Plantar Fasciitis

Many practitioners will say that they can treat Plantar Fasciitis, however a lot of them don’t really understand the true cause of it. I am going to explain in basic terms how it comes about and how to solve the issue.

Fascia is latin for ‘band’, fascia runs throughout the whole of your body connecting muscles and other structures together. Fascia can get sticky and tight or over stretched and irritated. When stretched it slowly lengthens in a ‘plastic’ fashion, similar to how chewing gum lengthens slowly. In the foot is can become irritated if it is stretched too much and this is how Plantar Fasciitis begins.

The reason why it gets pulled too much is because the muscles that act upon the toes of the feet become weak and allow the toes to extend (correct term is dorsiflex) too much. When these muscles are functioning correctly they safely control this movement and prevent over stretching of the plantar fascia.

The most common mistake made when treating this injury is that patients are only told to stretch out the sole of the foot, calves etc. This will lengthen the weak and tight muscles (a tight muscle is a weak muscle) and will help improve the conditioning of the muscles that are poorly functioning. However, patients should then perform exercises to strengthen the muscles of the feet to allow the fascia to return to its normal length and cease injury recurrence. A good stretch is pulling back the toes whilst gently massaging the sole of the foot for 20 seconds. Repeat this 30 times per day for best results, seems a lot but you need to make a significant change as soon as possible.

Seeing a specialist to help with any restrictions is very important as this will significantly increase your recovery time.

So remember:
Early acute pain: stretch, ice, taping, orthotics and very light strengthening to tolerance
Later phase of treatment: stretch, increase strengthening and gradually withdraw orthotics.

How can I improve my posture?: understanding muscles

I have written about this topic as it is good to understand what can occur to the muscles within your body. This will help you understand a little better what can occur in the body that can lead to ‘poor posture’.

Muscle’s Elastic properties

Muscles are made up of packages (known as units) of ‘elastic’ (rubber band like) fibres. These fibres are prone to becoming too tight or overlengthened (hypertonic). Within your muscles and their tendons are cells which regulate the length at which they should be operating. These cells are monitored by the brain so that each muscle is held at a set length, this set length can be altered depending on how the body is utilised on a day to day basis and by stretching techniques such as ‘Proprioceptive Neuromuscular Facilitation‘. A good example of a muscle that can operate at a length that is too long is the hamstring muscle. If a person has a pelvis that is tilted forwards due to tightness of muscles such as those of the front of the hip, top of the rear aspect of the pelvis and muscles of the lower back then the hamstrings get pulled too long. This often gets mistaken for ‘hamstring tightness’. When this occurs it is known as the muscle becoming ‘locked long’, a contributing factor to this posture in regards to the hamstrings is that of sitting and sports that heavily use the hip flexors, such as in football.

Fascia’s Plastic properties

What links each muscle together is a tissue called fascia, this tissue is also prone to getting tight and has been found to have muscle fibres in it. However, in fascia the muscle tissue is different in that it is ‘smooth muscle’ tissue as opposed to normal muscles which are made up of ‘striated muscle’ tissue. This basically means that you cannot control its ability to contract, it contracts of its own accord depending on environmental factors and its role. Smooth muscle can also be found in your gut where its role is in the movement of fecal matter. Fascia’s properties are more ‘plastic’ in nature and therefore require a longer hold when stretching to achieve length (activities such as yoga are great for this).

Stretching muscles

When stretching, it helps to have the muscles warm to get a maximum stretch (such as with hot yoga AKA Bikram Yoga). However to make the most of your new found flexibility research suggests applying cold on the regions of stretch to ‘lock in’ the new length for a longer period of time. If you do do ‘hot yoga’ I would highly recommend taking a cold shower or for those that are brave an ice bath to really watch your flexibility improve!

Trigger points

Another aspect of muscles is that they can refer pain to another region of the body when they are either ‘too tight’ or ‘locked long’. This occurs due to trigger points forming within the muscle fibres, I talk about trigger points briefly here in this post.

Postural vs Phasic muscles

Muscles around the body also have different roles, this is important as it is important to remember what the muscles true role is so as not to cause it to function incorrectly. For example, amateur weight lifters often train their upper shoulders and neck muscles to make their shoulders look larger (muscles known as upper Trapezius and Levator scapulae). However the way a lot of individuals go about this is incorrect, lifting moderate to heavy weight for 8-10 reps for 3 sets in this region will lead to tightness and compensations at this region rather than a noticeable gain in size. These muscles are known as postural muscles and are designed to be trained to keep the head and shoulders in the correct positions all day long, not lift heavy objects at awkward angles. If they are going to be trained for size then a light to moderate weight with lots of reps is what is necessary to build up its endurance, only then will size increase while maintaining function. As well as training these muscles their opposites must also be trained to prevent poor posture, these are the lower and middle muscles of the back that support the shoulder blades (known as lower trapezius, middle trapezius, rhomboid major and serratus anterior). If these muscles are not trained then the shoulders are more prone to being shrugged and rolled forward constantly. Anyway, back to my main point, there are also ‘phasic muscles’, these muscles are those such as your biceps, these are designed to be used to lift heavy objects etc and training with heavy weights for 8-10 reps for 3 sets in this area is perfectly fine for its required role.

