Plantar Fasciitis

You need to understand that there are 20 different versions of PF - most likely you are doing something wrong!

I have been seeing a ton of Plantar Fascia, foot and ankle issues in the clinic lately.  It’s true – the Universe runs in waves and we’re on a big wave of these issues.

First thing’s first, these issue are treatable and if you are willing to put your time into some basic at home rehab and exercises you can speed the healing of this issue up considerably.   

If you’re willing to just take a couple minutes to learn a little I can all but assure you will respond EVEN quicker.  

This is a condition we see in the office a lot and have had good success with it.  It is not usually a “quick fix” issue however.  Typically one treatment doesn’t make a huge difference and I think that’s why there is so much jumping from clinic to clinic and so much MISTAKE and disappointment with treatment and expectations.

You need to understand the issue and the foot…and the body, if you want to fix it and you really need to understand the rules of treatment so you understand what you are trying to accomplish.   There is an order to the treatment.  If the first step isn’t taken care of before the second step you’re just spinning.

This issue as much as any other condition we see is OVERLOADED with mis-information.

At the heart of the problem with treatment of PF is the name itself – collectively, Fasciitis (as well as any –itis) has multiple, different issues that are collectively called Plantar Fasciitis – see the picture and how large of a tendon, fascia and muscle we’re dealing with? Technically, almost any issue to this area with cause inflammation of some sore (itis) and now you’ve got a diagnosis.

This problem with this is that I could come up with 20 different issues are of which are typically called Plantar fasciitis.    20 different injuries need different treatments if they are going to be successful.   

You’ve got to dive a little deeper than, “this is what FB told me to do.”    You have to know what is happening that is screwing up the function of the foot… IE: “what is causing the –itis?” The twist is, it could be a few things.

It’s not that your friends, magazines, therapists OR hear-say is wrong – it’s just not specific – its giving you general information and you may not have the exact same condition.   

So if you’re looking for, “Doc, what exactly do I have to do to fix this?” I can’t help you on a blog or podcast – it’s going to take a little trial treatment and a lot of homework to get you to the right protocol.

There is good news though!   Despite 20 different versions, many times, just doing treatments in the right order and restoring proper foot, ankle and then hip function will take  care of the problem.   With this article, I will give you some basic ideas that seem to really help out the healing time and speed up recovery – general stuff that is a part of my “Rehab to Go” stuff for you to use at home.

OK, so let’s dive in. In almost all cases of PF it’s not so much the pain, but the lack of proper function of the foot and hip that is a major obstacle in the recovery of the issue.  Add to that – the lack of function is coming from some poor mechanics and form.   Now we’re getting down the rabbit hole!  This is why an injection or one or two treatments don’t fix this.

That’s why you won’t hear me push orthotics, braces and long term rest as part of your treatment protocol. I don’t like them for 99% of cases.

I’m not saying there isn’t a place for these but my protocol really pushes function and mobility as the key component to recovery. Let’s face it; Function and mobility need to be present before proper stability and healing can occur. Let me repeat that, Function and mobility need to be present before proper stability and healing can occur. Read it again and memorize it…that’s what this rehab focuses on.

My rules of at-home treatment

The most important rule being the one that is most often neglected!

The order of application makes a tremendous difference.

If you start rehab prior to getting the inflammation away I have seen next to zero recovery from this issue.  This is such an important factor that I cannot emphasize it enough. It is why I think the majority of rehab treatments for plantar fasciitis tend to fail.

Step 1!   You need to get the inflammation out prior to any start of rehab.

The stretches, the balls, the tools, the manipulation and mobilization needs to happen as the inflammation is under control and done. Why do you think cortisone is the recommended injection from the podiatrist? It is an anti-inflammatory.   

Often times when the inflammation is under control the pain also decreases or disappears- now is the time to start doing rehab. It blows my mind how often I hear in my clinic, “ I had this issue a few years ago on an injection made it go away.”   No – the injection stopped the inflammation – the problem still remained.    Cortisone doesn’t stop your crappy running form Karen.

This time around, plantar fascia version 2020-let’s do it better,  more thoroughly, finish the problem and then start to dive into how feet should function and move.

