[Podcast] Heel pain and running

Speaker 1: Adam Byrne, former BUPA physiotherapist

Hi everyone and welcome back to the Joint Approach podcast, a podcast dedicated entirely to the discussion of musculoskeletal physio conditions.

My name is Adam Byrne, I’m a physiotherapist working for Bupa in central London. On each episode of this podcast, we will discuss a specific topic related to physio with a special guest and today's special guest is Katharina Schaps. Kath is the Musculoskeletal Therapies Team Lead with a very special interest in foot and ankle conditions.

Today's area of interest for us is plantar fasciitis. Kath when I say plantar fasciitis what springs to mind for you?

Speaker 2: Katharina Schaps, former MSK Team Lead at Bupa

Plantar fasciitis is probably the most commonly known term for anyone who is experiencing pain around the inner heel area. Some people might even come across a different terminology. So ‘plantar heel pain’ is often used, ‘plantar fasciopathy’ or a really sort of layman's term could be a ‘runner's heel’.

So, you know, if you do suffer with these kinds of symptoms, you may hear different types of terminology depending on where you're going to get your diagnosis. For sake of ease, I actually prefer using plantar heel pain, just because it encompasses a larger section of different conditions that can be causing the type of heel pain that you might experience in that area.

We don't tend to like using plantar fasciitis as such anymore because the ‘itis’ in the fasciitis actually refers to something that has an inflammatory root cause. And lots of researchers have actually found that that isn't really the case. Plantar fascia inserts into the heel bone and it's often really associated with calcification of that area of the plantar fascia and there's new blood vessels and new nerves that infiltrate that area that actually shouldn't be there.

So it's really a condition where over time the plantar fascia becomes irritated and swollen. Often times, it's really more related to load capacity. So, how much that structure can actually tolerate in terms of maybe the walking load or the running load or whatever it might be that's originally aggravated that condition.

So plantar heel pain is really the terminology we want to use to describe it.

Adam Byrne:

Yeah, that's really good. And if there's somebody listening who thinks they may have this sort of condition in their foot, where would you expect them to feel the actual pain? If they were to look at their foot now, where would you say that you would most likely experience the pain of this sort of condition?

Katharina Schaps:

The really classic location is right under the heel, perhaps a little bit more towards the inner side of the heel but it's usually a very, very pinpointed location of pain. At times, there can be some people that describe a little bit of pain that travels into the arch of the foot that can be associated with the sort of plantar fascia pain. But usually, you wouldn't get anybody who describes pain more into the toes or into the back of the heel or around the Achilles.

At that point, we would then maybe be questioning, is this pain actually coming from somewhere else? So, most of the time it's a relatively easy condition to diagnose because it is so pinpointed in the pain. So, if you're listening and you've got some heel pain somewhere and you think it's kind of traveling into other areas, I would probably then start to question whether it is truly a plantar fascia problem or whether it's actually a different part of the body that is causing that type of pain.

But you know just talking about the classic signs. As well as having very pinpointed pain, usually these kinds of cases would also say that it's at its worst in the morning when they first step out of bed. The first few steps are very, very aggravating and very painful, often associated with probably a bit of limping. Classically, also walking downstairs in the morning can be a sign of plantar fasciitis or plantar heel pain.

And then sometimes depending on the aggravation pattern, so how irritated is the plantar fascia already, some people would also say that it's painful to stand up. So if you've been sitting down for a little while and then you stand up from your chair and you try to walk, you might find that you're hobbling again because it is quite uncomfortable.

Another thing to mention as well, is what sometimes happens when people start walking is that it's uncomfortable. But as they continue walking the pain actually starts to ease off. Then the pain might also only return towards the end of a really long walk, for example, or at the end of, let's say, you've done a really extra long walk over the weekend, taking your dog out for a walk, and then afterwards you might feel a bit of aching. But really, the most classic signs is that morning pain that people will often describe.

Adam Byrne:

And when you think of potentially the more active group of people, is there a group of people that this condition fits more with? You know like when I think of plantar fasciitis I think more down the kind of runners and people putting a lot of impact through the foot. Is that something that you see quite commonly also?

Katharina Schaps:

Yeah definitely I would probably say it's a mix of patients that present with these types of problems. Broadly speaking we will probably categorize them into, the really active patient that is maybe into their running or into lots and lots of walking versus perhaps the type of patient that doesn't engage in regular activity, that is maybe a little bit more sedentary in their job, for example. But I find it can happen in both population groups. It's not sort of a condition that is very much more geared towards the active population or not.

