Hello Plantar Fasciitis….:-( Part I

Ouch...

Here is a major drag in my life. I’ve run into injuries off an on over the past few years. Just as I get healthy a new one seems to crop up: back pain, shoulder pain, Achilles tendon pain… The latest and greatest issue is heel pain aka plantar fasciitis. (I’m going to call it PF.)

Minor symptoms showed up a few months ago but they sort of came and went. Pain on the outside of my heel wasn’t severe and it faded out rapidly. (I associated plantar fasciitis with pain along the inside of the arch of the foot.) I’d been running some and biking a lot. I’d changed my gait and I was running a good bit in my Vibrams–and I was feeling really good!! (Interestingly, my new gait pattern had helped my Achilles tendon pain. Seems I shifted the stress elsewhere.)

I’ve read up on the issue. What have I found? It seems that one person’s PF is very different from another’s PF. Some runners insist that once they went barefoot, their PF went away. Other runners swear by the opposite end of the spectrum and that orthotics were the cure. Still many many other runners have tried many different treatments but with limited success. Some people suffer with PF for a few weeks or months. Others deal with it for a decade. Much of PF is a big mystery. What’s important here?

Causes of plantar fasciitis:

This is hard to figure out. Like most things involving bodily pain, there’s likely more than one cause. “Improper footwear” is one culprit. Biomechanical glitches such as leg-length discrepancy or tight calves also get blamed, as do high arches, low arches, leg length discrepancy, poor glute firing patterns, tight illiotibital bands. Some sources suggest that PF is due to trigger points, or knots in the muscles. There are many potential culprits for this crime, and most likely some of them are working together.

(I’ll go a little further and suggest that all these issues have causes. If we’re not asking WHY the arches/glutes/IT bands/trigger points are tight/slack/dysfunctional then we’re definitely not getting to the true cause(s) of PF.)

Improper footwear is an interesting issue. Much of the conventional wisdom says we should run in well cushioned shoes that fit our foot type, support our arches and guide our feet properly. Funny thing is military studies such as those discussed in the previous post show that footwear matched to foot type does nothing to decrease running related injuries. Ask barefoot runners and they’ll tell you that any footwear is improper footwear. So what is improper footwear? Seems it’s dependent on the eye of the beholder.

Treatment of Plantar Fasciitis:

Conventional treatment includes rest, ice, anti-inflamatory medication. Orthotics are often prescribed as are calf and foot stretches. Further pharmacological treatment may include a steroid shot. That’s the conventional stuff. What else is there? Well, there are a multitude of therapies and strategies. As I mentioned, it seems that every case of PF is different from every other case. Therefore there are many variations on treatments.

Massage

Rolling a golf ball, lacrosse ball or similar ball along the bottom of the foot helps many PF victims. This is supposed to help break up scar tissue and keep the plantar fascia supple. A similar strategy involves using a foam roller to massage the calf, hamstring, illiotibial (IT) band, glutes, etc. These are forms of self-massage. More formalized massage methods may proove beneficial. Myofascial release, Active Release Therapy (ART), deep tissue massage, trigger point therapy, Structural Integration (aka Rolfing) are examples of massage-type techniques that may prove beneficial in addressing PF.

Shoes

Lots of options here! From barefoot to orthotics and all points in between, what you put on your feet (or possibly take off of your feet) may strongly influence PF. This series of posts on the Runner’s World Forum encapsulates the issue very well. One poster emphasizes wearing orthotics ALL THE TIME, while another poster says, “I think the thing that finally was a breakthrough for me was walking barefoot in the sand.” I’ve found very similar statements throughout my reading. So while there doesn’t seem to be any one shoe-based solution for everyone, consider the idea of changing footwear.

Orthotics are usually expensive. Cheaper options include grocery-store bought arch supports and heel cups. Superfeet and Sole Supports are similar to orthotics but also less expensive.

