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  • Lionel Pannunzio PT / SCS

Introduction


Plantar fasciitis is a condition causing heel pain. It affects players of all ages and when it becomes chronic it can be very debilitating even prevent you from playing soccer .

Learn how this condition develops and more important how to treat it.





What is Plantar Fasciitis (The Correct name is Fasciopathy)?


Plantar Fasciopathy is a condition causing heel pain. Supporting the arch, the plantar fascia, a thick band of tissue connecting the heel to the ball of the foot, can become inflamed or can tear.


The condition develops when repeated weight-bearing activities put a strain on the plantar fascia.


Plantar Fasciopathy is a degenerative Process characterized by Collagen Breakdown, nerve and vascular ingrowth.


In late stages of the condition it can progress to Calcifications .


The correct term for this condition should be Fasciopathy instead of Fasciitis since there is no real inflammatory process involved. As with the Achilles Tendinopathy, there are structural changes in the Fascia as a result of collagen breakdown that cause pain rather that inflammation.



Incidence and Causes of Plantar Fasciopathy


Incidence


Plantar fasciitis occurs most frequently in people in their 40s but can occur in all age groups.

The condition can develop in athletes who run a great deal and in non-athletes who are on their feet most of the day, such as police officers, cashiers, or restaurant workers.


Plantar Fasciopathy is a common foot condition. It occurs in as many as 2 million Americans per year and 10% of the population over their lifetimes.

Plantar Fasciopathy affects people of all ages, both athletes and non-athletes. Men and women have an equal chance of developing the condition.



Causes of Plantar Fasciopathy


Factors that contribute to the development of plantar Fasciopathy include:

  • Age (over 40 years)

  • Rapid increases in length or levels of activity, such as beginning a new soccer season or preseason program

  • Decreased calf muscle flexibility

  • Reduced ankle dorsiflexion in combination with reduced Great Toe Extension.

  • Reduced Toe flexor and evertor strength and decreased Hamstring Flexibility ( Sullivan et al 2015)

  • Increased body weight (Body Mass Index greater than 30)

  • Tendency to have a flat foot (pronation)






Plantar Fasciopathy highly related to Tightness in Calf muscles ?



In the picture above you can appreciate how the ankle and the great toe work together to push the body forward when walking or running . You can also see how a normal combined movement between Ankle Dorsiflexion and Great toe Extension are necessary to avoid excessive tension in the fascia. Any restrictions in these joints or their surrounding muscles will create excessive loading in the fascia creating the Fasciopathy if the movement is not restored.


Signs and Symptoms


People with plantar fasciitis may experience pain:

  • In the morning, when stepping out of bed and taking the first steps of the day

  • With prolonged standing

  • When standing up after sitting for awhile

  • After an intense weight-bearing activity such as running

  • When climbing stairs

  • When walking barefoot or in shoes with poor support

As your body warms up, your pain may actually decrease during the day but then worsen again toward the end of the day because of extended walking. Severe symptoms may cause you to limp.


How Physical Therapy can help ?


First of all, Plantar fasciopathy should ruled-in and other conditions like fat pad irritation, stress fractures, nerve entrapment or arthropathies should be ruled-out .

Once you are diagnosed with plantar fasciitis, your physical therapist will work with you to develop a program to decrease your symptoms that may include:

  • Improve the flexibility of your ankle and the plantar fascia

  • Use of a night splint to maintain correct ankle and toe positions

  • Selection of supportive footwear and/or shoe inserts that minimize foot pronation and reduce stress to the plantar fascia

  • Iontophoresis (a gentle way to deliver medication through the skin)

  • Taping of the foot to provide short-term relief

  • Increase Plantar Flexor capacity

  • Increase Great Toe mobility and Range of movement

  • Increase strength and flexibility of the Lower Extremity as a whole.

Research shows that most cases of plantar fasciitis improve over time with these conservative treatments, and surgery is rarely required.

