Steps to Address Foot Pain
"Do as I say, not as I do!" - Coach Amy.
Oh, the dreaded “plantar"! It has stopped many athletes in their tracks and certainly affects non-athletes as well, interfering with activities of daily living such as walking and standing for long periods of time.
Not all foot pain is "plantar fasciitis". Sometimes foot pain is the result of a trapped nerve, tendonosis, stress fracture, referred pain, joint sprain, arthritis, bone spur…there are number of different diagnoses.
Plantar fasciitis is a misnomer. Rarely ever is the fascia of the foot at fault. Say that three times fast! Not only is the fascia rarely involved but “itis” indicates inflammation and researchers have found that there is not a lot of evidence to support an inflammatory process with this condition.
A better name for this may be plantarmyalgia - pain in the muscles at the bottom of foot! This condition involves one or more of the tiny muscles on the bottom of the foot and/or the aponeurosis - a strong thick band of connective tissue that acts like a tendon at the bottom of the foot. These tissues act together as the “foot core”. Like the core of your trunk aids in stabilization of your spine, the foot core aids in stabilization of your lower extremity.
Pain is usually located in arch of foot and/or heel with weight bearing or push off especially in the morning, beginning of a run or after sitting for a long period and then standing up to walk. Symptoms usually improve as the day, walk or run goes on, only to worsen if up on feet all day or after running. In severe or chronic cases, pain can be constant but usually varies in intensity.
There are many different causes of "plantar fasciitis". Most often it is a combination of factors that may include but are not limited to:
tight calves
poor footwear
training error/over use
longterm use of rigid insoles/orthotics creating weak foot muscles
poor joint mobility in the middle of the foot and or “big toe”
If foot pain from plantar fasciitis is interfering with your function, it is important to determine and address what is causing the condition in the first place. Simply treating the symptoms rarely results in successful long term recovery.
What should I do about my foot pain?
Rest from or modify activities that increase pain.
Avoid barefoot, wearing flip flops and high heels until inflammation subsides and strengthening of these muscles can occur.
Use ice cup massage 5 min or less for pain control. See How To: Ice Cup Massage.
Apply moist heat such as Epsom salt soak 1-2x daily for 20 min. to improve blood flow and assist in recovery of connective tissue.
Use a Strasburg Sock or foot splint at night.
If symptoms worsen or do not improve in a few weeks with these initial measures, schedule an evaluation and treatment with an experienced physical therapist.
What Color is Your Pee? Signs, Symptoms and Causes of Acute Exercise-induced Rhabdomyolysis.
The infamous 2007 Chicago Marathon and Coach Amy's first.
Really, Amy? Are you asking me the color of my pee? I'm not suggesting you report the color to me. However, urine color can indicate a condition afflicts endurance athletes called acute exercise-induced rhabdomyolysis (AER). The media has once again brought this condition to the forefront with the recent hospitalization of several Oregon Ducks football team members.
What is AER?
AER is an acute, serious, and potentially life-threatening condition for which the hallmark symptom is cola-colored urine. AER occurs in the case of severe skeletal muscle damage sustained through injury or profound overexertion.
AER can cause damage to the kidneys, liver, and long-term nerve and muscle damage. The incidence of this condition in endurance athletes is still being determined [1].
Acute kidney failure may be less likely in AER than in other rhabdomyolysis causes [2]. Therefore, it is conceivable that some endurance athletes go undiagnosed and treated yet suffer from other long-term complications, such as damage to nerves and muscles.
Signs and Symptoms
I listed the signs and symptoms of AER below [1], but not all athletes with AER exhibit these symptoms. Other conditions may cause these symptoms as well.
Dark brown urine (cola colored)
Confusion
Vomiting
Muscle pain (not normal delayed onset muscle soreness)
Generalized weakness
Causes of AER
As with many issues afflicting the endurance athlete, the cause of AER is a combination of "the 'perfect storm' where there are several [contributing] factors (heat stress, dehydration, [muscle exertion], non-steroidal anti-inflammatory [e.g., Alleve, Ibuprofen] or other drug/analgesic use, and viral/bacterial infection)." [3]
The most common cause of AER is "too much."
Too much too soon (e.g., returning to sport or starting a new form of exercise without a gradual introduction).
Too much eccentric contraction of the same muscle group (e.g., high reps of heavy-weight jump squats).
Excessive heat (running long distances or racing in high temperatures without acclimatization).
Other significant contributors to AER include high exertion in concert with the following:
Dehydration
Certain medications, namely statins and NSAIDs (Aleve, Ibuprofen)
Hyponatremia (overhydration - too little sodium)
When you look at the list of causes, it is sobering, right? How many triathlons and marathons have you raced under the "perfect storm" of extreme heat before being acclimated, dehydrated, taking painkillers (even though your coach told you not to), and coming off an injury or illness?