Ice – I prefer a frozen water bottle so you can strip out the fascia at the same time. This needs to be done DAILY. And keep working it until numb, usually 8-10 minutes. Work the fascia out with the ridges and contours of the bottle. (as seen on this bottle)

You will get to the stage you might not need to do this, but you can’t go wrong here – if the foot is inflamed you need help putting the fire out!

step 2) shoe wear.   

Don’t use flip flops while there is pain.  Look, flip flops aren’t great. They make your big toe move incorrectly and then the foot is screwed up. I get it though, they are easy and practical and a common part of our days- people just won’t give them up.

Flip flops and dare I say it?  Shoes in general,  just jack up your motion man. They also force the foot to bend as one piece at the push off phase and this limits motion and rotation. This keeps the function of the foot less than optimal. Keep the flip flops if you have to, but save them for when your foot is fixed.

Limit your orthotics – (cough.. throw them in the trash)

This is where I get the most resistance in my office – these things are expensive, most likely ordered from a pro and you like them – I get it. But, the built up arch supports limit full ROM.  This really helps with pain initially but keeps perfect and proper motion which is vital while trying to fix the issue. Its vital to human movement.

Same reason I’m not a huge fan of the slings and braces – I want motion!  There are a few main arches in the foot and we want them mobile and functional, not limited! If you guys are in love with these things, keep them with you but try hours on and off and see what works better. Remember these are general rules of rehab, not laws and absolutes, everyone is different, but this seems to work in our clinic much faster than staying in them 24/7.

As I dove into the foot function more I found a group out of Canada made up of some fantastic physio’s that just have a knack for telling it like it is.  The group TFC (The Foot Collective is definitive worth your time if you want to really dive into it.)   They are very like minded, as our nearly all of the modern era progressive foot people.  To paraphrase TFC, “So you have super stiff and immobile feet huh?  It’s killing you to walk? Why in the world would you treat stiff and immobile with more stiffening and more immobility?   Get moving things moving again!  That’s your treatment.”  TFC, as well as myself recommends going barefoot as often as possible.

3) spell the ABC’s with your foot – Especially first thing in the morning –first two steps hurt like crazy and the fascia is restricted and stiff.   Get back into bed and put your foot through a full alphabet of movement. This isn’t a fix but at least you put the foot through all kinds of great ROM and it helps move the tendons, bones and fascia. This usually at least gives notable relief on the first agonizing steps out of bed.

4) Force Foot, Toe and ankle motion –    This is where again I would check out TFC.  You need this.   They are the best in the game.  Wiggle your toes, make a “foot fist”, rotate through the ankle not around it…etc. 

I tell my clients, “I cant repeat what is said and taught in a six hour seminar in a twenty minute office visit. Heck, Maybe I cant in 20 office visits! Do yourself the favor you need…learn this stuff for yourself. You need to!”

TAC balls  – (link to chadknows video)  use motion in all planes – look again at the picture of the foot and the different arches. Think of the inside of the foot, navicular bone specifically and the outside of the foot, the 5th metacarpal and cuboid bones.

Follow these steps: (with ball) Barefoot is best as these specific balls (TAC BALLS) have some grip and work the fascia better than a Lacrosse ball or tennis ball.

  1. Roll the ball from the front to the back – the length of the foot (not back to front however)
  2. Heel down, toes up – pivot shift side to side on transverse arch
  3. Inside of arch (navicular) – Smash and Shimmy then extend foot and toes
  4. Outside Mid Foot  – Smash and Shimmy then extend foot and toes
  5. Ball of Foot – Clamp Down and squeeze ball
  6. Separate Four toes and Big toes – separate squeezing
  7. Heels Down, Toes up- pivot and shift on ball of foot
  8. Using your hands – work the toes, foot  – knead and separate

This is a 2-3 minute process – work it, love it, get to know your feet – Get your feet back!

Usually there are other issues such as low back, hip rotation issues (every time), calf and anterior tibia strength ratio issues and others.   Then get to the cause – what are you doing to cause this.  I’ll fix this in 30 minutes in my clinic and you’ll undo this for the next 10 hours daily.  It’s a net loss and a comlete loss over time.  You need to fix this.    TFC recommends 2 minutes, 2x/day of self work for a minimum of two weeks as the MED.    I’m stealing this as our clinical protocol as well.   Easy to remember and apply.   

