Welcome to tonight’s physiotherapy corner, where we highlight how important it is to get a professional to assess and diagnose an injury to get the appropriate treatment, instead of trying to self-diagnose!

This evening’s case study focusses on a runner who was convinced he was suffering with the dreaded plantar fasciitis.

However, following the application of the careful and methodical process involved in the Maitland Concept of physiotherapy here at the clinic, it was discovered the patient’s symptoms were the result of a stiff neck, sustained in a car accident 18 months earlier.

Remember, our Blizard Maitland physiotherapists can get straight to the source of the problem using a detailed history, allowing you the patient to resume your normal activities quickly.

So what is Plantar Fasciitis?

Plantar fasciitis is a thickening of the plantar fascia, a band of tissue running underneath the sole of the foot

The symptoms of plantar fasciitis include:

• Pain in the bottom of your foot, especially at the front or centre of the heel bone (see photo below)
• 
• Pain that is worse when first rising in the morning (called "first-step pain"), when first standing up after any long period of sitting, or after increased levels of activity

What does the treatment involve?

Local treatment usually includes activity modification, stretching the plantar fascia and the calf muscles, as well as looking at the biomechanics to ascertain what is causing the plantar fascia to become irritated.

Plantar fasciitis can remain a problem for months, sometimes years, and can begin to irritate the opposite foot as that begins to take more of the weight in an attempt to offload the painful foot.

Did these rules regarding plantar fasciitis apply to the running patient in question?

In this case there were no causative factors - the runner had maintained the same training, worn the same footwear, and had continued to run on the same surfaces.

So what is the next step in the assessment process?

Next we looked for changes in other areas of his life, such as work positions, family time, stressors and so on. In this case, again, nothing had changed.

However, we also look at ALL other areas of the body that are symptomatic, no matter how chronic or minor they may seem.

In this case, the runner had a persistent stiff neck following a “minor” car accident some 18 months prior to the onset of the heel pain. The stiff neck was gradually becoming more of an issue as the months progressed.

Thus, rather than assessing the plantar fascia in isolation, it was necessary to exclude the neck as a source of the pain.

Whilst the history taking takes time - often 20 minutes at least - the assessment and subsequent treatment was brief and, importantly, productive.

This is what we found and how we treated - “or didn’t treat” - the plantar fascia

Assessment Findings

• To touch the plantar fascia it was painful, but the range was normal (first clue that it is probably not plantar fasciitis)
• Testing the mobility of the nervous system in the lower leg compared to the opposite side showed that there was a difference (the next clue that it probably is not plantar fasciitis)
• There was restricted mobility of the neck range of movement one side compared to the other
• We held the neck in this restricted position whilst at the same time testing the mobility of the nervous system again, and this reduced the mobility of the nervous system further - moving the neck to the opposite side subsequently increased the mobility of the nervous system.
• We tested the pain response to touching the plantar fascia in the painful spot when the nervous system was on and off tension, and it differed.
• Mobilising the joints in the neck on the same side of the painful plantar fascia reproduced a painful throbbing of the plantar fascia

Treatment

We mobilised the joints in the neck (see picture below) and then re-assessed the findings.



The nervous system was now of equal mobility on both sides, the plantar fascia was no longer painful and the neck moved equally both sides.

Home treatment focused on maintaining the range of movement in the neck, and the runner continued to run.

Analysis - why did we carry out this treatment?

In the end we didn’t treat the plantar fascia, but what is the reasoning behind this treatment?

• The joints in the neck were stiff, which were creating restriction of movement in the nervous system.
• We mobilised the joints to create more “roominess” for the nerves to move.
• Hence when the foot touched the floor during the running action, the nervous system was no longer under any tension.

This is an example of how a restriction in your nervous system in one area of your body can create an irritation of your nervous system anywhere else in the body.

The plantar fascia is supplied by the medial plantar nerve, which is a branch of the tibial nerve, which is in turn a branch of the sciatic nerve which arises from your spinal cord.

A restricted branch further up the spinal cord prevents restriction further down, if this is the bit that is being the most stretched i.e striding forward when running, then this is likely to be where it is most painful.

There is no thickening or inflammation of the plantar fascia, it is just the nerve that is causing the pain.

Local treatment just to the plantar fascia won’t make a bit of difference!

We hope this has helped explain why it is so important to not make assumptions about the source and cause of any niggle or pain you are experiencing, and to seek professional advice from a physiotherapist to ensure you get the most appropriate - and successful - treatment for you.

If you are suffering with a pain that you would like to talk to our physiotherapy team about, we have our monthly FREE physiotherapy advice service this Saturday.

The service offers free 15 minute appointments, where you can pop in at short notice and see one of our expert team for no fee, get your issue assessed and receive advice on whether you will need treatment or not.