[Bonus] Treating plantar fasciitis smarter, not harder with Luke Murray

In this episode with Luke Murray we discuss Paul Ingraham’s e-book on plantar fasciitis. We cover:

• Common causes of plantar fasciitis
• Is stretching effective for plantar fasciitis?
• Strengthening for the treatment of plantar fasciitis
• And more!

🎁 For a limited time, you can get Paul Ingraham’s 65 chapter e-book on plantar fasciitis for FREE when you join Practicals.

👉 Claim this offer here: https://physio.network/practicals-murray1

⏳ Don’t miss out - offer ends soon!

Luke is a Specialist Musculoskeletal and Sports Physiotherapist who has previously worked for Arsenal Football Club, London Irish Rugby Club & the National Health Service. Luke was a Strength & Conditioning intern at Chiefs Super Rugby & Rowing New Zealand throughout the 2014 season. He has a BSc in Sport and Exercise Science from University of Limerick in Ireland and MSc in Physiotherapy at the University of Brighton in England.

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Our host is @James_Armstrong_Physio from Physio Network

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Transcript

SPEAKER_01: 0:05

Of all the treatments within rest, stretching, knife splints, strengthening is probably the one where you're getting best bang for buck. But why you're getting best bank for buck is very up for debate. Is it because you're just getting more stimulus through the area, you're getting more of a stretch through the area, or is there something else happening where we're building up the capacity and that's having some sort of an analgesic effect over time?

SPEAKER_00: 0:30

Today on the Physio Explain podcast, I'm joined by Luke Murray, a physiotherapist and medical doctor with an extensive experience in musculoskeletal practice and sports medicine, including working closely with athletes across different levels of performance. Luke also manages the Physio Network Research Reviews, keeping clinicians up to date with the latest evidence. And today we have a really exciting episode. We have a bonus for you all to have the chance to win a free copy of Paul Ingram's ebook. It is a comprehensive guide covering everything you need to know about plant to heal pain, from assessment through to expert management. And in today's episode, we're going to dive into the management of plant to heal pain using Paul's book and pull out some key clinical gems from the book that you can apply straight away into practice, making this both a great conversation and a fantastic opportunity to get your hands on an invaluable resource. To find out how to get your hands on this resource, just listen to this episode and you'll find out exactly how you can get hold of the ebook. I'm James Armstrong and this is Physio Explained. Luke, welcome back to the Physio Explained Podcast. Great to have you on to talk about Paul Ingram's great new book, and we're going to be covering plantar fasciopathy, plantar heel pain, plantar fasciitis. We'll get to the bottom of that in a minute. But great to have you on, Luke. Yeah, thanks for having me, James. Good to see ya. Good stuff. So obviously, I mentioned in the intro, listeners have got a great opportunity to get their hands on this e-book from Paul Ingram, signing up to the practicals from Physio Network. But we're going to give them a little bit of a taster today on some of some tips and tricks around plantar fasciopathy and the treatment really. But let's kickstart with some definitions. Gluke, what does Paul talk about in the book in terms of his definition?

SPEAKER_01: 2:19

Yeah, so plantar fasciitis in its simplest form, simplest definition, is an overuse injury, potentially also considered a repetitive strain injury. So if you wanted to give yourself plantar fasciitis, go and do an unfamiliar activity that involves an awful lot of impact, whether that's even just simply walking an awful lot more than what you're used to, or doing a huge amount of running. If there's more pounding on the pavement, the better. And if you wear very unsupportive shoes or no shoes at all, you're running barefoot. That's great. That'll give you plantar fasciitis because it's a huge increase in volume, load, intensity, and that's what causes the overuse injury. What I also like is that it's not as simple as that. As in, that's a very simplified way that we can tell patients or people that are suffering with plantar heel pain about what might have contributed to them presenting with the problem. But it's not as simple as an a plantar fasciitis as itis as in inflammation. It's not as simple as it being an inflammation problem. Because if it was, then lots of anti-inflammatory treatments would work and solve it. But really, it's not as simple as that. It's an awful lot more nuanced. And Paul identifies research or cites research in the book that highlights that there's little to no inflammation present in plantar fasciitis. And actually, it may be more a thing of collagen degeneration or tendinosis as a slightly more accurate pathophysiology for what's going on. I suppose you can't really talk about the definition then without talking about risk factors and contributing factors to it. So like Paul goes through this in a huge amount of detail, but he talks less about it being a biomechanical problem. You know, he goes through and it myth busts a lot of the areas like overpronation causing plantar fasciitis. And actually, he steers you towards things like metabolic syndrome and the role of menopause and tendon health, and the role of estrogen and tendon health and obesity, and thinking about it in a much bigger picture so that your treatments aren't just stuck at the foot, trying to do loads of toe crunches and lots of things to manipulate the plantar fascia and the calves and thinking bigger picture about the person's overall cardiometabolic health and what you can do as a physio to address the risk factors that brought that patient to the clinic. So that's why I like the book. It's not just a standard simplified version of this is the definition of plantar fasciitis, this is your biomechanical analysis, and therefore this is your biomechanical assessment and this is your biomechanical treatment. It doesn't really fit in those categories. It's much more nuanced and bigger picture, which you can only really figure out by reading the detail yourself and getting into stuck into the weeds of it.