I do have to say if if there is a patient that is more sedentary, the onset of pain is usually related to some kind of change in activity. So, for example, somebody who doesn't exercise regularly and then suddenly decides to do a 30-mile hike and that brings on that pain. That is related to them not being very active usually and then suddenly overloading that plantar fascia and it becomes so painful afterwards.

Adam Byrne:

Yeah, that makes sense. And I guess the same sort of principle could fit really for somebody who is, let's say, a runner who runs 15 kilometers a week. Then next week and the week after, they double their mileage or whatever it might be. I guess even though they're part of somewhat of an active population, do those same risks apply to that group of people also?

Katharina Schaps:

Yeah that's a really good question. I think you always have to look at it on a case-by-case basis. So you might have a runner who let's say runs really, really, really regularly and you know their calves, their leg muscles essentially are very much used to being loaded and that includes the plantar fascia.

But then usually, there'll be some sort of change in their training routine either because they've suddenly done more, they've gone for a speed session or they've trained on different surfaces. Or, they've suddenly changed their footwear which can also have an impact on the onset of plantar fascia pain.

That's something that as physiotherapists, we usually go through in the history taking to make sure we understand where that change has happened and how can we now influence them not repeat the problem again. We also want to improve that load tolerance a little bit.

And we'll probably come to talk about exercises in a second and how we can actually change that load capacity a little bit more.

Adam Byrne:

Yeah, for sure. We're physios, we can't get away from exercises. Clinically, if somebody presented to you, are there telltale signs that you would look for? Like as they may present, obviously subjectively, what they tell you in their history will tell you a lot, but is there things then that you would go to to back that up straight away?

Katherina Schaps:

I mean, yeah, as I already mentioned, kind of the history taking is really important in terms of knowing what the activity levels have been like in the last few months.

And if somebody comes in and says, I've had this problem for over a year, I would actually go as far as going back through the history to understand what the change was at the time that might have led to this.

And sometimes there isn't sort of a very clear-cut sign. So you sort of need to think, ‘okay, what is the base level of activity tolerance?’ Has there been a change or has it been more a very, very slow and gradual overload? So it's almost like a repetitive strain type of problem through the plantar fascia.

The things we generally try to look for are, as well as sort of the loading pattern, is to understand whether their biomechanics are functioning well.

So for example, we would look at ankle mobility. Is the ankle moving as well as we wanted it to? Are the toes, particularly the big toe joint, really important for good plantar fascia function. We want to understand whether there's good movement or at least sufficient movement to be able to walk and run efficiently depending on what that patient is telling us is their preferred activity.

We want to really find out about footwear as well. What is their custom footwear, what do they feel more comfortable in? Has there been a change recently. Those are the main things that we would want to look for in the assessment.

It's important to reiterate that it's not just changes in volume that can cause these things. It’s really important for everyone to understand that it can be something as simple as a change in footwear but you're still doing the same sort of exercises. Like you say, it could be the terrain that you're running or exercising on that might be different.

Adam Byrne:

Looking down other sorts of routes, are there things that put a specific person at higher risk?

Katharina Schaps:

Again, good question. I think it depends very much on the individual themselves and what they are used to in their day-to-day life. Again, there are probably other factors that maybe we haven't talked about yet in terms of what additional things could be leading to or contributing to somebody developing these types of problems.

From the research that's been done around plantar fascial problems, most of the time, increased BMI, so body mass index, somebody who might be overweight or obese already has a slight heightened risk factor for developing these types of problems.

And then things in addition to that as I already mentioned would be the lack of movement in the ankle joint itself that can also be related to tightness in the calf muscles. Unfortunately, a lot of us have very tight calves and are limited in how well we're moving through the ankles. So looking at those kind of contributing factors.

And the last thing that we haven't spoken too much about is foot strength. How good is the foot supporting itself? Is it reliant on orthotics? Is it self-sufficient?

Do people have very good stability around the ankle and foot muscles? And is that perhaps something that if that isn't there, is causing excessive strain on the plantar fascia, hence why it's becoming painful and overloaded?

