Plantar Fasciopathy

Background

Plantar fasciopathy (previously known as plantar fasciitis) is the most common cause of heel pain in adults and affects up to 8% of running-based athletes. (Taunton et al., 2002) Symptoms of plantar fasciopathy include pain at the base of the heel that is worst in the morning or when performing sporting activity, particularly when warming up. (Thing, 2012) Plantar fasciopathy usually results from an acute overload of the plantar fascia i.e. when commencing a new sport or a chronic overload related to lifestyle and exercise factors. Risk factors for plantar fasciopathy include reduced ankle dorsi flexion, BMI > 30kg/m2 and work-related weight-bearing.(Riddle, Pulisic, Pidcoe, & Johnson, 2003)

Recent evidence suggests that the condition should be referred to as fasciopathy rather than fasciitis as the tissue pathology more closely resembles that of tendinosis. (Drew, Smith, Littlewood, & Sturrock, 2014; Lemont, Ammirati, & Usen, 2003)

Plantar Fascia Anatomy

Assessment and Diagnosis

Plantar fasciopathy is generally diagnosed clinically however ultrasound can assist if clinical diagnosis is uncertain. Ultrasound can be used to measure the thickness of the fascia however ultrasound findings have not been shown to change despite improvements in outcome. (Rathleff et al., 2015) In some case, patients with plantar fasciopathy present to physiotherapy with an X-Ray that may show a bone spur at the base of the heel. Interestingly, this has not been shown to be related to pain or outcome therefore is generally not of use in guiding management.(Lu, Gu, & Zhu, 1996)

Treatment and Rehabilitation

Treatment of plantar fasciopathy has traditionally consisted of stretching, gel heel inserts and injections (Rathleff & Thorborg, 2015) however recent advances in understanding of the pathology has led to increased focus on exercise and load management as treatment options.

A recent study by Rathleff et al, (2015) showed that a program of slow high-load strength training outperformed a stretching program over 3 months. The strength program consisted of progressively overloading a single leg calf raise performed in toe flexion (Image 1/Image 2) and progressing every second week. It is a high load slow tempo strength program. Stretching consisted of 10 x 10 sec stretches performed 3 x per day.

Start position

End position

The rationale behind the slow high load strength training program is that the program provides a progressive overload of the plantar fascia that promotes collagen synthesis to help normalise tendon structure and improve tissue capacity.(Rathleff et al., 2015)

While other management options do exist and are called in some cases of plantar fasciopathy the mainstay of effective management should be an appropriate load management and strengthening program administered and reviewed regularly by your physiotherapist.

Patient Tips

·       Increase the load on the plantar fascia by filling a back pack with books as you get stronger.

·       Perform the single leg calf raise with a rolled towel under your toe to utilise the ‘windlass mechanism’ whereby flexing the toes causes tensioning of the plantar fascia prior to loading.

·       Manage your activities around your pain threshold i.e. pain > 4/10 during or after loading suggests you have overloaded the tissue. For best results, discuss with your sports physiotherapist about an individualised load management plan.

Clinical Tip

·       When treating athletes or patients with plantar fasciopathy treatment outcomes are best measured using the Foot Function Index (FFI). The FFI consists of 23 items divided into three subscales that quantify the impact of foot pathology on pain, disability and activity limitations. Scores range from 0-230 with a minimal important change of 7 points for the total scale.

Written By Cameron Dyer

References

Drew, B. T., Smith, T. O., Littlewood, C., & Sturrock, B. (2014). Do structural changes (eg, collagen/matrix) explain the response to therapeutic exercises in tendinopathy: a systematic review. British Journal of Sports Medicine, 48(12), 966. doi:10.1136/bjsports-2012-091285

Lemont, H., Ammirati, K. M., & Usen, N. (2003). Plantar fasciitis: a degenerative process (fasciosis) without inflammation. Journal of the American Podiatric Medical Association, 93(3), 234. doi:10.7547/87507315-93-3-234

Lu, H., Gu, G., & Zhu, S. (1996). Heel pain and calcaneal spurs. Zhonghua wai ke za zhi [Chinese journal of surgery], 34(5), 294.

Rathleff, M. S., Molgaard, C. M., Fredberg, U., Kaalund, S., Andersen, K. B., Jensen, T. T., . . . Olesen, J. L. (2015). High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up.(Report). 25(3), e292.

Rathleff, M. S., & Thorborg, K. (2015). ‘Load me up, Scotty’: mechanotherapy for plantar fasciopathy (formerly known as plantar fasciitis). British Journal of Sports Medicine, 49(10), 638. doi:10.1136/bjsports-2014-094562

Riddle, L. D., Pulisic, E. M., Pidcoe, E. P., & Johnson, E. R. (2003). Risk Factors for Plantar Fasciitis: A Matched Case-Control Study. The Journal of Bone & Joint Surgery, 85(5), 872-877. doi:10.2106/00004623-200305000-00015

Taunton, J. E., Ryan, M. B., Clement, D. B., McKenzie, D. C., Lloyd-Smith, D. R., & Zumbo, B. D. (2002). A retrospective case-control analysis of 2002 running injuries. British Journal of Sports Medicine, 36(2), 95. doi:10.1136/bjsm.36.2.95

Thing, J. (2012). Diagnosis and management of plantar fasciitis in primary care. British Journal of General Practice, 62(601), 443-444. doi:10.3399/bjgp12X653769

ACL Rehab & Preventing Re-Injury

ANATOMY & BACKGROUND

Anterior Cruciate Ligament (ACL) injuries are very common in Australian sports and lead to a significant amount of time on the sidelines for the athlete. The majority of people who wish to return to their sport opt for surgical management to replace their ruptured ACL. There is still a high percentage of these injuries that undergo reconstructive surgery that re-rupture with return to sport, up to as high as 30% (Grindum et al, 2016).