Plantar Fasciopathy is a self-limiting condition of variable duration

With treatment symptoms usually improved in 3-6 months (some cases up to 9 months)



Stages of Rehabilitation


Pain Dominant Phase


Plantar Fascia becomes sensitive to load. Pain and stiffness when stepping out of bed and taking the first steps of the day. Pain with activities like walking long distance or prolonged standing. This phase can last 2-8 weeks.


Interventions


  • Control pain by reducing or modifying aggravating Activities: load management , reduce running distance or frequency of games played. For example if you are playing soccer 2 o 3 times a week this is the time where you only play once a week to allow time to recover from game to game.


  • Improve the flexibility of your ankle and the plantar fascia: mobility work for ankle and foot with emphasis on reducing tightness in calf and posterior chain.


  • Increase Plantar Flexor capacity: mainly Isometric strengthening progressing to light Isotonic strengthening as tolerate.


  • Increase Great Toe mobility and Range of movement: big emphasis on Improving Great toe extension to help with shock absorption and power generation in the stride.


  • Increase strength and flexibility of the Lower Extremity as a whole: quadriceps and Gluteal muscles assist with load absorption during the run so by strengthening these muscles group we help unloading the fascia.


  • Bicycle is a good option to maintain some aerobic capacity while allowing the fascia to heal . Players should avoid running or walking long distance during this phase.



Plantar Fascia Mobilization - Stretch



In sitting with the foot resting on your opposite knee, bend the ankle and big toe up holding for 10 -15 seconds and repeat 10 times



Ankle Strengthening




Turn the ankle out against the band and then in . 8-12 reps to each side




Isometric Toe Flexion



Push the big toe down as hard as possible and tolerated, Hold the contraction for 3-5 seconds . Repeat 5-10 times each foot.


Also in the Pain Dominant Phase we must address any excessive foot deviation by using over-the-counter orthotics or Taping for short-term pain management. If these help it may grant the investment in custom-made orthotics down the road.




Load Dominant Stage


We can move to the next phase once the Pain at 1st step in the morning improves and increases walking tolerance. Symptoms remain stable unless the fascia is overloaded ( runs or games) .


Interventions:

  • Increase Plantar Flexor capacity: progressing from Isotonics to Eccentric movements of the calf

  • Interval training to increase load capacity to develop calf endurance and Power : plyometrics.



Some exercises we like to use during this phase are shown below which are intended to create ankle Dorsiflexion and Great toe extension and at the same time mobility and strengthening of the plantar fascia and calf-ankle-foot- Toe complex muscles


Great Toe sliders




Great Toes - Plantar Fascia Strengthening - Push off




Double leg Heel raise with towel





Once the patient can do the above exercises and pain remains at a minimum or has disappeared we start thinking and the Return to Play Strategy: start with light jogging, increasing time and distance as tolerated and with no irritation (or minimal irritation). Then from there to sprinting , cutting and jumping. This stage must be guided by a Physical Therapist to assure a safe return to Play .





Conclusion


  • Plantar Fasciopathy and heel pain affect a large population of soccer players

  • Conventional physical or chiropractic treatment usually fails to address all the possible causes of this condition

  • Improve and restore plantar fascia length and Plantar Flexion Capacity with emphasis on Great Toe strength are the main goals of the treatment.

  • Our comprehensive approach is backed-up by the most recent research. Once you resolve the root of the problem the Plantar Fascia becomes pain free

  • Education and load management are key factors for people with Plantar Fasciopathy


White Bay Sports Physical Therapy is a Sports-Injury clinic that specializes in Plantar Fasciitis treatment .