Joint Mobility/Strengthening

Weakness of the foot muscles may be causing your PF. Therefore, strengthening the foot and lower leg and improving mobility/stability is vital. We may not spend much time thinking about strong feet but hey, we only have to use them all the time every single day right? Maybe it’s actually important! I look to Z-Health R-Phase and I-Phase drills to enhance neural communication and awareness in feet and lower legs. I’ll give some examples.

Start by simply moving the foot and ankle in all available directions. Make circles with your feet. Turn the sole in and out. Flex and extend the toes along with the rest of the foot (make foot waves). Ball-of-foot circles, toe pulls, and knee circles may help as well. You must concentrate and try to make the movements as smooth and refined as possible. Stay relaxed and breathe. Single-leg balance drills may be beneficial too.

My personal opinion is that at some point, barefoot or minimal shoe work should improve foot strength. (Again, some people insist this is the key to their overcoming PF.) It may be too much though if your foot is injured. The plantar fascia may be further damaged if you overload the region. So it may be a progression similar to adding weight to a strength program or mileage to a running program. Start with a small amount of barefoot balance work while still wearing whatever supportive footwear you’ve got. You may gradually add in more barefoot work if the pain decreases. Back off if the pain increases.

Ultrasound, Cold Laser, Shockwave Therapies

Physical therapists and chiropractors often use ultrasound therapy on soft-tissue injuries. The idea is to bring heat to the area and facilitate healing. Research is mixed on effectiveness.

Cold laser therapy is a somewhat new therapy that may aid healing of PF. The evidence is unclear though. Research continues as to what wattage laser is ideal, what wavelength should be used, and how often one should receive treatment. A Runner’s World article profiles one runner’s positive experience with laser therapy.

Extracorporeal shockwave is yet another electromagnetic method of addressing soft-tissue injuries. Similar to ultrasound and cold laser, research is mixed, which shouldn’t be surprising. If we’re dealing with a problem that may have multiple and varied causes it makes sense that one or another type of therapy may or may not be effective. Further, ultrasound, laser and shockwave therapies deal with focused energy. That energy can vary in terms of power and wavelength. An injury may be exposed to varying amounts of energy for varying amounts of time. Thus there are numerous factors that may or may not lead to healing of PF. Lots of choices….

I’ll continue this post with a look at night splints, walking on gravel, magical ceremonies and everything else used to drive out the evil spirit that is Plantar Fasciitis (plus my own strategy in overcoming this issue.)

Feldenkrais

I’ve been suffering with back pain and other symptoms (Achilles pain most recently) of something since about 2002. I’ve gone through a lot of types of therapy from physical therapy to chiropractic, to Muscle Activation Techniques to Active Release Therapy, acupuncture, massage, prolotherapy and lots of different corrective exercise protocols. My issue seems to be a movement issue. That is, as I move the sequence of events–muscle contractions, feedback from muscles and joints, etc.–that should be happening aren’t happening in an ideal way. I’ve gotten better especially with my introduction to Z-Health but nothing has quite yet resolved my issues. I’ve been aware of Feldenkrais for a while and it’s been on my list of modalities to investigate. I recently emailed Seattle-area Rolfer and Z-Health practitioner Todd Hargrove (Todd writes an excellent blog) to ask him his opinion and he suggested I search out a Feldenkrais practitioner, so I did. Yesterday was my first experience and it was quite interesting.

I met with local Denver Feldenkrais practitioner Ray Little for two hours and I became quite a bit more aware of how I move–and how I should move. Without any technical terminology or complicated instructions, he helped me feel how to walk properly. The most powerful thing he showed me was where on my foot to feel the impact of walking (right in front of the heel) and then how to effectively push myself forward. We discussed the idea of lengthening into stride, taking the impact of the foot strike and smoothly rebounding into forward motion. All and all it was a very enlightening experience and I very much look forward to meeting with him again next week.

As I’m about to post this, I’ve gone on two runs since Monday and I’ve felt better than I have literally in years. I think I’m back on the horse!!

