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Plantar fasciitis and sharp pain in the first steps
Plantar fascia accounts for 11-15% of all foot-related complaints requiring professional care and is the most common cause of heel pain presenting in the outpatient setting. Some publications also show high prevalence rates (22%) among a population of runners. (Tschopp, 2017). Sharp pain within the first few steps out of bed in the morning characterises this pathology more than well. The pain feels better during exercise, but returns after a period of rest, typically after long periods of sitting or standing.
How well do you know the pathology?
When treating plantar fascia it is essential to be aware of other important functions, apart from supporting the arch of the foot, in order to be as effective as possible in the treatment of plantar fasciitis.
The most important functions performed by the plantar fascia:
supports the longitudinal arches of the foot and helps prevent arch flatteningacts an essential role in assisting the resupination of the subtalar joint during the propulsion phase
helps the posterior compartment musculature (flexor hallucis longus, tibialis posterior) to limit the pronation movement of the subtalar joint by decelerating pronation in the stance phase of gait and accelerating it in the toe-off phase.
assists plantar intrinsic muscles
reduces tension forces within the plantar ligaments
prevents dorsal interosseous compression forces in the midtarsal and midfoot joint
prevents excessive dorsal flexion of the metatarsals, as this can lead to metatarsalgia, metatarsal stress fractures and compression of the metatarsophalangeal joints. (Kirby, 2016)
From the above list of biomechanical functions, it is clear that the plantar fascia plays a crucial role in the normal biomechanics of the foot, gait and affects other parts of the body. We can presume what biomechanical factors cause plantar fasciitis in our patients and correctly approach treatment using different physical modalities and exercises for plantar fasciitis.
Treatment options
Unfortunately, in past decades, surgeons have increasingly performed plantar fasciotomies as a common treatment for foot pathologies such as plantar fasciitis without always giving full consideration to the possible problems that may occur over time with plantar fasciitis surgery. Loss of integrity of the plantar fascia might lead to the development of new symptoms and pathologies not only in the foot area. Plantar fasciitis surgery should always be the last-resort option.
Plantar fasciitis, along with typical tendinopathies (tennis elbow, golfer’s elbow, Achilles tendinitis, etc.) are effectively treated with shockwave therapy thanks to effects such as myorelaxation, elimination of calcifications, reduction of pain perception and support in the regeneration of impaired tissues.
People often ask physiotherapists what the best shoes for plantar fasciitis are. Footwear certainly plays an important role and a visit to the podiatrist is highly recommended.
In the rehabilitation process, plantar fasciitis exercises focusing mainly on big toe mobility and ankle dorsiflexion mobility are recommended along with strengthening exercises of the foot muscles and eccentric loading of the plantar fascia.
How do Shockwaves work in this pathology?
Shock waves are generated in the applicator and spread through the ultrasound gel through the tissue layers to the affected area. Their mechanical stimulation triggers the cells' biological response, and various growth factors are released.
Cells react to this by proliferation (multiplying), migration (moving to the impaired area) and differentiation (mesenchymal cells start to change their character by developing into more functioning cells). These cell mechanisms lead to enhanced tissue regeneration.
In the case of calcifications or heel spur higher intensities will induce the growth of new lymphatic vessels that will help to wash out calcium deposits by reabsorption.
Focused or Radial Shockwave?
Although both shockwave technologies produce the same therapeutic effects, a focused shockwave allows for an adjustable depth of penetration with constant maximum intensity, making the therapy suitable for treating both superficial and deep-lying tissues.
A radial shockwave allows changing the nature of the shock by using different types of shockwave transmitters. However, the maximum intensity is always concentrated superficially, which makes this therapy suitable for the treatment of superficially lying soft tissues.
Available scientific articles have demonstrated the efficacy of the treatment of plantar fasciitis with both types of shockwave, focused or radial. It will be up to the clinician to determine which of the two types of shockwave is more useful for their daily practice.