I’m guessing this isnt where you are at right now.  Experience tells me most of us are trying “mash the hell out of for a day and limp around the next two or three days and then say, “it’s not working”    

version 2020 – have a better plan!

Its a monster of an issue but that doesn’t mean you cant fix it.  I hate to tell you brother, but you’re going to have to handle most of the work yourself on this one.

Just like everywhere in the body, one thing leads to the next. There is a systematic and bigger approach to fixing this condition than just attacking where it hurts. We say in the office all the time, “The victims scream, but the Culprits hide!”

Remember that 20 different issues are all called the same thing they are all PF and these 20 different injuries need different treatments if they are going to be successful.

Return to Play Criteria (For Coaches, ATC’s and YOU!)

to listen to the podcast version of this article:

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There is an issue that we have been seeing with Return to Play after Injury in high school aged athletes. It’s a small issue, more bureaucracy – not actual treatment issue.

It’s the problem of athletes/patients seeking treatment outside of the school.

As in, the high school softball player coming to my sports based chiropractic clinic for treatment for her sprained ankle.

I have presented this idea at high school in-services and have had great feedback and great implementation of plan improvement with a minimal effort and next to no expense.

My proposed idea gets the athletes, coaches, athletic trainer and ancillary staff on the same page and makes discussion of injury much more thorough with a huge addition of information. This, in my opinion, allows for better treatment of injured athletes, better compliance from the athlete and an improved ability to evaluate progress while returning from an injury.  

The above idea is what we all kind of have in our heads as the right way to work athletes.  It’s EXACTLY what the parents think happens. That the coaches and AT’s and the docs and the personal trainers all get together and discuss each case and nail out a full proof recovery action plan for every sprained ankle and tweaked muscle.   

The problem lies in reality.  

I don’t have your number and possibly even the time to go through every case.  My own kid’s practice is right after work and many of us in every field – aren’t getting home until 9 pm some nights!

If a patient is seeing another doctor, outside of the athletic trainer’s room, the buck passes to the MD, Pediatrician, chiropractor, PT etc rather the the athletic trainer and coach to make treatment, rehab and return to play recommendations.

While this may seem like a great idea for administration and liability issues, it creates room for problems.

Although I think the diagnosis and occasionally rehab/treatment for some athletic injuries and definitely for illnesses can best be managed by an adjunct doctor… 

The athletic trainer in conjunction with coaches is best suited to assess the athlete’s day to day recovery and return to play and practice.

The doctor is hampered in this regard as we just don’t get to monitor day to day function and have to rely on standard and structured testing to secure our diagnosis. Our job, as ancillary staff, is in the diagnosis. Further x-rays, testing, recommendations for surgery, ruling in/out major illness etc is our job and where our expertise is best utilized.

How long a basic sport injury keeps an athlete out of activity is not our strong suit.  

In this article I will explain this idea in more depth with a proposed idea on how to implement a BASIC but possibly improved “return to play criteria” for your athletes.

Let’s use an ankle sprain, in a high school track athlete, as an example.

A junior in high school 400 m track athlete sprains her ankle while playing pick up basketball one day after practice.   

Because the injury happened “after hours” – the parents take her to a minor ER clinic just down the road from their house.

The doctor makes the easy diagnosis of a grade 1 to 2 ankle sprain and recommends rest, ice, compression and elevation. Common Injury, Standard treatment.

The athlete then gets a note for time away from activity as it’s needed for the sports participation/ athletics period etc. as well as a courtesy for the coaches and training staff.

In some instances, this athlete may not even be able to receive additional treatment from the Athletic trainer due to the issue happening outside of the school. That’s a shame. Most of the athletic trainers I know would still treat the athlete… however their hands may be tied due to policy.

Before this athlete can return to play and practice, the MD that saw her must sign a note for release.   

Typically, the parents call the clinic and say, “Can I get a note for my kid to get back to competition?”    