And finally… Nutrition

No body health related post would be complete with out mentioning nutrition. Our muscles thrive on good nutrition, there is loads of great information on healthy eating out there on the net though here are my recommendations. Lots of water and read this post: What should I be eating? If that post is too intense for you then read this one, its a lot less caring about the specifics and hones in on the simple principle of generally eating foods with “low calories but good nutrition” rather than foods with “high calories and low nutrition”. I like this principle as it makes deciding what to eat a lot easier! Stay balanced .

Follow Danny Google+ and Twitter.

Predictably Irrational Review

Apologies, it has been some time since my last post, I have been insanely busy with work and going on Holiday (time to get away from computers ).

I found this book after looking at books similar to the genre which I enjoy. It is written in a similar style to that of Malcolm Gladwell, stories based around research. The theme of the book in this case is the author’s personal experiences leading to his work and research. The research that the author has performed is brilliant, often putting subjects through very grueling complex tasks to find out very simple behavioral tendencies. It is remarkable to read how the subjects in some of the tests reacted, it really does make you think a lot about peoples actions to various situations and stimuli. Dan Ariely briefly speaks about a few of the topics from his book in this TED talk if you would like a taster of what is to be expected from this thoroughly enjoyable read 4/5:

If you like this book and style of writing, try reading Malcolm Gladwell’s books: Outliers, Blink and Tipping point. Outliers is a particular favorite of mine.

This post is quite important for me as this short story is the reason why I became a Chiropractor in the first place. At the age of 14 in the midst of a promising young football career, I developed a disease called Osgood Schlatters in both legs. This disease is due to the repetitive pull of the quadriceps on the knee cap and therefore the patellar tendon that attached to the lower leg. This repetitive pull along with the softer adolescent bone leads to very subtle avulsion of the bone (pulling away) by the ligament itself. This condition does not last for ever, though it can last months, years and, rarely, it can recur. At the time of onset it stopped me from playing Football (Soccer) for 6 months. I was playing football 6 days a week for 3 different teams, so in retrospect it was not surprising that my body failed eventually.

What Happened?

Initially I was diagnosed as having Osgood Schlatters in my right leg which lasted around 3 months, however on returning to playing football again I had it in my left leg and was out for another 3 months. At the time I was playing for the youth academy of my local professional Football team Bristol Rovers and also had hopes to go professional as I was progressing well. When the team’s head Physiotherapist assessed me I was told that I had Osgood Schlatters, told I had tight Hamstrings, to stop playing football for 3 months and was recommended a specialised strap for my knee as well as being told I had an ‘abnormal gait’. Now a gait is basically the style in which we walk, and everyone has one, however my parents were not academics and I was told that I had a ‘gait leg’, amusingly this led me to believe that I walked as if I was hurdling a gait on one side… as you can imagine for a 14 year old this was very confusing indeed.

I am now 25 years old and have decided to write this post to help younger aspiring athletes to find a solution to their problem. I am now a Chiropractor, with extra qualifications and experience in treating sports injuries and can now treat this condition effectively.

What is it like to have?

Imagine running, and every time your foot hits the floor it feeling like someone has hit a bruise that you have at the top of your shin lightly with their knuckles. This would occur over and over again as you run, then kicking a ball would feel like someone has hit you a bit harder. Its not a sharp pain, just a very intense dull ache that following each session of running can last for 30 minutes or so after. It is draining as you cannot perform at your max and it makes you feel weak.

Why does it occur?

Osgood Schlatters basically occurs due to a combination of 1) Playing too much sport, 2) The type of sport that is played, 3) The compensations the body makes and 4) Nutritional intake. Now I do not have any studies or written evidence to back up what I am about to tell you, all I have is my knowledge from books and blogs I follow and my experience.

Not all causes of Osgood Schlatters will be the same, the only true way to get the cause examined is an in depth assessment by a sports specific manual therapist that is recommended and has experience in treating athletes. You have to find the initial cause of the problem, the obvious cause is the Quadriceps pulling too tightly on the point of insertion at the tibial tuberosity (the point that enlarges). So a simple recommendation is to stretch all four of the Quadriceps, this can be achieved in lots of ways, just look at youtube! I would recommend using a foam roller on the quads as well as the stretching routines you can find generally. Once the heels can reach the buttocks on both sides you can start working on strengthening the Quads to make sure minor strains and the build up of tightness does not reoccur.

How can you stop it coming back?

Now the bit that will stop it coming back again is by having a full bio-mechanical check over of the muscles of the pelvic region (this means checking muscle tightness, compensatory muscle imbalances and correcting muscles that are not firing correctly). This is hard to do at home and a specialist (a good Chiropractor, Osteo or Physio) can tell you which areas to work on to improve this area.