One case study tested four ultra-distance runners (two different years) after they ran the 95-mile off-road West Highland Way Race [4]. All tested positive for severe cases of AER. Each raced in at least half of the "perfect storm" conditions.
Takeaway
The takeaway from all this? Train smart with a solid training plan, do not take NSAIDs before or during a race, avoid racing when sick or after a recent illness, and acclimate to hot weather running or modify if you find yourself in those conditions unprepared.
As always, listen to your body. Be aware of contributors to AER and its symptoms. If you have cola-colored urine after extreme exertion and one more of the other signs, seek immediate medical attention; If treated early, we can reverse AER. When not appropriately treated, the long-term consequences could be severe; once an athlete has suffered from AER, they are more susceptible to recurrence.
Sources
[1] Brudvig T, Fitzgerald P. Identification of Signs and Symptoms of Acute Exertional Rhabdomyolysis in Athletes: A Guide for the Practitioner. Strength and Conditioning Journal. 2007 Feb;29 (1):10-14
[2] Sinert S, Kohl L, Rainone T, Scalea T. Exercise-Induced Rhabdomyolysis. Annals of Emergency Medicine. 1994 June;23(6):1301–1306.
[3] Clarkson P. Exertional Rhabdomyolysis and Acute Renal Failure in Marathon Runners. Sports Medicine. 2007 April;37(4):361-363.
[4] Ellis C, Cuthill J, Hew-Butler T, George S, Mitchell R. Exercise-Associated Hyponatremia with Rhabdomyolysis During Endurance Exercise. The Physician and Sportsmedicine Volume. 2009 April;7(1):126-131.
What the BOSU?
The BOSU isn’t an expletive, although some of my patients do swear when they use it. It is a funny looking piece of equipment: half ball, half platform. You can use one or two at a time, you can use them dome side up or bottom side up, you can put your feet on them, forearms, hands, knees, glutes…
It carries a warning on the bottom: "fall hazard." It’s goal is to stimulate the proprioceptors. What the heck are those? Proprioceptors are found in muscles, tendons and joints. They relay to your brain where you are in space. Yes, you are on planet earth in the Milky Way galaxy but what plane are you in? Is your body up or down, side to side, rotated right or left or a combination of these? The brain responds to this input by telling your body what to do to remain stable so ya don’t fall down!
The proprioceptors can become confused after an illness, injury, or post surgery for example. They then behave a little like your drunk uncle...responding sluggishly. In the therapy world we don’t start with the BOSU right away; it is used in a gradual progression of balance and stability training particularly with athletes.
The BOSU is not just useful for treatment of injury. It is a great tool for injury prevention and performance enhancement as well, especially when used in sport specific ways and always with guidance and instruction from a therapist or personal trainer.
PT Adventure Part I: Down and Out on the Slopes to Pre-surgery Rehab
Coach Amy of Coach Amy PT and Jennifer at her pre-surgery physical therapy appointment.
RRKC runner, Jennifer W. texted Coach Amy of coachamypt.com from a ski patrol hut, "Um. I think I'll be needing an experienced PT in the near future..." Accompanying this text was a picture of her lying on a cot with ice on her knee.
Jennifer fell skiing on the powdery slopes of Colorado and heard a pop in her knee. She was escorted off the mountain by ski patrol. Her main complaint, "...I can't put a lot of weight on it and it feels very unstable."
Suspecting an ACL (anterior cruciate ligament) tear, Coach Amy created a plan to expedite Jennifer's care. Before she left Colorado, she had an appointment with an orthopedic surgeon the day of her return to KC with strict PT orders: no weight bearing, ice, elevation and compression.
Within one week Jennifer had confirmation of an ACL and possible MCL (medial collateral ligament) tear, surgery scheduled and a prehab physical therapy appointment scheduled with Coach Amy PT.
For pre-surgery rehab, Coach Amy instructed Jennifer in a series of exercises to help restore stability of the knee and maintain her cardiovascular fitness. This will aid in a quicker and successful recovery post surgery.
JJ remains in good humor, "...do you have any tips on healing a bruised ego?" Her dedication to and positive attitude will do wonders in her recovery.
To follow Jennifer's adventure and to recieve all Coach Amy Says posts via e-mail, subscribe here: https://www.coachamypt.com/subscribe/
How to: Ice Cup Massage
Contrary to popular belief, icing an injury after the first 24-48 hours isn't the best way to decrease inflammation as it slows blood flow to the area. Blood flow brings nutrients and takes away waste and this is best achieved with moist heat after the first 24-48 hours. Ice can be useful in management of pain with chronic injury by numbing the area. One of the most effective ways to do this is with an ice cup massage.
Fill a 3-4 oz paper bathroom cup 3/4 of the way up with water and put it in your freezer.