Lionel Pannunzio is a Physical Therapist Certified in Sports Injuries. With more than 20 years of experience helping athletes return to their sports after an injury. He is the Owner of White Bay Sports Physical Therapy and Fitness, conveniently located in the beautiful City of Weston, where he treats Soccer Players and Athletes of all ages



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Introduction


Hamstring Injury Treatment has changed a lot in the last decade. Professional Soccer teams are putting a lot of emphasis on prevention and quicker recovery. There is good consensus now to safely accelerate the recovery process so player can return to play earlier and most important avoiding a re-injury






Rehabilitation Process - Grade II hamstring Injury


We will use a Grade II injury as an example (see picture above ) . As we mention in our previous posts about HSI, many patients with a hamstring start to feel better within a few days of the injury. However, there is an extremely high hamstring re-injury rate due to a poor rehabilitation process.


Hamstring strains are one injury that professional guidance is highly recommended for both an accurate diagnosis but also provide you with the best chance of avoiding re-injuries. Repeat hamstring injuries have sidelined soccer players for months.


Guidelines


In Physical Therapy the treatment we provide will follow these guidelines:

  1. Reduce hamstring pain and inflammation.

  2. Normalize your muscle range of motion and extensibility. Remember one of the causes of HSI is short and tight Hamstrings.

  3. The hamstrings create Hip Extension and Knee flexion simultaneously . Even though that in the beginning we may concentrate in improving each movement in isolation at some point The rehabilitation should address both the knee flexion and hip extension roles of the hamstrings together. High Speed Running is ultimate expression of the hamstrings doing this double action.

  4. Strengthen your knee muscles and hamstrings. A key factor in the recovery process is Eccentric Load of the Hamstrings. Regular exercises will not do it for this condition reason why we have developed a progressive and comprehensive Strengthening program with this in mind

  5. Strengthen your lower limb muscles: calves, hip and pelvis muscles.

  6. Normalize lumbo-pelvic control and stability - a co-factor in many hamstring strains. Another super important factor is your pelvic position. Almost every Hamstring Injury goes with excessive curvature in the lumbar spine called hyperlordosis and anterior pelvic tilt causing your hamstrings to be under tension constantly just from standing and even more tension during High Speed Running

  7. Improve your game speed, proprioception, agility and balance. Remember most of the HSI are the result of High Speed Running so this should be part of your rehabilitation process but most of the time it does not happened. At White Bay Physical Therapy this HSR and running mechanics drills are mandatory before we release players to train and prevent a re-injury.

  8. One note on Hamstring Stretching: Injured Hamstrings respond much better to strengthening exercises and movement than it does to vigorous stretching. Any tight muscle denotes some type of weakness, lack of movement control or postural deficit. In these situations the muscle gets “tight” to compensate for these other problems. So please, Stop stretching your hamstrings vigorously, it won’t get much softer. There is a type of contraction called Eccentric contraction where the muscle lengthens as it moves a weight ( own body weight or external weight). These types of exercises are the ones recommended for most of the muscular injuries because of this double benefit: strength + lengthening. We ,as therapist, know when to introduce these type of exercises in the rehabilitation process.

  9. To summarize, Long and Strong Hamstrings are the goals of the rehabilitation process


Stage I - Acute Injury

In the Acute phase we focus on resolving the pain with Ice , Ultrasound , Electrical Stimulation for Pain and We initiate an early mobility routine to safely put stress in the muscle to promote healing.


Hamstring Extenders - Mobility Workout



Setup

  • Begin lying on your back with one leg straight and the other leg bent

Movement

  • Bring your knee toward your chest and grab the back of your thigh with both hands. Slowly straighten your knee until you feel a stretch in the back of your thigh and return to original position. Repeat 10 Times.

Tip

  • Make sure to keep your back flat on the floor during the stretch and the opposite heel pushing against the ground during the stretch.




Hamstring Isometrics Strengthening




Bridge on Heels - Isometric HS contraction

Setup

  • Begin lying on your back with your knees bent and your feet resting flat on the ground.

Movement

  • Keeping your heels on the ground, lift your toes up.

  • Engage your abdominals and slowly lift your hips off the floor into a bridge position. You will feel your hamstring muscles contracting.