The majority of ACL injuries occur as non-contact injuries. Most commonly when an athlete is sidestepping, landing from a jump, decelerating or changing direction (Waters, 2012).

Anterior Cruciate Ligament Anatomy

ACL REHABILITATION

A safe return to sport while reducing the chance or re-injury injury rates requires a comprehensive and structured rehab program designed and implemented by a rehab specialist. It is important to address the initial cause that contributed to the ACL injury in the first place, whether that is strength, cutting mechanics or poor landing or decelerating mechanics these need to be worked on frequently before returning to your chosen sport. Objective lower limb and knee assessments such as Pitch Ready can significantly help guide this decision-making process.

Image Credit: www.pitch-ready.com/

TIME & STRENGTH

Two crucial factors for return to sport following ACL reconstructive surgery are TIME post-op and regaining normal STRENGTH in your lower limb. Good research has showed returning to sport after 9 months post-op can significantly reduce the re-injury rate.

Quadricep strength has also been shown to be a strong predictor for safer return to sport. Both TIME and quadriceps STRENGTH together combine to reduce ACL re-injury by over 80% (Grindem et al, 2016).

Most importantly returning to sport following ACL surgery should be made on a case by case basis following guidance from your sports physiotherapist and ultimately your surgeon.

Lower Limb Strength Rehab

OTHER FACTORS

There are many other factors that need to be covered in your rehabilitation from an ACL operation beyond the time you take to return to sport and your quads strength. Other variables including your jump and land mechanics, cutting technique, lumbopelvic and hamstring strength. These as well as many others need to be taken into account when decisions around returning to COD sports are made. Structured assessment of your movement, strength and power are also extremely important to help guide your safe return to sport.

Written By Chris Bailey

References

• Grindum H, Snyder-Mackler L, Moksnes H, Engebresten L & Risberg M. Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. British Journal of Sports Medicine (2016) 50. 804-808.

• McGrath T, Waddington G, Scarvell J, Ball N, Creer R, Woods K, Smith D & Adams R. An ecological study of Anterior Cruciate Ligament Reconstruction, Part 1. The Orthopaedic Journal of Sports Medicine (2016) 4. 1-7.

• McGrath T, Waddington G, Scarvell J, Ball N, Creer R, Woods K, Smith D & Adams R. An ecological study of Anterior Cruciate Ligament Reconstruction, Part 2. The Orthopaedic Journal of Sports Medicine (2017) 5. 1-9.

• Pitch Ready Webpage. http://www.pitch-ready.com/

Hamstring Injuries and Rehabilitation

ANATOMY AND BACKGROUND

The hamstring muscle group consists of 3 major muscles in the posterior thigh, that play crucial functions in activities involving running and sprinting, and also kicking.

Soft tissue hamstring injuries make up a large proportion of time lost to injury in field based sports (Orchard & Seward, 2010), and traditionally have a very high recurrence rate of up to 30%. The most commonly injured of the hamstring muscles is the lateral biceps femoris muscle.

Hamstring Musculature

CONSEQUENCES OF HAMSTRING MUSCLE INJURIES

Current research shows once you have injured your hamstring muscle, you are at an increased risk of re-injuring your hamstring in the future.

Due to a combination of factors including chronic muscle inhibition and wasting, shortening of your muscle fibres, potential neural changes in the way your muscles are firing, and a drop off in eccentric muscle strength, your chances of further hamstring muscle injury is increased (Opar et al, 2018). This re-injury may also happen at a load lower than that which caused your initial injury.

Thigh Muscles Cross-Section

ECCENTRIC TRAINING AND REHAB

Strength training and rehab running appropriate to your stage of recovery are integral components of getting you back to your chosen sport as quickly and safely as possible, while minimising your risk of injury recurrence (Bourne et al, 2017). Physiotherapy rehab programs targeting lumbopelvic strength as well as hamstring strength is heavily supported by the research (Heiderscheit et al 2010).

Eccentric strength in particular has been shown to improve hamstring muscles strength through greater ranges of motion, and also to increase the hamstring muscles overall length which in turn reduces the likelihood of hamstring muscle strain.

The Nordic Hamstring Exercise and Hip Extension exercises are great rehab exercises to achieve these goals. See Pictures below.

Nordic Hamstring Exercise

Hip Extension Exercise

REHABILITATION AND PAIN

Traditionally hamstring and posterior thigh pain has been avoided during the rehab phases following hamstring injury. It has now been shown that a tolerable amount of pain during strength rehab may not only be ok, but help get the injured muscle stronger quicker, and allow for a safer and faster return to running, sprinting and your sport (Hickey 2017).

This rehab should however be done under the guidance of a highly trained Sports Physio to teach you the correct exercises and technique. And also to help guide you through which pain is acceptable to push through, to get you back to your sport stronger.

Written By Chris Bailey

Reference List

·      Bourne M, Duhig S, Timmins R, Williams M, Opar D, Najjar A, Kerr G, Shield A. Impact of the Nordic hamstring and hip extension exercises on hamstring architecture and morphology: implications for injury prevention.British Journal of Sports Medicine. 2017

·      Heiderscheit BC, Sherry MA, Silder A, Chumanov ES, Thelen DG. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. Journal of Orthopaedics and Sports Physical Therapy. 2010

·      Hickey J. PhysioEdge podcast Episode 72. 2017

·      Orchard JW, Seward H. Injury Report 2009: Australian Football League. Sport Health. 2010

·       Opar D, Williams M, Timmins R, Dear N, Shield A. Knee flexor strength and bicep femoris electromyographical activity is lower in previously strained hamstrings. Journal of Electromyography and Kinesiology. 2013