That’s a fair enough request and this is how the system works on paper. It seems uncomplicated and proper policy. The MD wrote the note and decided, based on their expertise, the treatment plan.

And here is where the bureaucracy train starts the locomotive of inadequacy.

The doctor, in all good conscious, cannot sign a letter for return to play or practice without first running the athlete through a set of tests again to see if the ligaments are in fact strong enough, as in enough healing has occurred, to allow for resistance and activity.  To protect the athlete from further injury.

Is there a set standard – what should be done? This is in a clinic remember, not on the field of play – this is at the doctor’s office and even this is assuming the same doctor is in the same stand alone minor ER setting. It could be weeks before the athlete’s and doctor’s schedules even match up. Anyway, what should the doctor do in this situation?

Just call it in?  Have the receptionist just write a note after the suggested time frame?  That’s poor doctoring, I don’t think you’ll get much of that anymore…so what else?   Feel it? Have the athlete stand on it? Run up and down the hallway a time or two? Or more commonly – just go by the standard 6 weeks! rest and no activity.   I mean, that’s safe right?   (NOTE: recovery for this injury should not take 6 weeks.)

Is this doctor even qualified to make these decisions? A license as a chiropractor, MD, DO, dentist, PA, NP etc don’t necessarily make you expert level at sports injuries.  Diagnoses? Yes. Treatments and Return to Play, not necessarily. That kind of stuff takes experience even if you did have a sports specialization – which most don’t have – not to the degree an Athletic Trainer does.

Even if the athlete looks strong through the clinical exam and testing – Does that correlate well with the sports field, the track and the court?  The demands are completely different and maximal ‘game play’ exertion is unobtainable in the clinical setting.

So let’s assume this athlete waited 6 weeks for the ankle sprain and then has been cleared medically…ahhh finally. Well half the season has passed and now the athlete has not only been deconditioned and is behind the curve competitively but I would make a strong argument that 6 weeks of rest has in fact, not helped the sprain heal well but mostly just decreased pain. The initial sprain has need of a progressive resistance return and strengthening program and usually sooner rather than later.

Stated differently- Rest may have in fact, weakened the entire joint complex at the expense of rest and pain control.    

Again, the most qualified person to perform these treatments and exercises are an athletic trainer although I’ll allow the argument of a sports based physical therapist/ rehab specialist such as some chiropractors and even personal trainers work as.   There are qualified people, I’m just suggesting, most athletes at the middle school/high school level aren’t getting this.

Communication is the key to any and all patient recovery. It speeds up everything. But let’s not forget reality. This isn’t the NFL and there is not an infinite resource of trained staff and doctors and athletic trainer in a one on one setting out in the field. 

The athletic trainer ratio to athlete is not 1 to 1. More like 1 to 150, especially in the high school setting.

The athlete needs help – the Athletic Trainers need help too!

Using coaches in decision making.

Coaches are the ones out there. Despite not having as extensive of background to make complex medical decisions, they intimately understand body mechanics, gait, pain levels, wimpiness as well as just “knowing their athlete.”

Coaches can tell how hard to push an athlete and any ethical coach will not want to push an athlete too far. They need that competitor on their team!

Coaches and Athletic trainers have much more immediate communication with both the athlete and the injury. The athletic trainer with coaches input ARE THE BEST at the evaluation of the injury itself with regard to recovery.

Is the athlete going to make themselves worse? Do they need further consultation? Are they OK to move?

Ancillary staff – chiropractors, PT’s, pediatricians, team doc, surgeons etc can work one on one to help mitigate serious risk and allow for more direct work in a one on one setting and help get through the injury itself.

Again, my argument is that the ancillary staff is not qualified for return to play criteria. We aren’t on the field and don’t get to see the athlete in movement and sports specific situation.

Athletic trainers and coaches are together, the best qualified and should work together with input from the athlete on any and all return to play.

If “passing the buck” to ancillary medical staff, plan on a generic 6 weeks rest.

Basic return to play criteria

Use “pennies”

In the upper level sports and professional – the use of different colored jerseys or “pennies” are extremely common.

These pennies allow for immediate recognition to the coaches and staff both in live practice and video that the athlete is not 100%.

