WHERE IS THIS COMING FROM?

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Did you ever think you may have something in common with big names like Kobe Bryant, Tim Duncan,  Ryan Hall, Pete Sampras, or Scott Podsednik? "Walking on sharp glass" especially early in the morning is one possible symptom of Plantar Fasciitis. Sharp pain localized in the heel can be another symptom. The reality is that from basketball to tennis, running to baseball, even football to hockey does not discriminate when it comes to this condition.

 What most people don't realize is that there are a number of conditions that cause pain in the bottom of the foot or heel; yet the term Plantar Fasciitis is often wrongly used due to its familiarity to many people. It is important to see a professional for a correct diagnosis and to determine the underlying cause of the condition causing pain (muscle, fascia or tendon tears, nerve entrapment as well as stress fractures are just a few of the other conditions that should be considered). Early treatment is very important to better long-term outcomes, so instead of "running through it," read up on this 3 part series for information about treatment options, tips for home remedies and what to expect if you do need to seek care!

The Cause...



Before we can discuss how to treat it, we need to take a step back to understand exactly WHAT it is and what may have caused it to begin with. True plantar fasciitis was once believed to be inflammation of the thick band of tissue on the bottom of the foot known as the Plantar Aponeurosis (Fascia) - hence the name ending in "itis."  In recent years, a change in the cause of the condition has been recognized. Current research suggests that although inflammation may be present, the true cause of the condition may be atrophy or chronic degeneration of the fascial tissue (3, 4). The smaller and deep foot muscles (known as intrinsic muscles) are also sometimes affected by this degeneration or inflammation.  

Since everything in the body is about balance, we have to consider all 33 joints, 28 bones and over 100 muscles in the foot. The plantar fascia has direct connections to the muscles in the calf while at the same time opposing the muscles and tissue on the top of the foot. Each muscle, tendon and joint is responsible for sharing the load during standing, walking, running and jumping.  Improper fitting shoes, poor gait mechanics, lack of range of motion in any one of the foot or ankle joints, overly tight calf or ankle muscles are all possible causes, just to name a few.

Studies recently have used MRI imaging to link pain and chronicity to the size (and therefore assumed strength) of the small muscles in the foot which are used to support the inside arch of the foot (1, 2).  Weak foot musculature and/or lack of endurance in these muscles can lead to changes in pronation and the ability of the foot to distribute forces evenly and smoothly. Increased tension on the fascia or very fast transfers of force to the fascia cause irritation and eventually inflammation.

Diet and hydration can always be culprits. "You are what you eat" is an old saying for a reason. The types of proteins, fats and carbohydrates you eat are the building blocks of your tissues. The quality of your tissue is largely dependent on the quality of food you eat; furthermore your general inflammation is higher when you eat poorly and will be more difficult to calm down after an injury. Drinking plenty of (quality) fluids keeps your tissues more pliable and helps your body repair more quickly.

Training schedules and of course general overtraining are hugely detrimental. As a general rule, intensity of your workout should be increased by no more than 10% each week. Many people also fail to give themselves the recovery they need to heal and stay healthy after each workout- it is important to listen to your body and give it ample time to recover so it can adapt and get stronger. Using cross training, or mixing up your workouts with different types of activities is a great way to give yourself recovery time while working different muscle groups which pays off in the end as well!

Any combination of factors may lead to the inflammation that causes Plantar Fasciitis pain. As part of the natural healing process, the body creates scar tissue along the areas of inflammation. Scar tissue is not like the healthy tissue that lies underneath it; reduced pliability and stretch as well as increased diameter of the tissue leads to changes in how the foot functions. Changes in foot function leads to changes in the amount of force distributed throughout the foot during activities which can increase the irritation in the original tissues. It is easy to see the vicious cycle that makes Plantar Fasciitis such a chronic problem for so many people.

TREATMENT OPTIONS:

Every case of Plantar Fasciitis should be treated differently because every case has a different underlying cause. Improper fitting shoes, poor gait mechanics, weak foot musculature, lack of range of motion in any one of the foot or ankle joints, overly tight calf or ankle muscles, are all possible causes, just to name a few.