  • Hold contraction for 5 seconds. Then, Lower back down to the ground and repeat. Be aware this exercise can make your hamstrings to cramp. If that happens.

  • Repeat a few more times exercise 1. Do this exercise in 3 different angles: 90, 45 and 10-15 degrees of Knee Flexion to target the whole muscle group

Tip

  • Make sure to keep your abdominals engaged and do not arch your back during the exercise.





Stage II - Strengthening Phase

In the strengthening phase we will load the muscle progressively to assure proper scar mobilization and remodeling of the muscle to sustain higher loads everyday. We progress from simple contractions like Hold and Relax, then typical Hamstring exercises like leg curls and more Function-related exercises like eccentric contractions which not only make the muscle stronger but also increase the length of it. Remember we mentioned before that Short Hamstrings are highly related with HSIs.



Deadlifts




Setup

  • Begin bending forward with your back straight and feet hip width apart, holding a barbell that is resting on the ground with your hands placed slightly wider than your feet.

Movement

  • Keeping your back straight, stand up, engaging your back, buttock, and thigh muscles. Slowly reverse the movement and repeat. Allow body to move till you feel the workout in your hamstrings and Glutes. Mild discomfort at the injury site is ok .

Tip

  • Make sure to keep your abdominals tight, back straight, and do not shrug your shoulders during the exercise. Try to keep the barbell close to your body as you stand and bend over.




Single Leg RDLs



Setup

  • Begin in a standing upright position holding a landmine or dumbbell in one hand.

Movement

  • Lift the uninvolved leg off the ground and bend forward at your hips, lowering the weight toward the ground. Then return to an upright position and repeat.

  • Allow body to move till you feel the workout in your hamstrings and Glutes. Mild discomfort at the injury site is ok .

Tip

  • Make sure to keep your back straight during the exercise and try not to let your knee move forward as you lower the weight.



Stage III - Return to Play Phase

Finally in the third phase we simulate soccer activities to reproduce the demands of the game in a closed environment and assure the scar tissue will tolerate the activity. This includes some field drills by the end of the phase and right before allowing you to play.

Key factors in this recovery are restoring Eccentric strength of the Hamstrings, restoring hip and knee range on motion, restoring proper core strength, and finally restoring dynamic balance and control of the Lumbo - Pelvic - Hip area.

Once all these factor were addressed we expose the injured players to Running Mechanics and High Speed Running itself.

You can see that our rehabiliation process is comprehensive and it covers the gap between the Clinic / Gym and the fields to return to play safely with the only goal of preventing another HSI.




Conclusion


  • Hamstring Injuries (HSI) are the second most common muscular injury in soccer players (quadriceps is #1)

  • Grade I injuries recover quick, while Grade II and III will take long time to recover and have an unfortunate high risk of re-injury and becoming chronic ( Proximal Hamstring Tendinopathy)

  • Most of these injuries does not require expensive MRIs or Test. The clinical examination by a professional specialized in HSI is usually enough to make the diagnosis and treatment





Do you want to find out more about what you can do to get better from your Hamstring Strain?



Click the link below to get access to our PDF E-Book

where you'll find valuable information about Muscle Injuries in general

and Hamstring Injuries in Particular





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Introduction


Treatment of Achilles tendinopathy requires a comprehensive approach including pain control exercises, then strengthening followed by power and finally a well rounded return-to-play program to restore strength and function to this affected tendon.

In this blog, you will learn the main exercises we use with soccer player recovering from an Achilles Tendionpathy


Should I rest the Achilles or Loaded ?


Many soccer players may think that they need to ‘use’ the tendon ‘less’ in order to improve the pain and reduce the symptoms, so they rest or reduce the activity significantly and the pain usually gets better but here is the catch, once these players return to practice the pain comes back almost immediately

In our approach to Achilles Tendinopathy, the key is to fully rehabilitate the tendon by using the tendon more. More means progressive loading of the tendon to increase its resilience for the sport activity.