Tear away 3/4 of the paper cup (after ice is frozen) leaving the bottom of the cup for you to hold onto, and the ice exposed to rub onto your injury.
rub the ice over the areas of pain or discomfort for 5 minutes or until numb whichever occurs first.
Do not apply ice for more than 5 minutes as this can lead to frostbite. Let's not create another injury! As always, seek medical attention for proper evaluation, diagnosis and treatment of your pain.
How to Choose your Physical Therapist
Did you know you have the freedom to choose your physical therapist? Not all physical therapists are created equal and it is your right to choose your practitioner. Physical therapists vary in their professional and personal experience as well as their specialties personality and approach to treatment.
Consider a physical therapist who...
directs treatment according to your goals and needs, not according to an insurance company or third party payor
determines the root of your injury as opposed to putting a temporary bandaid on the problem
specializes in your needs and goals
listens to you
spends the entire appointment with you one:one
comes highly recommended by your peers, family and friends
uses progressive, active treatment techniques
Remember Kansas is a direct access state. This means you do NOT need a doctor order or script for treatment.
How to Safely Transition to A New Run Shoe
So, we've covered how run shoes can play a role in running related injuries by affecting the degree of load on your body in our article, Do Run Shoes Matter? Now suppose a change in run shoe is in your future, how should you transition to a new make or model?
While a change in shoe may help you prevent injury, a sudden or drastic change is likely to cause injury. Sudden changes to a lower drop shoe, for example, can lead to achilles tendonitis, fracture in the bones of the foot, or shin splints.
The injuries caused by shoe changes usually occurs because the change was too drastic or too abrupt or both. Your muscles adapt over time to shoewear. You may have shortened and or weakened muscles if they were highly cushioned or had a significant drop. These muscles may not tolerate a change without addressing strength and flexibility first.
A gradual change in cushion and drop is critical. For example, someone who is currently running in a 12mm drop model should ease into a 10mm drop as opposed to jumping from a 12mm to 4 mm drop.
Likewise, someone who is running in a high stability model or one with lots of cushion should gradually move to a moderate/middle before moving onto a minimal/low. When shopping for new run shoes, ask the salesperson for the specs on the models that you are trying and compare them to your current ones.
Shoe Change DO’s:
start with shorter distance runs (2-3 miles)
alternate your runs with the new/old shoes
choose a model that provides a gradual change
listen to your body - slight post workout soreness may accompany your change but you should not experience pain.
strengthen muscles of the foot and calf when transitioning to less drop.
Shoe Change DON’Ts:
Do NOT change shoes just weeks before your race.
Do NOT change shoes if you are battling an injury for which you are not being treated.
Do NOT continue with the new shoes if you experience pain.
Many factors including running habits (volume, surface), foot strike, strength, cadence, goals, past injury history etc. all play a role in the make and model that is best for you. If you are currently suffering from an injury, you should be evaluated and treated before making any changes in shoe.
Do Run Shoes Matter?
Shoe used in Rice, Davis, Jamison study is shown bottom, right.
The answer is, yes! A soon to be released scientific study shows that forefoot runners (those that land on the ball of their foot - see photo below) experience less impact forces in the lower extremity with a minimalist shoe. [1] A minimalist shoe is defined as minimal cushioning and a heel-toe drop less than or equal to 4 mm as compared with a standard run shoe.
Forefoot Landing
There are several studies that reveal increased load on the lower chain whilst running/jumping on cushiony shoes and surfaces.[2] Seems counterintuitive doesn’t it?
A study is currently being conducted specifically testing a brand that sells models that are specially highly cushioned. I won't mention the brand here but since I've seen runners wobbling around in them, I've been cranky. I’ll keep you posted.
So generally speaking based on scientific studies, cushion + more drop = more force. More force can mean greater risk for specific running injuries.[3]
Run shoes are not the only factor on impact forces and possible running injury. I’d say they play a relatively small role in comparison. But, when you consider that running is jumping on one foot over and over again at three times your bodyweight and there are shoes that lead to increases in force sustained by the body, it stands to reason that they do matter.
So, if you are a forefoot runner should you go out and buy the least cushion and lowest drop shoes on the market and head out for a long run? If you currently wear cushion shoes, should you throw them to the curb and replace them with minimalist shoes? Ummmm....no!
For details on how to transition, check out my post: How to Safely Transition to New Run Shoes.
[1] Rice H, Jamison S, Davis I. Footwear Matters: Influence of Footwear and Foot Strike on Loadrates During Running. Medicine and Science in Sports and Exercise Coming Soon.
[2] Bishop M, Fiolkowski P, Conrad B, Brunt D, horodyski M. Athletic footwear, leg stiffness, and running kinematics. J Athl Train 2006;41 (4):387
[3] Zadpoor AA, Nikooyan AA. The relationship between lower-extremity stress fractures and the ground reaction force: A systematic review. Clin Biomech 2011;26(1):23-8.