Activity As previously discussed, runners are especially prone to plantar fasciitis as a result of overuse, and the risk goes up with more aggressive training for speed and distance. Many runners also experience plantar fasciitis as an indication that their running shoes are worn out and need to be replaced (see “Poor Support/Footwear”). A sudden increase in exercise activity, as in those who have just taken up running and might not have developed good form yet, can also be a cause of acute episodes of plantar fasciitis. However, athletes are not the only ones to suffer from repetitive strain injuries. Jobs that require standing for long periods of time, such as retail, food service or warehouse work, can be a risk factor, and even more so if they require standing for many hours on concrete surfaces. Additionally, jobs that require frequent use of ladders can tighten the calf muscles and irritate the plantar fascia because of the way the calf muscles work when standing on a ladder to achieve balance. The activity risk factors do not necessarily have to be sports; they can be any activity that is frequent and repetitive. Case study A 53-year-old male snowboarding instructor presented with pain and tightness in the lower left leg and ankle and foot pain on the sole of the foot near the heel, especially upon standing. The client has high arches in both feet, and the soles of his shoes tend to wear more on the outer edge, signifying that the later aspect of the foot bears more of his body weight. The client’s normal stance showed a moderate degree of intoeing, or that he was “pigeon-toed,” and he noted that his snowboard bindings are typically set between 9 and 15 degrees of lateral rotation, (meaning that both of his feet are bound to the snowboard slightly turned outward) and his left foot is his “front” foot, and that the weight distribution shifts from front to back in the feet as the board travels across the surface of the snow. He also noted that he wears custom orthotics inside the boots and compression sleeves on the lower legs when snowboarding. He noted that his typical day of giving snowboarding lessons was usually six hours long, after which time the pain in the lower leg and foot were constant and would last throughout the rest of the day. Palpation showed the lateral side of the gastrocnemius was very hypertonic, as was the lateral soleus to a lesser degree. Both ankles showed inhibited dorsiflexion when manually manipulated while the client was lying prone, with the left being slightly worse. A consultation with an orthopedic specialist ruled out a stress fracture to the fibula (due to the location and intensity of the pain) and damage to the Achilles tendon. The client was prescribed six weeks of physical therapy, which consisted of balance exercises, resistance band exercises, and a lot of stretching. The client concurrently had massage therapy sessions focused mainly on the lower legs and feet during those six weeks, which included deep tissue massage and Gua Sha techniques. The client also routinely used a percussion massage gun at home on his legs in between sessions. While some relief was noted by the client during the six weeks of therapy, the pain did not significantly relent until snowboard season was over and the repetitive positioning and activity of snowboarding was discontinued for several months. All evidence pointed toward an overuse injury that could not make significant healing progress until the overuse ended.
Decreased ankle dorsiflexion Decreased dorsiflexion in the ankle is considered to be the most common risk factor for plantar fasciitis, and this can also be common in runners and other athletes. One study found that people who had 10 degrees or less of dorsiflexion had an odds ratio of 23.3 of having plantar fasciitis compared to the group of people who had 10 degrees or more of active dorsiflexion (Riddle et al., 2003). There are several causes for decreased dorsiflexion. Injuries to the ankle joint itself and subsequent scar tissue can create a dysfunction in the joint that limits the range of motion. Excessively tight calf muscles, especially the gastrocnemius, can be a contributing factor. The primary function of the calf muscles, such as the gastrocnemius and soleus, is to move the ankle into plantar flexion, which is typically a stronger action than dorsiflexion, making them the naturally dominant muscle group. When they become hypertonic, the calf muscles can inhibit dorsiflexion. While tight calves are commonly seen in runners, women who wear high- heeled shoes frequently can also develop hypertonicity in the gastrocnemius muscles. Injury to the Achilles tendon, especially the scar tissue that develops from a healed rupture, can dramatically limit the range of motion in the ankle. Whatever the cause, the effect of an increased risk for developing plantar fasciitis is the same. Case study A 38-year-old female long-distance runner presented with pain in the right calf and the sole of the right foot during the later stages of training for a half-marathon. At this point in her training, the long training runs were around eight miles at least once per week, with the goal of getting to ten-mile training runs within a month. The client had surgery for scoliosis as a teenager and has permanent hardware in her low to mid-thoracic spine. The curvature in her spine is primarily lateral with no perceptible twist in the spine. As a result of the scoliosis and surgical treatment, her hips are not level. The right hip is a bit higher than the left hip, indicating that the left and right feet impact the ground differently when running, giving her a functional leg length difference. The client also admitted to often neglecting to stretch after a long run. She also noted that it might be time to replace her running shoes, as she had been putting a lot of miles on them. Upon palpation during a therapy session, it was noted that the right gastrocnemius and soleus were both significantly more hypertonic than the left side. The right arch also seemed slightly higher than the left when standing, and the right ankle was capable of a lesser degree of dorsiflexion than the left ankle. The right side of the body was generally overly responsive to pressure, and it was noted that the right leg never felt completely relaxed, even when lying on the therapy table. Over the course of four weeks, the client had weekly therapy sessions that included passive stretching for the calf muscles, and she committed to self-care at home that included comprehensive stretching for the legs with a focus on the calf muscles, and ice applied to the plantar fascia every night before going to bed. She also replaced her running shoes. She was able to increase her mileage according to her training schedule and complete the half-marathon with only minimal discomfort in her right leg and foot. The pain resolved after the event with a decrease in mileage and continued self-care at home. The client noted that she will continue to make stretching a more integral part of her training.
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Book Code: MLA1225
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