What are the best exercises for Achilles Tendinopathy?


Build plantar flexor capacity !!!! Do all types of calf raises


We discussed above that in Tendinopathies, loading the tendon is the way to improve this condition.


The goals is a progressive increase in loading the tendon through rehabilitation exercise that ultimately will include what is known as ‘heavy slow resistance’ work that typically is performed in a gym setting with appropriate resistance.


I like to see soccer players being able to do heavy gastrocnemius and soleus work in a gym (targets 1.5x body weight soleus seated calf raises & 0.3-0.4x body-weight standing calf raises aiming for 3x 8 reps with good control.


Of course even though the goal is to go heavy on the tendon, we cannot start with heavy stuff because it will most likely irritate the tendon and create more pain.


The logical progression for this exercises is to build up capacity with Isometrics first, then isotonics (full Range of movement) , then eccentrics (emphasis on the movement down of the calf raises ) and finally plyometric exercises with all types of jumps to challenge the super important and ultimate function of storage-release mechanism of the tendon )



Isometrics


Isometric contraction is a very powerful type of muscle activity in which the muscle contracts quite strong but there is no movement at the adjacent joint. Isometric exercises help with pain in the tendon as well as with the develop of force.

Isometric contractions are used early in the treatment process for these reasons.



Bilateral Calf Raises - Isometrics




Setup

Begin in a standing upright position with your hands resting in front of you on a wall.

Movement

Slowly raise your heels off the ground and hold that position. Start with 5 seconds and build it up until you can hold for 45 seconds . 5 repetitions and 3 sets are recommended .

As you get stronger you can add weight to this exercises with a vest or backpack



Unilateral Calf Raises - Isometrics



Setup

Begin in a standing upright position with your hands resting in front of you on a wall.

Movement

Raise your heels as high as you can then Bend one knee up to 90 degrees and hold the weight of your body on the opposite Foot raised , hold that position . Start with 5 seconds and build it up until you can hold for 45 seconds . 5 repetitions and 3 sets are recommended.



Isotonics Exercises


Once you are able to manage the Isometrics without a flare-up in pain or symptoms we start loading the tendon progressively in the full Range of motion available. Adding a step to the equation allows for more demand on the tendon fibers.

It is very important with these exercises below that you control the pace of the movement and go from one end of the movement to the other. This is how we will show the tendon where to align the newly formed fibers of collagen : “in line “ with the force which makes the tendon more resistant to the load.


Calf Raises on Step



Setup.

Begin standing at the edge of a step with your heels hanging off the edge. You may hold onto a stable object for support.

Movement.

Raise up onto the balls of your feet, then slowly lower your heels down off the edge of the step and repeat.

Tip.

Make sure to maintain your balance during the exercise. Keep your movements slow and controlled. Use the following pace: 3️ seconds to get to the top position, hold for 2️ seconds, 3 seconds to return to starting position. You can start with 3 sets of 5 repetitions and progress to 3 sets of 8 repetitions and finally to 3 sets of 10 repetitions as long as you can maintain the quality of the contraction.


Bent Knee Calf Raise on Step



Setup

Begin standing on a small step or platform with your heels off the edge, holding onto a stable object for balance.

Movement

Bend your knees, then raise both heels up, and lower them down slowly. Repeat these movements.

Tip

Make sure to keep your back straight and knees bent throughout the exercise. Keep your movements slow and controlled. Use the following pace: 3️ seconds to get to the top position, hold for 2️ seconds, 3 seconds to return to starting position. You can start with 3 sets of 5 repetitions and progress to 3 sets of 8 repetitions and finally to 3 sets of 10 repetitions as long as you can maintain the quality of the contraction.





Excellent… by doing calf raises Am I cured ? ….

The answer will be NO... YET....


