Ouch! My foot hurts! But is it really plantar fasciitis?

It’s 7 o’clock in the morning and you’re just waking up.  You are feeling great, stretching out your arms while simultaneously yawning, it’s going to be a great day!  Then, you put your foot down with a little weight through it and – Ouch! It hurts! Now your day is ruined and you may be worried about what’s going on with your foot. Now, does foot pain normally appear randomly like so? Not really.  Foot pain is typically more insidious in onset, but this story is all too familiar.

Specializing in treating foot pain, it is common for me to have patients come in self-diagnosing themselves as having plantar fasciitis for any sort of foot pain.  I’ve seen patients misdiagnose their metatarsalgia, neuropathic pain, Achilles pain – all for plantar fasciitis.  It’s easy to go onto Google or Web MD and type in “plantar fasciitis” and find out that a symptom is pain on the plantar (bottom) surface of your foot.  Eureka! I correctly diagnosed myself with plantar fasciitis! More often than not, that is the wrong answer. Many times symptoms that act like plantar fasciitis are indeed not plantar fasciitis. The goal of this blog is to help give you more information to understand that the foot can be complex, and may need a physical therapist to help make a diagnosis and treat your pain.

As an evidence-based practitioner, I pride myself on using current research to help my practice.  In 2014, clinical practice guidelines for plantar fasciitis were published in the Journal of Orthopedic & Sports Physical Therapy (JOSPT), one of the most revered journals in the world of physical therapy. In the diagnosis of plantar fasciitis, we find that one must have pain to touch at the insertion of the plantar fascia, limited ankle range of motion and pain following a period of inactivity amongst other things.  There are more complex components involved in the diagnose as well.  This would include ruling out any nerve complications as well as identifying structural foot abnormalities. This is where the provider comes in. As I mentioned previously, plantar fasciitis is non-discriminatory.  We cannot simply say that because our ankle is stiff or that we are overweight that it means we have plantar fasciitis.  Fun fact: according to a systematic review by Lopes et al, running can actually be a risk factor too!

Let’s create a hypothetical situation in which you have read and understood the clinical guidelines. You find that you have pain in your heel or your arch, but the math isn’t quite adding up.  You do not have pain with touching the insertion of the plantar fascia, and you do not have pain with your first couple of steps in the morning. Another day goes by, yet your heel and your arch still hurt. At this point, you are likely blue in the face from rolling your foot on an ice bottle.  What else could it be? Let’s familiarize ourselves a little with myofascial pain.

Myofascial pain is essentially muscle pain derived from contracted fibers of muscle we call trigger points.  These trigger points are typically starved of good oxygen and blood supply given their contracted nature. These are the tender knots that you can feel in your muscles.  If left untreated, over time these trigger points will create referred pain.  Providers who treat myofascial pain are very familiar with the pain referral patterns that these trigger points cause.  Take a look at the following picture; do the red areas of pain look familiar?

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If it does, great! What you are seeing in this image is that trigger points in the gastrocnemius and soleus muscles can cause referred pain that mimics heel pain and plantar fasciitis! Your next question should be, “how do we treat this problem? More rolling on the ice bottle?” Absolutely not! Myofascial pain is effectively treated by functional dry needling, which is performed by Doctors of Physical Therapy.  Not familiar with dry needling? Here’s the definition:

“Dry needling is a technique used to treat dysfunctions in skeletal muscle, fascia, and connective tissue, and diminish persistent peripheral nociceptive input, and reduce or restore impairments of body structure and function leading to improved activity and participation”

-American Physical Therapy Association, 2013

Tekin et al have demonstrated that dry needling is a proven effective treatment to relieve the pain and improve the quality of life of patients with myofascial pain. Now dry needling is a hot topic, and I’m sure you will have many questions, but we will leave that conversation for a future blog post!

So with dry needling and exercises aside, what other options are available to treat this heel and arch pain? In a meta-analysis by Lee et al, it was determined that an orthotic (shoe insert) can be used to reduce pain and improve function in patients with plantar fasciitis. Don’t worry, it gets better! This orthotic does not need to be expensive or custom! In a systematic review by Landorf et al, it was determined that a custom orthotic is no better than a prefabricated orthotic. So there is no need to go out and spend lots of money on a custom orthotic that you will have to wait weeks to be made, when you can get a prefabricated orthotic and leave with it on the same day!

Lucky for you, I know a thing or two about orthotics and dry needling treatment.  I choose to make orthotics for my patients out of prefabricated materials for two main reasons:

  1. It is cheaper for the patient
  2. The patient can leave with it the same day!

So the next time you have heel or arch pain, you should appreciate that there may be a number of things it could be.  All risk factors aside, find a physical therapist that you trust and connect with to help diagnose your pain.  As we have learned, diagnosing one’s foot pain is a little more complex than a search on Web MD!

Foot Orthotics: Custom vs Prefab?

Foot Orthoses in Lower Limb Overuse Conditions: A Systematic Review and Meta-Analysis

As a physical therapist specializing in foot pain, I have come across a number of patients with different types of foot orthoses. A foot orthotic is an insert designed to help support, align or improve function of the foot. Many people seek out orthotics to help alleviate foot pain, but are troubled with deciding whether they need a custom orthotic.

Custom orthotics are inserts generated from a 3D print of the patient’s foot. These are not normally made by physical therapists. Most commonly these will be made by either orthotists, prosthetists or podiatrists. A custom orthotic can cost upwards of $500 with little coverage from insurance. Many times I have seen these custom orthotics fail for a number of reasons. The device can be made too rigid, not allowing for proper tri-planar movement of the foot. Runners with this type of device can be at risk for tibial stress fractures. My biggest issue is that many times the orthotic may be measured in non-weightbearing. Many people do not have pain in non-weightbearing, so why would we make an orthotic this way?

This systematic review by Collins et al offers us some perspective into the effectiveness of foot orthoses in lower limb overuse conditions. Lower limb overuse conditions typically arise from either abnormal foot mobility or through excessive tissue stress. This can result in foot pain, such as the commonly known diagnosis of plantar fasciitis. The article suggests that a foot orthotic can be helpful in the plan to remedy this pain, however a custom orthotic is NOT necessary.

When prescribed correctly, prefabricated devices can be just as effective as custom devices in treating lower limb pain. The biggest advantages to prefabricated devices is that they are cost effective, as well as readily available. Some of the troubles with custom orthotics are that they are resource intensive and expensive, and can have a large gap of time from the fitting, to the actually supply of the orthotics (~2 weeks). As previously mentioned, these orthotics may also be fitted by an orthotist. An orthotist does not have the same training as a Doctor of Physical Therapy, whom we may consider to be a “movement specialist” or “gait specialist.”

Hopefully the next time you feel pain in your foot, you’ll consider a few things. First, you will want to think about who you want diagnosing your pain. Consider a Doctor of Physical Therapy, a movement specialist who can properly analyze gait and movement dysfunction. Secondly, you will want to consider cost. Prefabricated devices are readily available and can be modified to effectively and efficiently treat your pain. Please feel free to reach out to me when considering how to solve your foot troubles or for a consultation.