Plantar Fasciitis: The Role of Physical Therapy

Plantar fasciitis is one of the most commonly treated types of foot pain in physical therapy.  Overuse or repetitive stress to the bottom aspect of the foot is the most common cause.  It typically affects younger females however males are also likely to have symptoms. Older individuals are at risk for developing plantar fasciitis as well as athletes.  Individuals with an elevated body mass index are prone to heel pain and other foot conditions. Typically symptoms of plantar fasciitis will include pain on the bottom of the foot upon standing after prolonged inactivity or after an increase in activity.  This is common when runners increase their distances.  Symptoms may include chronic heel pain leading up to plantar fasciitis or chronic calf tightness.

What is Plantar Fasciitis?

The plantar fascia is a thick band of connective tissue that spans the bottom of the foot. It runs from the calcaneus (heel bone) down towards the toes.  The plantar fascia assists in walking by providing stability to the ankle and foot. In cases of plantar fasciitis, the tissue is “overloaded”.  This may cause pain that is most pronounced when standing for prolonged periods of time or upon standing after prolonged sitting. Chronic calf tightness or flat feet may be risk factors for developing plantar fasciitis.  However, any activity that increases the force on this structure may cause symptoms.

What can a Physical Therapist do for you?

Techniques utilized by a physical therapist can significantly decrease plantar fasciitis related symptoms. Some of these techniques include manual therapy to increase the ankle range of motion.  Improving ankle/foot range of motion through patient-specific exercise is also important. Your physical therapist may recommend exercises that reduce the load on the foot to start, including bike riding or swimming. Various athletic taping techniques have been proven to help reduce the load on the foot and allow the plantar fascia time to “rest”. These taping techniques have been shown to be an effective form of care in treating plantar fasciitis. Your physical therapist may also be able to assist you in an orthotic recommendation. Orthotics may be especially effective for individuals who respond well to taping techniques.

manual therapy for plantar fasciitis

Balance exercises are incorporated as symptoms improve.  Exercises to target hip and knee strength and range of motion impairments may also assist in improving symptoms. Calf and heel cord stretching is another effective method to reduce symptoms. These techniques will help progress a patient back to their sport or daily function without pain and allow for pain-free activity and improve your overall quality of life.  Talk to your physical therapist to see if your plantar fasciitis symptoms can be alleviated by some of these treatment options.

plantar fasciitis exercise

Conclusion

Plantar fasciitis is a common form of foot pain that impacts many lives and limits function.  Plantar fasciitis symptoms may resolve on its own over time, sometimes up to one year.  However, treatment by a physical therapist may assist alleviating pain at a rapid pace. No one treatment works best for everyone.  A physical therapist can assist you in determining the treatment plan that is going to be the most effective for you to reach your goals. There are many other forms of foot pain that may mimic plantar fasciitis. Your physical therapist can help in screening for these other types of injuries. Come to talk to your physical therapist today!

Written by Dr. Steve Ferro, PT, DPT, OCS

References

1.Martin R, Davenport T, Reishl, S, et al. Heel Pain–Plantar Fasciitis: Revision 2014. Journal of Orthopaedic & Sports Physical Therapy. 2014;44(11):A1-A33. DOI: 10.2519/jospt.2014.0303.

2.Cole C, Seto C, Gazewood J. Plantar fasciitis: evidence-based review of diagnosis and therapy. American Family Physician. 2005;72:2237–2242.

3.Pollack Y, Sashua K, Kalichman L. Manual therapy for plantar heel pain. The Foot. 2018;34:11-16. DOI: 10.1016/j.foot.2017.08.001.

4.Stecco C, Corradin N, Macchi V, et al. Plantar fascia anatomy and its relationship with Achilles tendon and paratenon.  Journal of Anatomy. 2013;223(6):665-76. DOI: 10.1111/joa.12111.

Ankle Sprains: Diagnosis, Treatment and Return to Sport

What are Ankle Sprains?

Ankle sprains are one of the most common injuries that people experience.  These injuries account for one million physician visits each year.  Lateral ankle sprains, also known as inversion sprains, are the most common.  They are particularly common in sports.  Forty percent of all traumatic ankle sprains occur during sports.  However, only 50% seek medical attention. The lack of medical care results in an increased risk for developing chronic ankle stability.  There are 3 different grades of ankle sprains, which progressively worsen with each grade.  Healing times vary from a couple of days to up to 6 months depending on severity.

Grades of lateral ankle sprain

What are Lateral Ankle Sprains?

Lateral ankle sprains occur when the outside of the ankle is stressed .  This usually occurs when the ankle is forcefully turned inward. This can happen when stepping on an uneven surface or landing awkwardly after jumping. The lateral ankle sprain typically occurs with stress to 1 of the 3 ligaments that stabilize the outside of the ankle. Depending on whether the foot is up (dorsiflexed), neutral, or down (plantarflexed) different parts of lateral ankle ligaments can be injured.

Lateral ankle sprains

How does a Physical Therapist Diagnose a Lateral Ankle Sprain?