The first step in treating this condition should be obvious: stop doing whatever caused the pain. Whether it was increasing mileage for running, standing for a long time, wearing high heels or jumping during training for you sport, the longer you keep pounding and aggravating the tissue, the harder it will become to treat and the longer it will take. Depending on why your pain has begun, varying treatments can be used to improve your outcomes.

Initial treatment can be performed at home with little to no equipment. Stay tuned for Part II of this article which describes many commonly used homecare techniques in more detail. If your pain has not improved considerably within 7-10 days of diligent homecare, then it is time to seek professional care sooner rather than later. Part III will discuss professional care techniques that are commonly used.

STAY TUNED FOR PART II: HOMECARE OPTIONS TO FIND OUT WHAT YOU CAN DO AT HOME TO HELP!

 
CITATIONS:

1. Chang R, Kent-Braun JA, Hamill J. "Use of MRI for volume estimation of tibialis posterior and plantar intrinsic foot muscles in healthy and chronic plantar fasciitis limbs."  Clin Biomech (Bristol, Avon). 2012 Jun;27(5):500-5.

2. Chundru U et al. "Plantar fasciitis and calcaneal spur formation are associated with abductor digiti minimi atrophy on MRI of the foot."
Skeletal Radiol. 2008 Jun;37(6):505-10. doi: 10.1007/s00256-008-0455-2.

3. Kaikkonen M, et al. "Treatment of Plantar Fasciopathy." Duodecim. 2012;128(17):1777-85.

4. Cornwall MW, McPoil, TG. "Plantar Fasciitis Etiology."
J Orthop Sports Phys Ther. 1999 Dec;29(12):756-60.

 
 
What is IT band syndrome?

The first question to answer is what is the IT band? IT band stands for Iliotibial band which is a large sheet of thick fibers that connect the hip to the knee on the outside of the leg. Various muscles and other kinds of soft tissues connect to the IT band. IT band syndrome is an overuse injury common in runners and cyclists. The distal (bottom) portion of the thick band crosses over the lateral epicondyle (outside bony part) of the knee. As the knee bends and straightens that portion crosses over the lateral epicondyle which can cause irritation and/or a popping sound.

How do I prevent IT band syndrome?

Athletes can help prevent IT band syndrome from occurring. Proper mechanics should always be used while exercising regardless of the intensity. It is important that our muscles and joints are used the way that they were designed to be used. Incorporating a dynamic warm up and cool down decreased the rate of injury. This allows blood flow to the muscles while stretching the muscles. IT band syndrome can be an effect of tightness of one or more of the muscles that attach to the IT band. Also, a number of soft tissue techniques could be used including ART (active release technique) and Guasha (a scraping technique). Most soft tissue techniques have the same end goal with different approaches. People react different to different techniques.

How do I treat IT band syndrome?

There are many treatments for IT band syndrome ranging from conservative care or surgery. It is common practice to begin with conservative care, working of proper mechanics, soft tissue techniques, and stretching. From there if no results are found then the injury would be re-evaluated and the case would progress from that point.

-Amanda Roberson, MAT, ATC, LAT
 
 
Written by Susan Voss. Edited by Dr. Therese Miller, DC.

What is it and why does it happen? 

Iliotibial Band Syndrome is due to inflammation of the iliotibial band, a thick band of fibrous tissue that runs down the outside of the leg. The IT band begins at the hip (iliac crest) and extends to the outer side of the lower leg (fibula) just below the knee joint.  The band functions in coordination with several of the thigh and hip muscles to provide stability to the outside of the knee joint, which is where the irritation usually occurs.  Irritation can also occur at the hip or cause hip "bursitis" as well. 
 
Iliotibial band syndrome is an overuse injury most common in runners and bicyclists.  Runners can develop ITBS when making mistakes in their training or with poor mechanics.  Roads are banked to allow for  water runoff.  If a runner always runs on the same side of the road, it produces the same effect on the body as having a leg-length discrepancy. Running too many hills can also inflame the IT band.  Bicyclists may develop ITBS if they have improper posture on their bike and most commonly if they "toe in" when they pedal.  This increases the angle of the IT band as it crosses the knee, increasing the risk of inflammation.
 