Adam Byrne:

And if you were to then move on to, we've diagnosed that it is a plantar fascia-related kind of condition or plantar heel pain is what you've diagnosed. What's, let's say, it's quite an acute presentation. What's the management strategies for us as a therapist that we would go for?

Katharina Schaps:

Yeah, so usually you know it's a very acute onset. I find that there's a varying range for how painful this condition can be and some people are really, really quite sore where they even struggle to put their foot down at all and the pain just sort of stays like that for the entire day. It doesn't sort of vary according to what they do with it. And then there's other people who actually function at a really high level. They can perhaps still run on it but it just becomes maybe painful afterwards. So the degree of irritability can be vastly different.

Now if we're talking about somebody who has a really acute onset and by acute onset we mean it's a really new pain, it's only happened in the last few weeks or very suddenly. The first thing we really want to do is to reduce the pain and perhaps the swelling that's sort of created around the plantar fascia insertion.

The usual things that we do as physios to help with pain and swelling is really looking at activity modifications. Do we need to go as far as even thinking about immobilizing the foot a little bit more, do we need to go as far as offloading the plantar pressure a little bit further? And a really good way to do that is to use silicone heel cups. They're really easy to get, you know, off the internet or from any kind of pharmacy.

They usually have these types of heel cups that you can just insert into the shoe. They often feel very comfortable because they're like a silicone gel type of texture. So whenever you're stepping on it, you're easing the pressure away from that heel that is just really sore to walk on. So in the really acute stages where the pain is very fresh, I often resort to advising my patients to getting some kind of silicone heel cup because they are very, very effective. But they only take you so far, it's really just in those first few stages.

Then looking at footwear, what kind of footwear is that patient wearing? Could we maybe improve the footwear a little bit? If we find that the foot is actually quite weak, do we need to go as far as putting insoles into the shoe temporarily just to support that foot a bit better and offload the plantar pressure?

So yeah, insoles have often the reputation of being extremely helpful for these kind of problems, but actually research hasn't really found that it is that efficient in treating these kind of problems in the plantar fascia long term.

So it really is, I think, a decision that the patient needs to make with their clinician, whether it is appropriate to use in their case, would it help them? And if yes, how long do they need to use them for? Is it going to be a long-term thing or is it just going to be a short-term thing until the pain has settled to the point where we can move on to the next stage of the treatment?

Adam Byrne:

Yeah, that's good. I would agree with you with the silicone heel cups. That's something that I've noticed makes a really nice impact in those early stage quite acute patients who come in when it's just tender putting their heel down. Like you said they are so easy to get and you can pop them out and put them in all of your different shoes as you change but they do make such a nice difference.

Katharina Schaps:

The other thing that we could even consider are things like taping. Some physios like to tape in the very acute stages when everything is really sore and swollen. And there are certain types of taping techniques that can actually be really useful to easing off pressure of the plantar fascia. So it's certainly something that some physios may resort to doing as well if it's indicated for that particular patient.

As long as it's done in the short term. Don't try to get too hung up on that type of thing, use it in the short run and then as soon as you feel better with that pain, move on to your exercises essentially.

Adam Byrne:

Yeah, it can be something that can kind of bridge the gap between that acute pain and starting exercise just to offload it. In terms of then you have somebody who's more active but they're still getting some kind of fascia pain, it might be kind of the more load they do.

With these more load dominant type presentations where the more they do they start getting pain as opposed to putting their foot on the floor after rest, that sort of thing. What’s the difference here in management strategies?

Katharina Schaps:

What we're aiming for -- which is probably targeting the underlying issues a little bit more rather than just treating symptoms -- is to improve the load tolerance of that plantar fascia. It’s almost like making the tissue more robust. You’re building an armor around the foot so that next time you put the same amount of loading through it, whether that's a really long hike or whether that's your 5km run, whatever it might be, your foot is actually more tolerant to that kind of loading.

And I always find it fascinating how our bodies are so adaptable and so moldable. You just need to put them through the right environment to get them to that stage. And I think this is the beauty of exercise in general, we can change our bodies and we can change the structures in our bodies.

So whether you have a heel spur or not, that's often something that we get a lot of questions on. I've got a heel spur, the doctor said I've got a heel spur on my heel, my plantar fascia, does that mean I need to have surgery to get it cut out? Sometimes, that isn't the case.