They allow for the athlete to still be present, play in correct positions, see in-play decision making for game day corrections, have movement and be participating with the team.

Teammates can easily recognize the injured athlete is not 100% – so contact, speed etc should be appropriately controlled so as to allow for recovery.

Coaches can evaluate practices with the understanding that the athlete is understanding week by week adjustments and is engaged mentally with the ability to digest that the athlete may not be fully functional in practice but with the understanding that by game day they may. Reps, even at a reduced speed,contact and ability is infinitely better than no reps and I think in 2019 everyone can agree rest alone is almost never the best recovery option.

My suggestion: use pennies in nearly every practice. Get the athlete on the field.

I utilize a 6 day recovery to 100% model for low grade injuries.

Day 1 : 50%

Day 2 : 65%

Day 3 : 75%

Day 4 : 85%

Day 5 : 95%

Day 6 :100%

The athlete can not go past his assigned percentage for each day.   

If the athlete passes the day with no setbacks or recurrences he is moved up the chart to the next percentage.

If there is a re exacerbation, the athlete stays at the same percentage for the following day or a reduction in percentage based on the Athletic Trainer’s and coach’s discretion.   

Further therapies, rehab techniques, clinical work etc is done IN ADDITION to practice, not in substitution of.    

Certain max ability drills such as sprints, gassers, max out weight room workouts etc are not done until the athlete can tolerate them. The additional therapies required for maximal recovery may work into these time slots.

By game day, the AT and the coach will have a good “working idea” of the athlete’s ability and chance of exacerbation and re-injury.

The reality is in all sports, the athlete may not be 100% in each case. I’m not suggesting 100% before competition as I think that’s another “on paper” reality that isn’t a realistic in the sports world.  By 6 games in to a typical high school football season, I would argue, no one is 100%. I bring this up because I had conversation with an athletic trainer that didn’t want his athlete’s seeking out my care as a sports based chiropractor because he had a policy of “100% healthy or No Play.”   This meant that if they were seeing me for a pre-game “tune-up” , it equated to being injured and he threatened to sit athletes out of competition that week.

The reality of this is that athletes rarely would seek out treatment form the athletic trainer for fear of being benched for little tweaks or tight muscles. They knew that if they had any reported “complaints” it was viewed as injury.

This is a double kill situation where the athletic trainer saw very few athletes. He could go about his day blissfully unaware of basic, simple care his teams would benefit from – completely confident that his teams were perfect with no complaints.  The actuality was no one dared seek their team’s “professional.” The coaches wouldn’t use him as they knew he would sideline their players, the parents used outside staff exclusively for the same idea and the athlete’s themselves had no confidence or even worse were scared to talk to the athletic trainer about injury or sports performance. The best qualified member of the staff was “out of the loop.”

Back to return to play…

The alternative to doing what I feel is correct, is rest. Wait for a release from a doctor that doesn’t have any way to make a decision other than allotted time, and I feel, a significant chance of re-injury, as the athlete has had no ability to re adapt and prepare for the demands of competition.

I understand there needs to be policy. I understand that policy at certain districts are at odds to my proposed ideas. Understand this is a very generic, very vanilla return to play criteria offering an improvement in the current status quo with minimal effort level.   It benefits the athlete, the team, the coach and the training staff. It isn’t created to circumvent policy but to focus on the fact that the sports arena as a whole has a lot of gray areas and a one policy for all is a dangerous concept and often not in the athlete’s best interest.  

Obviously, any criteria for an injury and return to play is a case by case scenario and should be adapted for each individual case to best match the needs.

My points…

We are having the return to play being either negated or done sub par in cases.

Often it is by the wrong provider based on circumstance and perhaps policy.

Policy should reflect what is best for the athlete, not be based on the degree of the practitioner.   

I argue that the Athletic Trainer with help from the coaches is THE BEST qualified people to create and implement return to play criteria, not a note from an ancillary provider.

Communication helps. Use the information from the ancillary staff to help make better informed decision in certain cases. A text or quick call makes a huge difference.

Return to Play can be fairly simplistic and done in a way that benefits…EVERYONE.