What are the symptoms of ITBS? 

Pain on the outer side of the knee is the most common symptom but pain on the outside of the hip is also common.  There may initially be a sensation of stinging or needle-like pricks that are most often ignored. Some people may feel a snapping or notice a popping sound at the knee, and there may be some swelling.  Occasionally the pain may radiate along the IT band on outer side of the thigh between the knee and
hip.
 
How is ITBS treated? 

Initial treatment for ITBS includes rest, ice cup, compression and elevation; in addition to determining the underlying cause of the irritation. Depending on each individual case, any number of techniques may be helpful including ART, Graston, Kinesiotape, Trigger Point Dry Needling, Class IV Cold Laser Therapy, or many others.  Anti-inflammatory ointments can help to reduce inflammation.  
 
After the acute phase has subsided, focus should be on correcting muscle imbalances or improper mechanics which caused the inflammation to begin  with; this is different in each case. Treatment may include flexibility, stretching, and mobility or strengthening as well as gait retraining, bike adjustments or addressing other movement patterns. 
  
An important step in recovery is to evaluate the underlying cause of the problem. ITBS often becomes a chronic concern because steps are never taken to change and address why the irritation and inflammation actually occurs. 

Finally, patience is required for optimal results in healing ITBS. Whether it is waiting for mechanics changes to develop or simply returning to activity too soon-these common mistakes delay healing.  Listen to your body so you can return to and enjoy the sport you love!
 
 
The first concern when any athlete is suspected of concussion is to rule out the really serious that could be deadly or constitutes an emergency. Once this is done, evaluation can begin. There are several areas to evaluate: symptoms (what the patient reports), memory and ability to process information, and signs (what the healthcare provider can identify).

Symptoms: The patient is asked to describe their symptoms (which do not always begin immediately after the injury).

Memory/Cognitive: There are a variety of tests. Asking the patient to count backwards, recite well-known facts, remember items that will be asked approximately 5 minutes later are all common aspects of this portion of the exam.

Signs: This is often a major area of focus because these items cannot be altered or "faked." Many athletes are anxious to return to the game, and this portion of the exam gives a clear answer to some of the damage that may be present. There are 12 cranial nerves inside the skull as well as nerves that exit the spinal cord that can be tested for changes in their function. Changes in pupil size, ability to smell or hear, tracking of your eyes with movement, changes in sensation in particular areas or strength in certain muscles can be indicators of changes in your central nervous system.

These three areas will be tested at rest. If these areas are all normal under resting conditions, retesting under "exacerbation" or after performing challenging athletic tasks is used to further identify problems. For football, the athletes are likely asked to sprint 25-50 yards, perform jumping jacks, pushups, squats, etc to elevate the heart rate then are retested immediately. 

Based on the findings at rest and/or during activity, we can determine the degree of injury. Treatment is based and later, monitored, by these tests. 

Stay tuned for the next post on Treatment Options. 

 
 
Concussion itself is defined as a "mild traumatic brain injury" and its symptoms typically last fewer than 24 hours. It is important to realize that the head does not have to "hit" anything and there does not have to be a large force to cause a concussion. Our bodies are designed to absorb forces front-back better than any other direction, so a hit from the side or a jarring from an angle may be enough even under low forces.

The severity of a concussion and the severity of the after-effect are determined by a number of factors including the severity and length of the symptoms, previous history of head injuries, and severity of past injuries. The big concerns aside from initial complications are Post-Concussion Syndrome and Second Impact Syndrome.1

Post-Concussion Syndrome is a condition that causes significant aftermath following a concussion. These can range from personality and emotional changes (changes in anger, temperament, etc) to reduced response time, headaches, chronic pain, fatigue and a host of other problems. In many cases post-concussion Syndrome is short-lived but it may be a permanent change. These changes can quite literally be life-altering and must be taken seriously and treated properly.