We don't really, in the medical world, we haven't really figured out whether those heel spurs actually are, you know, the chicken and the egg type of scenario. Are they a cause because of plantar fascia pain or is it something that was already there and is compressing the plantar fascia.

I would always take things like that with a pinch of salt and really look at the function of somebody who has maybe a heel spur in their ultrasound scan and still go through the usual routine of a graded exercise program.

Talking about that a little bit, we want to put deliberate load through the plantar fascia, we want to do that in a very controlled environment, we don't want to make it too dynamic.

Usually, we go for a very slow controlled calf raising exercise and just to add a little bit more load specifically to the plantar fascia, we would put a rolled towel under the toes. So you almost sort of lift it through the toes and then you're doing your nice and slow calf raising exercises, ideally on one leg.

If somebody is still very irritable, so the pain just keeps sort of coming up whenever they're doing their calf raises, we would then maybe adjust and modify a little bit.

Maybe start on two legs and then gradually progress to one leg. But really what we found through research into these types of conditions is that actually the tissue responds really well to slow controlled calf raising exercises and doing them every single day.

Recommended dosage is probably between 8 to 20 repetitions in four sets. You know, how much load you put on is then down to the individual.

Could we add more weights to that? A good way is either holding a dumbbell or popping a rucksack onto your back and popping some dumbbells into that. That's often a good way to do that.

And being quite persistent with doing that sort of regime for anywhere between 6 to 12 weeks is really the ideal recommended dosage for these types of exercises until you feel like the irritation has reduced so drastically that you can allow that person to come back to normal function and continue with their sport or their routine.

I generally find that somebody who's very diligent with their exercises actually does well in the long run.

It's usually the types of patients that we see in clinic that maybe are too busy to do regular exercises that will have more recurrent flare-ups. That’s because they're not making a huge change to the load capacity of that tissue; they're not really building that armor as I said around the foot to make it a little bit more robust to loading. Yeah so that's probably the main goal of the rehab that we do.

And then as we mentioned earlier, working on calf flexibility with some calf stretches. Again, research found that doing calf stretches in combination with plantar fascia stretches are more effective than just doing plantar fascia stretches by themselves. So trying to combine a stretching regime almost for both of those structures is really useful.

And again, you know, working maybe a little bit higher up the chain on core stability and hip stability. Then we're probably more looking at it on an individual basis, whether that is something that needs to be worked on to support the kinetic chain or the whole movement system a little bit better so that the foot doesn't become overloaded as quickly. And there certainly is a huge link between all of those body parts.

Adam Byrne:

Yeah, that's great. And let's say we have a runner who's in clinic and we're in the perfect scenario, we have a treadmill. Would you look at them running? If, obviously pain allowing, would you get them on the treadmill and do somewhat of an assessment of them in that painful phase to see what could potentially be happening?

Katharina Schaps:

Yeah probably, even if they weren't a runner, if it was indicated and if the pain was manageable. But the one thing we don't want to do is flare people up, right? So you've got somebody who's really sore through their plantar pressure and you suddenly get them to run for five minutes on the treadmill, they might actually walk out of your clinic worse than they've been.

Adam Byrne:

So that's definitely something that we're keen to avoid.

Katharina Schaps

It's a good idea. If it fits, you know, if it's a good day, let's say, then yeah, certainly I would have a look at runners run and I would have a look at walkers walk, you know, you want to get as much information as possible.

But certainly if I think there's something that can be tweaked slightly or we could change their gait system just a little bit to make it actually more efficient.

Because one thing we know about the plantar fascia is it's actually a structure that is designed to be ultra efficient. It's natural tissue that is almost sort of tensioned and released.

So whenever we're walking on our feet, the plantar pressure helps us an enormous amount at being more efficient at walking. And oftentimes, the reason why it breaks down is because we're not as efficient as we can be.

So looking at the whole chain makes complete sense and I would use it if it's appropriate for sure.

Adam Byrne:

Yeah that's great. In conjunction with some rehab based stuff is there anything else that you know. Because there's a lot of shockwave happening these days and is that something that you have found to be of benefit for this sort of condition?

Katharina Schapps:

Yes, so certainly we know plantar fasciitis or plantar heel pain is a condition that can be more persistent and ideally we want to catch those people before the condition is more than seven months old.

