoskeletal injury is elevated in those who have loss of function of one lower limb. Perhaps indicating that whole body adaption must occur.

Intrinsic foot muscles adapt to tendinopathy of the Achilles. With Abductor Hallucis Brevis and the Flexor Digitorum Brevis thickness increases. Additionally the cross sectional area of Flexor Hallucis Brevis and Flexor Digitorum Brevis was increased.

There is a link between foot posture and lower extremity pain.

Foot exercises and combined orthotic use is more effective than knee exercises for patellofemoral joint pain (PFJ pain).

Assessments looking at the alignment of the rearfoot and foot pressure patterns, found that athletes with medial tibial stress syndrome (MTSS) showed the rear foot eversion on walking, high foot pressure of the medial metatarsal areas and narrow figure of center of pressure path., showing that Rear foot malalignment in individuals with MTSS can be detected on walking, even if the alignment on standing is normal. Additionally, this study showed that an arch increase, caused more tibial stress.

Injured runners run with smaller foot inclination at initial contact. Along with greater contralateral pelvic drop at midstance, and with greater femoral and hip adduction at midstance, during the running cycle.

In some cases, using shoe insoles for leg length discrepancy correction, ‘appears to assist in improving postural symmetry and dynamic balance’.

Hip muscle strengthening exercises are an important part of plantar fasciitis management. Especially for those with apparent high-arch feet and concurrent intermittent pelvic pain. With the suggestion that ‘clinicians should try to identify the hip abductor muscles weakness’, and consider ‘incorporating hip strengthening exercises’.

In flat foot individuals, navicular drop and pronation of the foot, and the resultant changes to the plantar arches (lateral longitudinal arch, the medial longitudinal arch (MLA), and the transverse arch), were improved with toe spread exercises for muscle activity of muscles such as abductor hallucis, and gluteus maximus strengthening exercises.

Additionally, Combination treatments of Hip Strengthening and Manipulative Therapy (manual therapy) for the treatment of Plantar Fasciitis has been assessed.

Measuring pain intensity (Numeric Pain Rating Scale), pressure-pain threshold (algometry), and perceived exertion (OMNI Resistance Exercise Scale). They found an improvement in pain intensity and an increase in the pressure-pain threshold). Perceived exertion was also improved after hip muscle strength training. Concluding that the ‘combination of hip strengthening and Manipulation therapy improved foot pain in a patient with a clinical diagnosis of plantar fasciitis’.

Gait deviations associated with plantar heel pain, can be compared to asymptomatic cases or limbs, assist in identifying movement-related gait dysfunction for treatment decisions, or as outcome measures of recovery.

Dynamic Exercise Therapy is very useful for foot pain. This includes plantar heel pain exercises, which can be good for general foot health.

This may show why whole body assessment and treatment, is reported anecdotally to be so effective in clinic.
These positive effects from manual therapy and exercise, may be due to the increasing body of evidence, that pain is a brain interpretation of data, and the local structure itself, cannot be consistently linked with pain or general function.
Additionally, manual therapy by an osteopath including the use mobilization and manipulation, and prescription exercise therapy, are all safer than long, or even short term medication treatments, such as non-steroidal anti-inflammatory drugs (NSAIDs). Additionally, these are statistically safer than surgical intervention.

The point here is that there are many opinions and many solutions, to treating foot pain (joint pain / heel pain / plantar fascia pain / ligament pain / muscle pain). Perhaps some, in our opinion, are more rational than others and some statistically safer than others, and some more empowering than others.With all treatments, it’s important to get the diagnosis, advice, and treatment programme from people who are trained, skilled and prepared to aid your musculoskeletal needs, such as at our Cambridge Osteopathic and Physical Rehabilitation Clinic.

Treatment Options

The guidelines for ‘foot pain’, includes the guidance to when suitable remain as active as possible, seek support and advice at a specialist clinic, for, assessment, diagnosis, education, management advice, prevention of reoccurrences advice, stabilisation and manual therapy including mobilisation treatment, hydrotherapy application, increase in strength and muscle control (motor control training) and specialist exercise therapy for rehabilitation.

At Elementary Health, our Cambridge Osteopath Clinic, we provide a seamlessly layered combination approach, of diagnosis, education and therapeutic application. This includes education of anatomy and pain theories, manual therapy, osteopathy for foot pain, posture advice and training, lifestyle advice, hydrotherapy guidance, dietary overviews, and dynamic exercise therapy with motor control training rehabilitation. All of these work together to provide a uniquely structured approach, towards the aim of restoring your brain’s interpretation, or ‘mapping’ of your healthy functioning body, giving you back the control!

Next Steps

If there are any other questions, or, you wish to book a consultation with Michael Parr the consulting osteopath in Cambridge, based at Elementary Health. Please don’t hesitate to call or email.

Cambridge Osteopathy
& Rehabilitation Clinic

8c Romsey Terrace
Cambridge
CB1 3NH