Second-Impact Syndrome is a condition that can be deadly and is still not fully understood. First described in 1984, it involves a second head injury (typically prior to complete healing of the first). The brain swells and bleeds more severely than expected. There is a large hole in the base of the skull that the brainstem travels through on its way to becoming the spinal cord; as the pressure increases around the brain from the swelling the brain can actually be deformed and pushed through this hole. This is known as herniation and can be deadly. While still controversial, growing evidence supports higher risk with concussions that are not managed fully. This is the primary reason concussions are gaining so much more attention.

Stay tuned for the next post on Concussion Evaluation....
 
 
HOW LONG SHOULD I WAIT AFTER AN INJURY TO GET CARE?
         
Unless your injury is truly minor and will heal completely by itself in 2-4 days, the answer is almost always - DON'T WAIT! Evaluating an injury quickly will not only reduce the severity of the injury and speed healing, but will also typically save you money! Here's why: Inflammation. What's Really Wrong? Pain Cycles. Compensations.

INJURY AND INFLAMMATION 101

When you have any type of injury, some cells are broken open and damaged. This damage releases chemical messengers into the body and to the brain to "send reinforcements" to begin healing the area. Some of these chemical messengers are toxic and irritating- they irritate nerve endings causing pain and can irritate or damage the surrounding tissues. This is a process known as inflammation. Bruising, swelling, pain, redness and heat are all signs that inflammation is occurring.

Overall inflammation is a good thing. It causes nutrients, oxygen, blood and building blocks for new tissue to be sent to the area. The problem is controlling this inflammation.

SECONDARY DAMAGE.

The body goes into hyper drive! As all of these new products are sent to the area, the lymphatic system (the structures that work like sewers to drain away the "waste" and damaged tissue) can't keep up. You get one huge traffic jam. As congestion builds, pressure builds up and begins causing damage to the surrounding tissue (this is combined with irritation and damage still occurring from those previously released chemicals). As this damage occurs, more chemical messengers are released. Snowball!!!

REASON #1: Stop the inflammation and prevent Secondary Damage.

This is the premise behind RICE: Rest, Ice, Compress, and Elevate. These are very important to quickly control the inflammation and reduce the secondary damage!

There are also many additional treatment options to reduce inflammation quickly. Kinesiotape, electrical stimulation, lymphatic massage, ART....the list could go on and on. The sooner we are able to address a problem, the less inflammation is allowed to persist. Decreasing inflammation means decreasing secondary damage. Decreasing secondary damage means actually reducing how severe the injury could have been.

REASON #2: WHAT'S REALLY WRONG?

This one seems obvious, but many serious injuries are often overlooked thinking the injury is something else. Some of those more serious injuries may require special treatments, or may actually get worse with some treatments that are otherwise recommended. The longer the big injury goes untreated, the higher the risk of long-term problems and even disability over time.

For example....Did you know there are 5 common sites of ankle fractures connected with simple ankle sprains? And one isn't even in the ankle- it's in the knee! So if you aren't looking for it, it's likely to be missed. And contrary to popular belief, most people can walk on several of these fractures! There are also 6 commonly sprained ligaments in any ankle sprain. Treatment is very, very different depending on the location and severity of fracture or sprain. Three of these common injuries, if left untreated will result in needed surgery- when they could have been corrected simply with early treatment!

Needless to say: A quick exam to rule out the scary stuff is well worth your time and money!

REASON #3: PAIN CYCLES

Your body is much smarter than most of us give it credit. It actually learns patterns and forms habits. Two of these patterns are pain cycles and compensation patterns.

As your nerve endings are irritated with chemical messengers, or have been damaged themselves the obvious occurs- you experience pain. Like any information carried through your nervous system, the signal is transported up the nerve and "synapses" with the next nerve. It continues "leap frogging" or "synapsing" with each new nerve until it reaches the brain.

Every time a synapse is used to transport information, that connection becomes reinforced. That connection becomes stronger every time a signal is relayed. What happens when that signal is relayed constantly for 3 weeks, 3 months, 3 years, before you decide to do something about it? It becomes infinitely stronger and more difficult to break. This is known as a pain cycle.

This is one reason why we may be able to treat an injury completely in one visit immediately after the injury occurs, but the same injury may take weeks or months of treatment to respond if the condition has been there a long time. Needless to say, again, a quick evaluation and treatment early on will save you time....and money......in the long run!