So you know the risks of it becoming a more chronic issue are much much higher if you see somebody who's had that problems for more than seven months. That is the strongest indication at the moment whether we think somebody is going to do well with rehab and exercise therapy only or do we might need to consider other options in their treatment that could help accelerate that rehab and encourage the tissue to regenerate itself a little bit more.

So shockwave therapy is a fairly innovative sort of management form that is being used more and more for tendon conditions and other kinds of soft tissue conditions. And it's essentially using shock waves that are being sent into the tissue.

It feels a little bit like a mini electric gun without putting people off. But essentially, the benefit of shock waves is that you're stimulating the tissue to provoke a very small inflammatory response so that the body starts to repair the tissue that is not able to repair itself.

So in certain amounts of cases, I found Shockwave to be very helpful. As I said, more in the persistent pain conditions.

So generally speaking, I would say if you are somebody who's had physio for more than four to five sessions and you've not noticed any change whatsoever. Or you might even be getting worse, I would certainly be thinking about maybe some shockwave therapy to accelerate your rehab. What's probably really important to emphasize is that it's not one or the other.

Oftentimes you need to combine shockwave with your exercise therapy to really progress you into sort of the stages where the pain gets significantly better. So we work together with our MSK colleagues, our MSK physicians here at Bupa in particular, and we often make a decision in combination. We have chats to the MSK physicians whether we think somebody is appropriate for shockwave therapy. Usually that collaboration actually works really well for most patients.

Adam Byrne:

Yeah, it makes a great difference. In terms of then if somebody's listening and they don't have this pain but they're kind of afraid that they may get it or worried that they may get it in future from certain activities.

Is there things that people can work on as a preventative measure?

Katharina Schaps:

Yeah, definitely. I mean we've already talked about all the risk factors that we know can lead to the plantar fascia becoming painful.

So watch your weight, make sure you keep your weight as healthy as possible. If you're not sure how to do that, I think it's often worth having a chat to your GP about how to manage your weight a little bit more appropriately if you feel you are somebody who struggles with weight loss.

Then the other thing is what's your load capacity? What is your body currently used to? How much daily walking are you doing? How much running are you doing? How much standing are you doing? Is there something that we can change?

If you're looking to increase your activity levels, be mindful to do that very gradually. Don't go from 0 to 100 within the space of a few days. Really do it very gradually so that your body can acclimatize to that level of loading really, really slowly. And I find sometimes people underestimate or overestimate what they're able to do. So just be mindful, take time to essentially get there.

We know that general strength and conditioning is really useful. So doing regular lower limb strengthening exercises, particularly calf strengthening exercises, quads, hamstrings, glutes, always a really good idea particularly if you are somebody who runs regularly rather than just focusing on running.

We know that a huge range of different running related injuries can actually be prevented by exercising or by doing some gentle lower body conditioning regularly outside of running.

And then I guess ankle range of motion is the last one, so making sure you've got flexible calf muscles, stretch regularly, maintain that mobility if you can. That would probably be my strongest advice to those who want to prevent these kind of problems.

Adam Byrne:

The advice of having strong conditioned lower limbs is the preventative measure for a lot of the conditions that we see. So I think that's really good advice. I think we've hit the nail on the head with a lot of things here actually. I don't think there's much else we would need to cover at the moment. Is there anything else you'd like to add before we wrap up?

Katharina Schaps:

I guess just to add, if somebody is in a situation where they've suddenly got this heel pain, they don't know what to do with it, do they try and self-manage, do they go and get it checked out because that certainly is a question we get a lot. At what point do I need to go and see somebody about it? My advice would always be don't ignore it and don't wait too long because these types of overload issues are much, much easier to treat and tackle when they're still acute. As soon as they become chronic and persistent, it's much harder to get rid of.

So if you are somebody who's had those symptoms for nearly sort of six to seven months, I would say it's definitely time to get it checked. You just don't want to leave them for too long to be sort of a grumbly background noise of pain.

It's always better to be proactive with these kind of things because unfortunately we see many people that have had plantar fascia problems for years and they've never done anything about it. Then the sort of full recovery is not as likely in those chronic stages.

Adam Byrne:

I think as humans we're excellent at ignoring things until they become a much greater issue than they should be. So yeah, takeaway message, don't ignore it. Katha, thank you very much. I think we'll wrap it up there.

Katharina Schaps:

Thank you for your time. I really appreciate it.

Adam Byrne:

My pleasure. My pleasure. Thanks, Katha.