REHABILITATION OF INJURY

SAMPLE REHAB. SESSION

OF PLANTAR FASCIITIS

BY
COLIN MACGREGOR
99302110
 INTRODUCTION

This essay aims to provide the rationale behind a selected hypothetical treatment
session of an injured athlete during the rehabilitation phase. The case outlines a
possible scenario presented to a physiotherapist and then a typical session that could
be implemented.
The athlete concerned is a 28 year old male cross country runner, who competes at
national level. In the initial consultation they reported the occurrence of pain along the
medial longitudinal arch of their right foot towards the heel. This pain would appear
with the first few steps taken in the morning but would subside after about half an
hour. In the evenings when they would train, there was very little pain felt whilst
actually running but it would resurface an hour or so after finishing.
After careful assessment of the athlete it was observed they were over pronating and
had reduced flexibility of the plantar flexor muscles – gastrocnemius and soleus and a
reduced flexibility of the achilles tendon. Further questioning revealed that they had
introduced hill running into their training along with the existing programme. They
also reported that they had purchased a new pair of trainers’ which were dissimilar to
their old pair.
This led to the diagnosis that the athlete was suffering from Plantar Fasciitis. Plantar
fasciitis is the most common cause of heel pain in runners (Nunn, 1997). Plantar
fasciitis is considered an overuse injury and involves an inflammatory reaction at the
insertion of the plantar fascia into the calcaneus (Krivakas, 1997). Overuse injuries
can occur from repetitive stresses being imparted to anatomically weak or
biomechanically inefficient structures (Gordon, 1984). That is tearing tissues down
faster than it is able to regenerate (Ames, 1986).
Plantar fasciitis aetiology can have many contributing factors. During running as the
foot moves from mid-stance to toe-off the plantar fascia plays a very-important role
by re-stabilising the foot. When excessive pronation occurs in the support cycle, the
result is pushing off with an unstable foot and an overstretched plantar fascia. Over
time plantar fasciitis can occur from this overstretching (Warren, 1984). It was found
that between 81 and 86% of individuals with symptoms consistent with plantar
fasciitis have been classified on examination as having excessive pronation (Cornwall
and McPoil, 1999). A tight achilles tendon, reduced plantar flexion strength and
reduced flexibility of the plantar flexor muscles are other intrinsic factors which have
been implicated to the cause of plantar fasciitis (Tanner and Harvey, 1988; Cornwall
and McPoil, 1999). Suggested extrinsic factors have included an increase in training
volume and shoe design, which can increase the stress placed on the plantar fascia.
The athlete displayed a number of the above factors. They had limited flexibility
around the plantar muscles and achilles tendon, they had increased their training
volume (hill running) and they had changed their footwear. The shock absorption of
footwear can have a marked effect on the amount and rate of pronation. Nigg and
Segesser (1992) found that shoes with softer soles increased pronation and overall
rear foot movement.
The rehabilitation process of plantar fasciitis can be broken down into three phases as
describd by Leadbetter (1991). The acute phase, the recovery phase and the
maintenance phase. It is out with the boundaries of this essay to describe every
session of every phase in infinite detail, but a description and rationale of a typical
session during the maintenance phase has been detailed.
 REHAB SESSION (MAINTENANCE STAGE)