REASON #4: COMPENSATIONS

As I said above, the body is smart! The second type of learning it does with an injury is learning compensations.

How many times have you sprained an ankle only to find your other leg begins to hurt, or your knee, or your back? Your body doesn't like pain and will do anything to get away from it- even without you knowing. Your gait with change, you will use your arm differently, etc.

These changes, known as compensations increase the amount of strain on other tissues, joints and ligaments. Similar to pain cycles, every time you use the new pattern- that pattern is strengthened. Overtime, the body forgets how to use "normal" patterns. Overtime those tissues are not designed to withstand the types of forces they are being subject to. Overtime they break down, stop working or cause pain themselves.

Controlling pain quickly and treating an injury appropriately and completely discourage compensations from occurring.  The last thing you want to do is spend time, energy, pain and money addressing a second, third or fourth problem all because you didn't take care of a simple injury to begin with!

SUMMARY: Evaluating and treating an injury quickly and completely will save a lot of pain and hassle in the long run. If you are even unsure if an injury needs to be treated, assume that it does. At the very least, you will avoid future injuries and potentially costly treatments and learn something about your body in the process!

 
 
If you have not already seen my blog posts this past month regarding a knee case Elizabeth and I were working on, it's worth checking out (www/millerswc.com/blog.html). I received a call one day from a patient who had tripped and fallen, landing straight on her knee. Although she could walk on it, it was really bruised, swollen and stiff. She had put off getting care for injuries in the past- and had paid for it later; she wondered if there was anything we could and/or should do for it. Check out the blog for exactly what had happened, what we did to help her and the speedy recovery she was able to have!

 

We hear stories like this all too often, and I myself have fallen victim to "it will just get better." After all, "do as I say, not as I do" could easily be my motto. More than once (three times in fact) I chose to keep competing on a fractured limb just so I wouldn't have to miss my sports season, or stop doing what I love. 16 major injuries in just  11 years has given me a very clear understanding of what my patients are going through!

 

There is a reality there we must all acknowledge. The reality is that the longer an injury is left untreated, even if seemingly minor, the worse off it will be in the long run. This is for several reasons:

  • Secondary damage is allowed to set up, which causes more damage.
  • Your neurological system actually "learns" pain and new pathways to transmit it, which become increasingly more difficult to break.
  • Last but certainly not least: compensations, compensations, compensations.
 

SECONDARY DAMAGE

                Stay tuned for upcoming posts on my blog which will go more in-depth into the cause and results of secondary damage. For now, we'll just touch on the basics. When the body sustains an injury, messages are sent to the brain about the damage and the need to "splint" the area and/or begin repair work. The body sends tons of materials to the area to provide support and "building blocks" for the construction to come. It also causes many surrounding muscles to spasm or in some cases "turn-off" in an effort to protect the area.

                Several problems occur. First, a traffic jam is created and the old, damage tissue struggles to clear the area. Second, as smart as the body is, it " kills an ant with a boulder" and completely overdoes repair work and tissue formation (scar tissue or adhesions sound familiar?) Thirdly, many joints get more nutrients through moving and increasing blood supply, if they are "splinted" unnecessarily they actually heal slower and with decreased quality of tissue.

               

LEARNING PAIN

                As the neurological system sends messages to and from the brain, neurons must talk to each other to transmit these signals. Over time, these connections are strengthened and the body "learns" these pathways. These connections become increasingly more difficult to break the longer they are in place.

 

COMPENSATIONS

                The body always finds ways to accomplish what it needs to. The question is what will it use to substitute for a damaged muscle, ligament or tendon; what other joints are overworking for the lack of movement in a "splinted" area.  The structures and tissues forced to compensate and take the extra pressure are not designed to take on these extra loads. These tissues are at high risk of injury, and in addition, the body also learns these new compensation patterns. So something seemingly minor can create poor "mechanics" or body patterns even years down the road.

 

So whether it's a new injury, or a chronic ache and pain you have been putting off treatment for, remember that its always better to be "safe than sorry"!