Now, here are my recommendations:
i) Stop all sporting activity other than swimming (non-weight bearing and maintains fitness)
ii) Use an ice pack on the region 10-15 minutes 2-3 times a day initially and after each time it feels sore. Consider taking ibuprofen tablets and applying ibuprofen gel to the region daily also.
ii) Foam roller on the quads and after a week of this begin using general Quad stretches, make sure your pelvis does not tilt forwards with these stretches as this is cheating and decreases the benefit of the stretch)
iv) Once you heel can reach your buttock on each side, progress on to gentle wall squats increasing the angle of squat each time till you reach 90 degrees without pain.
v) At this point try gentle jogging on soft grass progressing in intensity over a week, then try on concrete for a week, then make the intensity more sport specific by changing direction as you run. All the time you are returning to sport make sure you are stretching and icing the knee region. If pain is felt again at the knee, stop immediately, Ice the region and take 2 steps back then build back up again. Pushing through the pain will not gain you anything but more pain with this problem.
vi) Have a specialist check over to see if there is anything else you can do at home to improve function of the pelvis.
vii) Increase Vitamin D, Vitamin K and Calcium intake as this ensures good bone density and will aid in the healing of the region of bony avulsion.
viii) Read my post called What should I be eating?, you do not have to change everything in your diet, though I would highly recommend trying some of it as decreasing your level of Pro-inflammatory fatty acids and increasing your anti-inflammatory fatty acids will increase your general healing rate as an athlete exponentially. Remember, ‘you are what you eat’ and the general UK diet is high in grains which is not normal for the human body, crops are only a very recent development!

ix) E-mail me, I am always happy to help others with Osgood Schlatters, teams or individuals, it is a very common problem which affected me personally by ruining my Football career. No team wants a Footballer that can’t play for months on end and I hate hearing of others, and their potential careers, suffering unnecessarily.

Who gets it?

This post is on a common running injury called Iliotibial band syndrome, also known as runner’s knee. This injury is more common in women, this is probably due to the fact that women tend to suffer from their knees being knocked in (also known as Genu Valgum) more than men. However this problem has been known to occur in people with bowed legs (Genu Varum). The reason for females having a higher likelihood of their knees being ‘knocked in’ is still contested. However, the most common theory is because females have a wider pelvis to give birth and therefore wider hips and a different center of gravity compared to men.

What is the Iliotibial band?

The Ilio Tibial Band (ITB) is the longest tendon in the body, it originates from the anterior iliac crest outer lip, anterior border of the ilium and the outer surface of anterior superior iliac spine. As well as from the Gluteus Maximus and Tensor Fascia Lata muscles (In normal words that is an area of the upper outer edge of the pelvis, the muscles originating from the very front upper outer region of the pelvis and part of your bum muscle). Previously thought of as just a connective piece of tissue, recent research has found that tendons and fascia do in fact often contain smooth muscle fibers. ‘Smooth’ muscle fibers are the type more often found in the gut, ‘striated’ fibers are found in the muscles of movement attached to the joints. It aids in leg abduction (leg raising directly out to the side) and force distribution through the leg, it is also an important player in producing fascial tension that supports the Thoraco Pelvic Canister and therefore the lower back.

So what happens?

ITBS basically is due to repetitive rubbing of the band on the outer part of the knee (lateral femoral condyle), this leads to thickening of the band over time and eventually irritation that takes a number of months to resolve if not managed correctly. Self management of the lower limbs and building good movement patterns when not in pain is the key to preventing this injury from coming back.

Do In-soles help?

Footwear is another modern age addition to the body we all are using, which the human body adapts too, often causing problems. The lower limbs often suffer with injuries due to poor function and compensations. Also add in the sports we repeatedly challenge our body with and the abnormal positions these entail and you end up with multiple reasons why chronic lower limb injuries such as ITB Syndrome can occur. Orthotics can be helpful in reducing the pain in the short term, though this makes the lower limbs even lazier relying on the artificially induced arch and may cause consequences over time. For example what do you do once the pain comes back when the arch no longer does its job in the long term? You’ll be in a bigger mess!. Make the decision as to whether you want to rely on an in sole (like a band aid), or cure the problem in the long term. However, in the short term use the insoles are a fantastic way to help reduce the inflammation and irritation of the band, though in the long term it is a whole other ball game.

What can I do about it?

ITB syndrome can be self managed in a variety of ways, a foam roller, tennis ball and an Ice pack are your key utensils to getting over this condition. Many rehab ‘specialists’ will recommend simply using a foam roller on the ITB to stretch it out (youtube it to see). However, there is soo much more you can do to help this problem. It requires a lot of time and effort though the results will come a lot faster than simply ice and ITB foam rolling, though. A home treatment plan is not within the scope of this post and causes will differ from one person to another so a bio-mechanical assessment by a movement specialist is what I would recommend getting and a second opinion is always something worth considering. Just remember, the whole lower limb has to function correctly, not just one area. It is all related, foot, knee and hip though it is the connecting musculature and fascia that are the cause, with some areas more related to the ITB than others .

Sports Chiropractors (skilled and well read ones) are movement specialists having further qualifications in sports science and constantly reading the latest books and research to get your body functioning better (not just the latest rehabilitation fad!). If you are suffering from ITBS or repeatedly suffer, then contact me for more info and advice. Danny@longlevenschiro.com