It is important to give a brief overview of what the rehabilitation would have

consisted of up until this point. In the initial stages the athlete would be instructed to
cease all running activities. This would allow for a reduction in any inflammation and
prevent further damage to the tissues. The foot would be initially taped in the neutral
position as this has shown to give rapid relief from painful symptoms (Norris 1998).
Modalities such as ultrasound could be administered as this is said to increase fibro-
plastic repair of damaged tissues (Evans, 1980). The rehabilitation process would
progress with increased loads being placed on the tissues with strengthening by the
use of isometrics and on to theraband exercises. Increased usage of appropriate
loading of the tendon and surrounding muscular is required to allow the proper
stimulus for healing on a clinical and cellular level (Kibler, 1990). Increasing the
flexibility about the ankle joint should be encouraged along with proprioception
training, gripping the floor with the toes. The aim is to train the muscles to be
stimulated and allow joint stabilisation effectively limiting joint displacement (Norris,
1998). The athlete would be instructed to cease running but it would be necessary to
seek out alternative conditioning programmes for them to maintain their fitness.
Cycling and swimming both of which are non-weight bearing are recommended for
maintaining cardiovascular fitness (Tanner and Harvey 1988). As well as maintaining
fitness it also helps to alleviate the boredom. The athlete could be running up to five
times per week and for them to stop everything suddenly would be a very difficult
lifestyle adjustment to make. It is therefore deemed necessary to keep the athlete as
active as possible to maintain their motivation and focus.
As we enter the maintenance phase the athlete should be returning to their sport whilst
concentrating on further strengthening and flexibility to allow for a functional return
and to lessen the chance of injury reoccurrence. A session during this phase would
include a variety of strengthening and flexibility exercises. Advancement to this phase
requires that the athlete has a similar range of motion to that of a noninjured person
and that strength is 75% of normal (Chandler and Kibler 1993).
Flexibility training is used to increase the range of motion about a joint, in this case
the ankle. Kibler, Goldberg and Chandler (1991) identified range of motion deficits in
runners with plantar fasciitis compared with controls. Gastrocnemius and soleus
muscle stretching along with the achilles tendon is most frequently recommended
(Cornwall and McPhail 1999). Inflexibility in these structures can lead to foot
placement or stride length changes whilst running. The athlete maybe landing on the
meta-tarsals as opposed to a heel first position. This improper biomechanic phase can
lead to excessive loading of the plantar fascia which is associated with plantar fasciitis
(Leadbetter, 1991). The use of Proprioceptive Neuromuscualr Facilitation (PNF)
technique stretches have shown to be the most effective at improving flexibility
(Etnyre and Lee 1987). A typical session would include 15-20 minutes of stretching.
The restoration of muscle strength should include activities for both the extrinsic and
intrinsic muscles of the foot, especially the invertor and plantar flexor muscle groups.
Kibler et al. (1991) identified that muscle strength imbalances were observed in a
group with plantar fasciitis compared to that of an age matched control group. The
most important role of the plantar flexors, (calf muscles and achilles tendon) is to
control dorsiflexion of the ankle during the stance phase of running. It aims to prevent
the ankle from flexing too much while the foot is planted on the ground, and to
prevent abnormal pronation, which has been attributed as a contributing factor of
plantar fasciitis. During this activity the achilles tendon and the calf muscles must
contract eccentrically to prevent the collapse of the shin over the top of the foot and
the inward rolling of the foot (Andersen, 1998). It would then be beneficial to
strengthen these structures eccentrically. This can make them more forceful during
eccentric activity bringing dorsiflexion and pronation under control (Reynolds, 1997).
An example of a typical eccentric strength exercise within this session is detailed
below.
To begin with have the athlete face the wall about 30 inches away with their feet
together. They then pick up the left foot and hold this leg out straight. Whilst bending
at the knee leg they move the left foot out in front to touch the wall with the toes. The
movement is ended by returning to the start position. Following on from this they
undertake the same procedure but this time move the lifted left leg from right to left
attempting to touch the wall. When this happens the right foot pronates as you would
during the stance phase and forces the plantar flexors to contract eccentrically,
naturally as they do during running.
Moving on from this the leg should be brought across the front of the body. So a
raised left foot will travel across to the right in an attempt to touch the wall. This
exercise allows the supporting leg to suppinate as it naturally does during running
towards the end of the stance phase. It is recommended to perform 4 to 6 repetitions
of each exercise with both legs (Reynolds, 1997). This exercise also does the job of
strengthening the knee and hip muscles and co-ordinating their activities with what is
happening down at the plantar flexors which in essence is increasing prorioception of
these tissues.
These exercises combined with rest periods could encompass 20-25 minutes of the
session. Combined with a 5-10 minute warm up, 5 minutes of pre exercise stretching
and 10 minutes of post exercise stretching would bring the session to around an hour
in length.
These exercises should never be attempted without a proper active warm up. The
nature of this eccentric work relates to the specifics of the athletes sport. This type of
training has been shown to increase the amount of Delayed Onset of Muscle Soreness
(DOMS) due to the greater force production developed. This DOMS can last up to 72
hours (Clarkson, Nosaka and Braun, 1992). Therefore these types of sessions would
only be practiced two or three times per week.
At this stage of the rehabilitation process it is important to note how the athlete is
coping psychologically. It is important that for complete recovery both physical and
psychological aspects of injury rehabilitation must be considered (Gould and
Weinberg 1995). By building rapport with the athlete, educating them about the injury
and goal setting in the early stages of rehabilitation, you will be fostering social
support which has been associated with greater adherence to rehabilitation
programmes (Byerly 1994). At this stage of the rehabilitation process it is important
to emphasise the importance to the athlete of the specific exercises in the prevention
of a further occurrence. The return to their sport at his stage may increase the athletes’
motivation to train and carry out the rehabilitation exercises. This may at first appear
sound but highly motivated people tend to overdo (Gould and Weinberg 1995). The
programme should still follow a gradual progression to lessen the chances of setbacks
or re-injury.
External modalities that may lessen the re-occurrence or prevention of plantar fasciitis
is that of footwear and foot orthoses. There are now many types of footwear and foot
orhtotic devices’ which allow for greater total foot contact. This gives support to the
plantar structures of the foot reducing stress on the plantar fascia during weight
bearing (Kogler, Solomonidis and Paul 1995). It would be advisable to undertake
some of the rehabilitation modalities first to see if the symptoms can be alleviated. If
the pain still persists then an examination by a podiatrist may be required to help with
running shoe selection and the possible fitting of orthotic devices. In some extreme
cases it may be necessary to undergo surgery.
 CONCLUSION

Plantar fasciitis is one of the most common pathological conditions found in the foot.
It can occur from a wide range of factors both intrinsic and extrinsic. It is normally
due to a combination of factors rather than one isolated abnormality. The type of
treatment is often varied and may not follow exactly the one previously described.
They can include many different individual interventions. It has been impossible to
determine if one type of treatment is more effective compared with another as most
studies have grouped all forms of therapy together. What can be said is that by
ensuring correct footwear is worn, the volume and intensity of training is progressed
gradually and that if there is an adequate range of motion and strength about the ankle
joint it may help in preventing plantar fasciitis occurring.
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