A physical therapist can use tests and measures to diagnose ankle sprains. Typically this will involve checking ROM (range of motion) and strength of the ankle and lower leg.   Additionally, special tests and joint mobilization testing  can bias the ligaments to determine which are involved.  Movement analysis such as the FMS (functional movement screen), hop testing, and running/agility tests can also be used to help determine some of the impairments that may have contributed to the ankle sprain.  If you are seeing a physical therapist with direct access (seeing a PT first without going to a physician) they will perform other tests and screening procedures to make sure physical therapy is appropriate.  If your physical therapist feels you need different services, he or she will direct you to the best healthcare provider.

How are Ankle Sprains Treated?

Depending where you are at in the recovery phase and your goals, a physical therapist will approach your care differently. Early in treatment crutches or a boot may be used and a physical therapist will focus more on pain, swelling and maintaining motion and strength.   As your recovery progresses, your treatment will progress to more active treatments.  This will include manual therapy to improve ankle motion,  proprioceptive training, training for return to activity and strengthening exercises targeting areas that the therapist has found to be weak.

How do you Know you are Ready to Return to Sports?

Physical therapists have a great deal of experience in determining if you are ready to return to sports, work, and other activities.   A few of the tests a physical therapist can use to determine if you are ready to go back to your sport are the FMS, Y-Balance test, hop testing, tuck jump assessment, and the Landing Error Scoring System.  A physical therapist can also give you recommendations on footwear and proper training tips to help avoid ankle sprains in the future.  Contact your physical therapist to learn more about managing ankles sprains.

References

  1. Vuurberg G, Hoorntje A, Wink L, van der Doelen B,van den Bekerom M, Dekker R, van Dijk C, Krips, R, Loogman, M, Ridderikhok M, Smithuis F, Stufkens S, Verhagen E, de Bie R, Kerkhoffs G. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline.British Journal of Sports Medicine 2018;52:956
  2. Doherty C, Delahunt E, Caulfield B, et al. The incidence and prevalence of ankle sprain injury: a systematic review and meta-analysis of prospective epidemiological studies. Sports Med 2014;44:123–40
  3. Verhagen EA,van Mechelen W,de Vente W. The effect of preventive measures on the incidence of ankle sprains. Clin J Sport Med 2000;10:291–6
  4. McGuine TA,Keene JS. The effect of a balance training program on the risk of ankle sprains in high school athletes. Am J Sports Med 2006;34:1103–11
  5. Kobayashi T,Tanaka M,Shida M. Intrinsic Risk Factors of Lateral Ankle Sprain: A Systematic Review and Meta-analysis. Sports Health 2016;8:190–3
  6. Ivins, D. Acute ankle Sprain: An update. American Family Physician. 2006:741714-1720
  7. Wolfe M, Uhl T, Mattacola C, McCluskey L. Management of Ankle Sprains. Management of Ankle Sprains. 2001,63:93-1004
  8. EIM 2018 Sports Physical Therapy Competencies 2018 Lab Manual

Self-Management of Pain: Your Physical Therapist as a Guide

Too many medical approaches in today’s society are dependent on others (therapists, doctors, etc) and include passive treatments (medications, injections, etc.).  It can be empowering to take control of your own health and seek active forms of treatment for conditions such as low back pain, arthritis, or even every day sprains and strains.  Self-management allows you to develop a sense of control over your problem and offer you tools to use for a lifetime.  However, many are unsure where to start.

Therapeutic Alliance and Self-Management of Pain

In order to optimize self-management for any painful condition, a meaningful working relationship, or therapeutic alliance, in which the patient and provider work together, should be established.  This begins by developing a patient-preferred approach to treatment.  If you prefer to exercise aerobically then you should not be forced to perform lumbar stabilization exercises for your back pain.  If you enjoy strength training in the gym you should not be prescribed aerobic exercise for your knee pain.  Exercise you enjoy is medicine for the body and mind.  Both forms of exercise have been shown to be beneficial for managing back pain.  Let’s choose together what you prefer.

Developing a positive therapeutic alliance with your physical therapist also allows for the careful monitoring of progress over time.  There are going to ups and downs along the way.  Your physical therapist can help pick you up during challenging times.  Your physical therapist can also progress your plan appropriately when things are going well.  A physical therapist can work as a coach offering constructive feedback and encouragement.   They can help you make periodic adjustments to your self-management program.  With this approach, you are in control of your own health and your therapist acts only as a guide.

The interaction between you and your health care provider has been shown to be one of the strongest predictors of patient satisfaction with physical therapy care, and a key contributor to a successful outcome.  Research shows the amount and quality of the interaction between a patient and their physical therapist has a profound impact for those with persistent back pain.  Taking advantage of these positive interactions will magnify the effects of any exercise program or lifestyle modification. Having the same therapist, will potentially enhance the therapeutic alliance, guide you towards your preferred self-management strategies, and help you achieve the best possible long-term outcome.