MRIs & Docs May Not Have All the Answers

We’d like to think that our modern medical technology and treatment methods can diagnose and heal any problem. PET scans, CAT scans, MRIs and X-Rays allow us to peer inside the body and examine tissues and organs. Our MDs and surgeons are the beneficiaries of hundreds of years of evolving medical education. But guess what! Not every ache and pain has an obvious cause and many docs are as mystified by our ailments as we are.

New Study Finds 70 Percent of Able-Bodied Hockey Players Have Abnormal Hip and Pelvis MRIs comes from Science Daily. The piece explains the findings of a study conducted by the American Orthopedic Society for Sports Medicine. The study used the MRIs of the pelvis and hips of 39 collegiate and professional hockey players. Seventy percent of the images showed abnormalities yet only two players reported pain. In other words, most of the players had what we might identify as “injuries” yet only two of them were “hurt.” So this goes to the issue of just how valuable are these sorts of diagnostic tools.

Matthew Silvis, MD, Assistant Professor, Department of Family Medicine and Orthopedics at Hershey Medical Center at Penn State University College of Medicine stated,

“Unexpectedly, the majority of players had some abnormality in their MRI, but it didn’t limit their playing ability. The study raises many questions, but its value to surgeons is to recognize that imaging doesn’t replace good clinical judgment, which includes a detailed history and complete physical exam. This study might make you hesitate to read too much into an MRI.”

A lot of us probably assume the MRI is very precise and can show us exactly why our back, knee or shoulder is in pain. Yet we may need to think about whether or not we’re looking at chickens or eggs here. Do these abnormalities cause pain, or are they simply coincidental to pain?

Obviously the only reason anyone gets an MRI outside of a study like this is because we’re in pain and we need to know why. (I have yet to meet anyone who had an MRI simply out of curiosity about what they look like on the inside.) So automatically we have a self-selected group to study. If this study is any indication then in fact it’s entirely likely that people who feel healthy may indeed appear to be injured according to their MRI. Thus what is seen on an MRI and attributed to our pain–bone spurs, a torn labrum, or a herniated disks for instance–may or may not be the cause of our pain. Perhaps the source of our pain is something else entirely. The point is the MRI is not always as precise as we’d like to believe.

I’ve had personal experience with this sort of situation. Several years ago I was performing a barbell snatch and I felt a pop followed by very sharp pain in my left shoulder. A cortisone shot helped only temporarily. I underwent an MRI and according to the image there was no serious injury. It wasn’t until a surgeon had a look inside my shoulder and saw that my supraspinatus tendon was about 90% detached. After he reattached the tendon he later explained how MRIs can be helpful but they’re not always very precise.

On a simiar theme, a recent New York Times story examines to what degree doctors sought medical attention for their aches and pains. You might be surprised to learn that docs who were interviewed rarely visted other docs when they’re hurting. (The Times story also references the MRI story mentioned above.) Doctor-athlete, Paul D. Thompson, a marathon runner and a cardiologist at Hartford Hospital in Hartford said the following:

“I think most folks should not go, because most general doctors don’t know a lot about running injuries,” he said, adding, “Most docs, often even the good sports docs, then will just tell you to stop running anyway, so the first thing is to stop running yourself.”

So all-and-all, as much as we’d love to believe that the modern mainstream medical profession has all the answers–or at least the tools to find all the answers, it simply ain’t so in a lot of cases. The fact of the matter is most MDs don’t fully understand human movement and how all the parts of the body–bones, muscles, organs, and most importantly the nervous system–act together in a 3-D world governed by gravity. Just look at how many specialists there are around us. There are podiatrists for the feet, spine specialists, knee specialists, shoulder specialists, low-back doctors, etc. There are surgeons that specialize in opening us up and tinkering about. There are docs to analyze blood, the eyes, reproductive organs, the heart, our minds…. But guess what, we’re all one big system! If we or the people who are assessing us believe that we’re just a bunch of separate parts then we’re way off the mark. And if your doc just wants to feed you pain medicine–definitely go get another opinion. (As one acquaintance put it, “Your pain wasn’t caused by an ibuprofen deficiency.”)