Building plantar flexor capacity is just part of the treatment. Once you have more control of your calf muscles we need to reproduce the demands on the tendon. Tendons are like springs. Let’s say you are running and every step you take you absorb your own weight in the foot and then you push your body forward to continue running. This load absorption and release is the main function of the Achilles Tendon.






So in order to get completely better, strengthening only will not be enough and you need to reproduce and train this energy storage-release mechanism.

To recreate this, Therapists use what it is called Plyometrics exercises intended to simulate this function. Examples of Plyometrics are bilateral and unilateral leg jumps , quick calf raises , box jumps and other.

Plyometrics are high level exercises need to be done by a therapist to properly choose the right doses in order to avoid irritation of the tendon



Ankle Plyometrics - Double Leg and Single Leg Ballistic Heel Raises


Set Up

Stand up on the ball of your feet

Movement

Do Quick Rebounds mid amplitude

Then switch to one foot only and repeat mid amplitude heel raises

Sets of 10 reps


Load Management



When returning to the activity in this case playing soccer, you must do it gradually. Knowing exactly what brings out your symptoms will empower you to make the right adjustments for the healing process to take place.

Movements that create high loads and use the tendon as a spring (jumping or sprinting activities for example) increase cell signaling and can create the over-response that sparked the pain you are feeling. Therefore, start with walking and jogging session, followed by jogging only session, changes of speed (50-75-90 %), cuts 45-90-180 degrees, speed and agility drills, ball possession drills until you can practice a whole week without irritation of the tendon. If during the progression there is pain after the activity of the morning after it means the pain you’re experiencing is your tendon telling you it is not tolerating the loads you are placing on it. It is there for a reason. Listen to it.

For such cases, try changing one variable in your training program and see how your tendon responds. For example, if you currently train seven days a week, decrease the frequency by dropping one session. If you can’t sacrifice one day of training, you must make a change to either the amount of high intensity loads or the total volume of your training. Regardless of which variable you choose, only change one factor at a time and wait to see how your body responds (everyone will be slightly different so there is no golden rule).




Finally...Should I stretch Tendon Pain?

Despite what you may have learned elsewhere, we do not want to stretch an Achilles tendon injury!

No matter what form of tendinopathy you may be experiencing, stretching should not be a part of your rehabilitation program.

Remember that Insertional Achilles tendinopathy injuries occur due to high levels of compressive load to the tendon against the calcaneus bone. Stretching your calf muscles will only serve to add more compression (and lead to more pain) on the already injured area.

While there is less cause for concern for those dealing with a mid-tendon tendinopathy injury, research has not shown any benefits to stretching whatsoever.

Instead, if you do have limited ankle mobility or you feel tight in your calves, you can safely perform soft tissue mobilization to the calf muscles with a foam roller or massage stick. Foam rolling has been shown in research to improve ankle mobility without placing harmful compressive loads on the tend




Conclusion


  • Achilles Pain from Tendinopathy is very common in Soccer players (see statistics at https://www.ncbi.nlm.nih.gov/pubmed/23770660)

  • In this Tendinopathy there is an imbalance between the amount of load that the tendon in receiving and the tendon's capacity

  • Weakness in the calf musculature is the main reason for Achilles Tendinpathy.

  • Physical Therapy can help by building Calf Raise Capacity to improve the strength of the calf and reinforce the remaining of the healthy tendon.

  • A combination of Isometrics, Isotonics, Eccentrics and Plyometrics exercises is necessary for a safe and pain-free return to play process

  • Education in Load Management and a strategy to progressively load the tendon without (or minimal) irritation are also mandatory if you want to play pain-free



Do you have other questions about Achilles Tendinopathy?

Do you want to know if Physical Therapy can help your particular case ?



Give us a call at 754 244 2561 and we will help you answer these question and even we will schedule you a Free consultation


Visit www.wbsphysicaltherapy.com for more information

on how to talk to a Sports-Certified Specialist

and start getting better today...



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