What Self-Management Looks Like

Your physical therapist will first seek to understand your beliefs about pain and your condition.  Many people hold negative beliefs which are unhelpful to recovery or they are simply untrue.  For example, many people continue to believe that a herniated disc will never heal.  Your physical therapist will redirect you towards what you can control and strategies to improve self-efficacy.

Often a large amount of active participation over a long time is needed to change unhelpful beliefs and poor lifestyle habits.  Your physical therapist will guide you towards forms of physical activity you prefer and which are appropriate.  It is also important that you fully understand the time it takes for the body to heal itself.  The body’s natural healing mechanisms can be enhanced with the appropriate dose of physical activity.  Start too slow and your recovery will be delayed.  Start too fast and “flare-ups” will kill your motivation. Your physical therapist will help you find the best starting point and teach you how to progress.

Exacerbations of pain are going to occur.  You are going to have “flare-ups” of your back pain, neck pain, or shoulder pain.  This needs to be accepted and expected.  You want to develop resilience for these set ups.  There are always strategies available to help you through these challenging times.  Thinking the worst is never helpful in these situations.  Remaining optimistic is the first step.  Next, identify what is under your control to get you back on track.  This is where your physical therapist can help you focus your efforts.

Closing Thoughts                         

People with persistent painful conditions don’t always need more medical treatment.  They need a coach or guide to show them how to manage on their own with active forms of treatment.  Physical therapists can fill this role.  Developing a positive working relationship, or therapeutic alliance, with your physical therapist will get you set on the right track.  The rest is up to you.

Direct Access Physical Therapy: Q & A

Many healthcare consumers are unaware of the fact that they are free to access the services of a physical therapist without a physician referral. Every state allows for evaluation and some form of treatment without a physician referral. This has been the case in the state of New Jersey for almost 15 years, yet most of the patients that we work with in our Barnegat and Manahawkin physical therapy clinics are unaware of this. Most continue to believe that they must first visit another health care provider before seeking the services of a physical therapist. When we educate people about direct access we are greeted with a bit of surprise and many questions. Below are a few of the common questions we receive about Direct Access.

Direct Access saves time, saves money, and improves outcomes.

What are some of the advantages of accessing the services of a physical therapist first?

Directly accessing the services of a physical therapist saves time and money. Consumers are able to avoid wait times to see physicians and avoid delays in treatment while further testing might be pursued. Often these tests are not necessary and can potentially slow or negatively impact recovery (MRI for Low Back Pain>). A 2014 systematic review concluded that direct access controls health care costs and promotes high quality healthcare1. Compared to accessing physical therapy through a physician referral, those who directly accessed services were more satisfied with care, were prescribed fewer medications, underwent fewer diagnostic tests, and achieved better overall outcomes in fewer physical therapy treatment sessions. We have observed similar findings at both our Barnegat and Manahawkin physical therapy clinics. Patients who access our care directly achieve better overall outcomes in 20% fewer treatment sessions.

Are physical therapists qualified to deliver direct access services independent of physician referral?

Yes. Physical therapists are licensed healthcare professional who hold doctoral degrees. Physical therapists undergo extensive training in differential diagnosis and medical screening. This entails distinguishing non-serious musculoskeletal problems (low back pain, rotator cuff problems, meniscus tears, arthritis, etc) from more sinister potentially life threatening conditions (cardiac disorders, cancer, etc). Physical therapists at BSR Physical Therapy have also undergone more extensive residency, fellowship, and board certification training which focus further on these diagnostic skills. Physical therapists are not trained to make or confirm serious diagnoses but we are able to recognize when patients do not belong in our clinics and need an appropriate medical referral. We routinely refer patients to other medical specialists based on our physical exam or when the patient is not progressing towards their goals. Physical therapist’s clinical examination skills are on par with or better than most other healthcare professionals (Evidence here). How many other healthcare providers are going to spend one full hour actively listening to their patients in order to elicit all their concerns and then perform a comprehensive physical examination?

Will insurance companies cover direct access physical therapy services provided without a physician referral?

More and more health insurance companies are now covering physical therapy services without a physician referral. This is because of emerging research evidence showing cost savings with this approach2. At our clinics our front office professionals verify all health insurance benefits before starting treatment. In the majority of instances (>75% of cases) we are finding that a physician referral is not necessary to access and cover physical therapy care.

Approximately 10% to 20% of our patients access physical therapy care directly and this number is on the rise. Healthcare consumers are saving time, money, and achieving superior outcomes with greater convenience when directly accessing physical therapy. Health insurance companies are now recognizing these advantages as well. As health care reform continues to evolve, the health care consumer is becoming a more active participant in their own care. Direct access to physical therapy is here to stay and growing.

References:

  1. Ojha H a, Snyder RS, Davenport TE. Direct access compared with referred physical therapy episodes of care: a systematic review. Phys Ther. 2014;94(1):14-30.
  2. Pendergast J, Kliethermes S a, Freburger JK, Duffy P a. A Comparison of Health Care Use for Physician-Referred and Self-Referred Episodes of Outpatient Physical Therapy. Health Serv Res. September 2011:1-22.