(BTW, please don’t take this as my hating on the entire medical profession. If I’m in a car crash and I’ve got a piece of steel stuck in me, please go get me a surgeon and not a massage therapist or chiro.)

Recognize that the arms and neck are highly affected by the feet. Weak eye muscles can cause bad posture and thus neck pain. Medication for our high cholesterol may cause low-back pain. Shoulder pain may be rooted in poor wrist and hand mechanics. Even if the tissue of a years-old injury has healed, the ability to move and control the limb may not have been restored–and that may be causing pain in any number of areas. The bad mood you’re in may be driving that aggravating hip pain.

The body and the nervous system is tremendously complex and all its parts are highly interactive at all times. Always keep this in mind if you’re in pain and looking for relief.

Z-Health Day 1

Yesterday was the first day of the Z-Health R-Phase certification here in Denver and I found it very informative and enjoyable. We learned a tremendous amount about the nervous system and why doing joint mobility drills can relieve pain. (I started the day with some low back pain. We progressed through only a few drills: foot/ankle drills and knee drills. Soon after there was no back pain and I still am pain free this morning as I type this.) It sounds strange I know, but the ways of the body and nervous system are often less than obviously logical.

The class of about 20 students is the most diverse class I’ve seen at any sort of exercise course. In addition to personal trainers there’s a physical therapist and a PT school student in attendance, a yoga instructor, a school teacher, and a nurse. One man is a client of a Z-Health trainer who’s simply been impressed enough by the results that he wants to learn more. One woman has seen her elderly mother go through hip and knee surgeries with poor results. She said she didn’t want to get old in the same fashion.

I don’t want this to sound like some sort of a weird cult thing or blind devotion to some oddball system. Z-Health creator Eric Cobb has drawn on a wide variety of sources in developing the system. Much of what informs Z-Health is neurological research and an understanding of what pain is, how the brain views pain and they myriad ways we can address pain. Cobb urges students and Z-Health trainers to read a lot and learn as much as possible about these issues.

One criticism of Z-Health is that it’s hard to explain. People ask “What is Z-Health?” and those of us who’ve been exposed to it often can’t give as succinct an answer as we wish we could. I think the Z-Health web site should give a better explanation of what Z-Health is and how it works. The course I’m taking is called R-Phase. “R” stands for restore, rehab, and re-educate. There are other phases but R-Phase forms the basis for the other phases. I’ll do my best to give an explanation.

The driving concept is that the nervous system is the key driver of of every facet of the body. Absent an acute injury like a broken bone, cut or dislocation our pain is a movement problem. For example “My knee hurts when I climb stairs,” or “My shoulder hurts when I reach overhead.” Those are movement problems. The nervous system drives movement, not the muscles, not the bones, not connective tissue but the nervous system. Thus is if we want to eliminate pain then we must address the nervous system in order to improve movement. (Interestingly, if any movement pattern is compromised–ankle movement for example–then it may create pain and/or weakness in other regions such as the neck or a shoulder. It’s sort of similar to the way a storm in Seattle may impair air traffic in Miami.) The way we do this is by moving each joint one at a time through its full, pain-free range of motion. We do this very precisely under strict control. In this way we improve the brain’s map of the body (the homunculus). We increase the nervous system’s recognition of these joints and limbs thus we improve movement and control of the body.

That’s the brief, non-technical explanation! I wish I could put it more briefly. Medical and body work professionals may still prefer a more thorough explanation. Z-Health looks somewhat like tai chi. In fact Z-Health draws on martial arts, tai chi and dance for various mobility drills.

For anyone wanting more information I suggest you call the Z-Health offices. The people who work there are very much willing to discuss Z-Health and answer any questions. They’re a very helpful and well informed staff.

