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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





#Hamstringpain #HamstringStrain #PulledMuscle #Soccerinjuries #Soccergroinpain #westonsoccer #westonhippain #hippainsucks #westonflorida #westonfloridaphysicaltherapy #daviefl #coopercityflorida #pembrokepinesfl #miramarflorida #weston #physicaltherapy #southwestranches #westonfitness #livinginweston

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Introduction


If you are over the age of 40 and have had a calf strain your risk of sustaining a second injury is really high and without treatment is even higher up to 60 % of chances of having a second injury. Soleus Muscle Injuries may take up to 6-8 weeks to heal sometimes.





Type of Calf Injuries



A calf strain is an injury to the muscles in the calf area. The calf muscle is actually composed of up to 9 separate muscles, any of which can be injured individually or together.


The 3 more common muscles injured in soccer are: soleus muscle, plantaris muscle and Medial Gastrocnemius ( MG)


The vast majority of the injuries are in the Soleus Muscle which is a very large muscle that functions as the powerhouse of the lower leg.


Soleus Muscle

The soleus muscle is located below the gastrocnemius muscle in the calf.

The pain is often reported as a deep soreness or tightness in the calf that can be reproduced when bending the knee and dorsi-flexing the ankle (pulling your toes back toward your shin) at the same time.

Soleus injuries are very difficult to recover from and may require more time to heal.



Plantaris Muscle Rupture

The plantaris muscle is a thin muscle that runs along the gastrocnemius muscle but is only a fraction of the size. When the plantaris muscle ruptures, often as a result of lunging forward, a sudden, snapping pain in the back of the leg is felt. Swelling and bruising in the back of the leg may occur, along with cramping of the calf muscle.



Medial Gastrocnemius

A medial Gastrocnemius strain is another common cause of acute onset calf pain with the typical symptom described as pain in the inner part of the lower leg, swelling, bruising, inability to run or jump. This is called “Tennis Leg”



Soleus Muscle, Not your typical Mechanism of Injury...


One can think that muscle injuries happen only with sudden movement like shooting a ball , accelerations or quick change of directions but the calf injuries sometimes occur with a gradual onset which means the muscle injury happens over a period of time and not with one episode.


The typical example is a Soleus strain that happens during warm up or the patient starts feeling a sharp pain the following day to a soccer match without remembering any injury per se.


Steady running or jogging can also trigger a Soleus strain.



Signs of a Calf Injury





Calf Strains: How long Does it take to Heal ?



Depending on the severity of the injury, the healing time could be from 1-2 weeks to 1-2 months at times.


As usual with these muscular injuries, healing time does not mean rest.


For the contrary, pushing the muscle to the limit of tolerance ( guided by mild pain or discomfort ) is the best path to create a strong and flexible scar tissue strong enough to tolerate the high demands of soccer.



Soleus Muscle - High Reinjury Rate


If you are over the age of 40 and have had a calf strain your risk of sustaining a second injury is really high and without treatment is even higher up to 60 % of chances of having a second injury.


Because of this high reinjury rate is that you will benefit from recovering under the guidance of a physical therapist to reduce this risk to a minimum and guarantee and successful return to play.


The calf muscles create a lot of power to sprint and jump. Before return to play after a calf strain you must be sure that you have restored not only the range of motion of the ankle and knee, the strength of the Gastrocnemious and soleous but also you have training the injury to tolerate high speed running and jumping on the injured leg otherwise you are setting yourself up for a re-injury



What can I do to help the healing process ?


Acute Phase (1st week aprox.)




The goals of this phase is to control pain and inflammation and to start moving the injured fibers as tolerated:

  • Reduce Pain: Including ice for 1st 1-2 days , also ultrasound, electricity, taping, heel lifts, and hands-on therapy

  • Improve Motion: Gentle Range of motion exercises as tolerated: I like Gastrocnemius activation with ankle pumps (video 1), first with the knee in flexion to relax the calf muscle and allow more ankle excursion and then with knee straight to challenge more the injured fibers inside the muscle.

  • Improve Strength. Band resisted Calf exercises (video 2). As soon as tolerated we start with resistance training using bands




Strengthening Phase


The goals of this phase is to start loading the muscle and restore the strength of these powerful muscles progressively


My two favorite exercises are:


Weight Bearing Isometrics Bilateral



  • 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.




Weight Bearing Isometrics Single Leg




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

  • Movement. Bend one knee up to 90 degrees, then raise your other heel off the ground and hold that position.


Calf Raises on Step


The goal of this exercises is to continue loading the muscle and to challenge the muscle in the whole length of its fibers.

Adding a step helps to achieve these goals. It is very important you go from one extreme of the movement to the other. Challenge yourself to get to the end of both movements. In this way the scar tissue forming inside the muscle to repair the injury, will align in the line of stress / force and will get stronger in the whole range.

In the video I show them using a weighted vest but you should start with your own body weight and progress to a vest or backpack once you can knock down 10-12 good quality repetitions.




  • 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



Return to Play , How and When ...?


Heavy Lifting

The soleus muscle must endure 7-8 times your bodyweight therefore heavy lifting is required to restore the capacity of the calf complex. This is the part that most people neglect or miss, reason why they get re-injured as soon as they return to play.


Field Training

Another common denominator I see in calf injuries is the lack of Field work before allowing players play again .

Besides getting the muscle stronger the Soleus muscle injury will require a progressive return to play program that must include field work.

I like to expose my clients to multiple drills that will challenge the calf complex little by little .

The different components of this stage are accelerations, jumps , quick change of directions, sprinting full speed and kicking / shooting.

The injured player has to demonstrate me they can handle the demands of soccer match before allowing them to play.

Finally the return to play must be in instalments, 15-20 first , followed by two 25-30 minutes and then a full game in a 2-3 week period.

Maintenance and prevention

Once the recovery is completed, I recommend my clients to continue exercising



Conclusion


  • Calf muscles are very common in Soccer players.

  • Healing time depends on the severity on the injury but usually 3 to 6 weeks is a good estimate

  • Resting for 3-6 and returning to play will not help . You need to restore the size, strength and power of the calf musculature. Use the videos above as guidance for training

  • Be sure you work on Gastrocnemius strengthening

  • A good return-to-play training with field work is mandatory if you want to avoid another injury




Do you want more information on muscle injuries ?


Click the link below to get access to our PDF E-Book where you'll find valuable information about Muscle Injuries in general and Calf Injuries in Particular


Muscle Injuries in Soccer Players





#whitebayphysicaltherapy#calfpain #calfStrain#PulledMuscle #Soccerinjuries#Soccercalfinjury #westonsoccer#westoncalfpain #westonflorida#westonfloridaphysicaltherapy#daviefl #coopercityflorida#pembrokepinesfl#miramarflorida #weston#physicaltherapy#southwestranches#westonfitness #livinginweston

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