Achilles Tendon Issues: Help from Dr. Ivo at Summit Chiropractic

My wife and I just recently enjoyed a long weekend in the mountains full of skiing/snowboarding, sleeping in, and wishing we had a condo near the slopes. Part of that weekend included a visit with Dr. Ivo Waerlop at Summit Chiropractic in Dillon, CO. I went in hopes of 1) getting help with my sore left Achilles tendon that’s been bothering me for months, and 2) get some of his thoughts on barefoot running. The visit was very helpful and enlightening.

Dr. Waerlop was featured in a Denver Post article on barefoot running. My wife looked up his web site and it grabbed my interest. Dr. Waerlop is involved in the biomechanics of cycling, running and skiing (three things I love), and he’s involved in barefoot running. In fact, he’s a biomechanics advisor for Vibram. He’s also an accupunturist.

I won’t go into every detail but his asessment of my gait was very precise and his explanations very thorough. He assessed my feet, legs and trunk; observed my gait; and presecribed several exercises for me plus a sole lift for my shoe.

Most importantly we focused on attending to the causes of my problems (faulty biomechanics in the feet and toes) rather than the symptoms (pain in the Achilles–oh yeah, and my low back and my left shoulder).

He also advised me on barefoot running. I probably won’t ever be a full-on barefooter but I likely will be doing some barefoot running in the near future. (Gotta take it slow!)

There’s more. Dr. Waerlop is part of the Homonculus Group. (What is the homonculus? Excellent question. Click on the word to find out.) This is a group of physicians and sports performance/injury rehab professionals who are “committed and driven to better understand the problems of pain and movement impairment in this world (basically the aches and pains that ail individuals.)” The Homonculus site is rich with podcasts, articles and discussion threads (though it appears their discussion board has received a lot of spam which should be removed. Go to page 1 of the discussion board for legitimate information.) Finally, Dr. Waerlop is one of the Gait Guys whose lectures on gait assessment are found at Youtube.

I am very excited to dig into the articles and podcasts. If you’re a trainer, coach, or injury rehab professional–or if you’re just a fitness geek with some spare time, I highly recommend you investigate some of this material. I can’t get enough of this stuff!!!

Z-Health for Toe Pain

This will be brief. I’m enormously excited over the results I’ve been getting from my Z-Health work. My back pain, Achilles pain and shoulder pain have all improved quite dramatically over the past few weeks. (I also added 70 lbs. to my deadlift in one fell swoop!) Yesterday it was my wife’s chance to be surprised by Z-Health.

My wife is a triathlete who’s had intermittent big toe pain in her left foot over the past several months. It comes and goes and it never had a clear-cut cause. Yesterday, after visiting with Jason Wood in Lakewood, CO I went home and had my wife go through some Z-Health R-Phase drills. One of the Z-Health concepts deals with opposing joints. That means since my wife’s toe pain was in her left foot, I had her go through drills with her right hand and thumb. The result? No toe pain whatsoever! As she gaped in bewilderment, she drove her foot into the ground and wiggled her foot all over and she could not replicate the pain. The toe pain returned this morning during a dog walk, she went through the drills again for a few moments and again the pain was gone. (As an aside, the toe pain comes on most notably in a pair of hiking boots. Perhaps the shoe is interfering with the natural function of her foot, as I’ve discussed here.) Pretty cool stuff this Z-Health.

I’ll be taking the R-Phase certification in March and April of this year and I’m extremely excited. I’ve just barely begun to scratch the surface with this exercise protocol and I expect to see more and more dramatic results. If you’re a fellow personal trainer, a chiropractor, physical therapist or anyone else involved in the health & fitness business, I highly suggest you look into Z-Health for everything from injury treatment to increasing sports performance. If you’re an athlete or just an everyday fitness fan who’s either in pain or not performing as well as you’d like, you would do well to seek out a Z-Health trainer for help and advice.

Denver Fitness Journal

All Things Health and Fitness by Kyle Norman, MS, CSCS, FMS, RRCA Running Coach

Injury Rehabilitation