SPEAKER_00: 5:06

Definitely. And I think that's really useful, isn't it, with having a really good understanding as a clinician of the definition, you can really help your education of the patient because I know for a fact in clinic, the amount of patients I have had who've come in with really poor understanding of what might have caused it, they blame the over pronation, they get told that they've been wearing the wrong shoes, or they get told that it's because of something that actually might not be. And we can pull the lens out a little bit and give them a bit more of guidance in overall treatment, which is really useful.

SPEAKER_01: 5:37

That's it. And like Paul Eile said, like stuff like that may help. So like getting a more supportive shoe or getting an orthotic may help, or doing specific stretches or strengthening of the plantar fascia may help. But we have no evidence to say that it definitely will help, and we have no evidence to say that everyone should absolutely be doing those things. He said the one thing that we can be sure about is that we don't actually have a definitive treatment plan or a definitive cure for it, because if he did, then his book wouldn't even exist. So we then need to think about what is the goal of treatment and is it to try and cure the pain, or is it a case of trying to manage the pain and potentially some damage control options that we can implement to try and maybe slow down the whole stubborn nature of it? Because that's one thing, that's one thing that Paul highlights is like you can have plantropasciitis and people will complain about it for years because it's something that's always there. But then he he says, is it stubborn because of the actual pathophysiology of what's happening, or is it stubborn purely because of how it's being managed? And then if it is the latter option where it's poorly managed plantar fasciitis, then the onus is on the therapist and on the patient to try and figure that out. So he uses the example of the number one treatment being rest. So that's not really what people want to hear. If you're a runner or even like a chef, somebody that you're just up on your feet and you're loading your plantar fascia all day, every day, then rest is an extremely difficult thing to do. And we expect a huge amount of our feet. We expect our feet to be able to cope with the demand on them on a daily basis, 365 days of the year. So then when we think of rest, we've got options. We've got absolute rest, where we make ourselves bedbound until the pain goes away, or we've got relative rest, and that's where the magic happens with some of the relative rest stuff. Some people will say, Oh, yeah, I've rested for three, four, five days, and it hasn't gotten any better. Paul says, Well, actually, we probably need more prolonged rest. We don't need to make ourselves bedbound, but we probably need prolonged rest. So he goes through a systematic approach of if somebody has fairly severe plantar fasciitis, they're rating it pretty high on your pain scale. Their quality of life is impacted quite a bit, and their day-to-day function is in is impacted quite a bit. And if that's the case, then we might need to actually prolong the amount of rest. And we need to be very clear about what that rest actually means. If it's a case of somebody that's really not able to cope with that pain, then maybe we have to offload the plantar fascia and put them in a boot. That's something that I've never done myself. So when I read it initially, I was a bit taken aback because I was like, I've never put anyone into a boot for plantar fasciitis. Maybe it's just the type of population that I see with it, or or maybe it was just never an option that I even considered for somebody with plantar fasciitis. But he says if you put them into a boot and at least then you can keep them some ways active for three to four weeks while you have them in a boot. And then once you've got symptoms calmed down enough, then you can start to build them back up to where they were and hopefully manage their symptoms as you're doing that. For other people that are runners, you might be thinking, okay, we will cut back their volume and their load, the total distance that they're doing or the total mileage within a week, strip them back completely. But because they're going to be people that want to be active, we need to think, let's rest the planta fascia but exercise the person. So then we're thinking about getting them rowing or getting them onto an elliptical or getting them into the water. And what method you choose will very much depend on the person's preferences and the sensitivity of the feet. Like for some people, rowing could be a very provocative position for somebody's plantar fascia. And for other people, it might be absolutely fine. So we're thinking about our plan A for every single person that we have is rest. And then the magic happens when we're trying to figure out how to get that person to rest the plantar fascia more while also keeping them physically active, physically healthy, and allowing them an outlet for exercise without irritating the plantar fascia itself. So that'd be sort of option number one. Plan A, get them resting more so that you can offload the plantar fascia more. And really, if somebody's telling you that they've rested for four or five days, they probably need to think more about a few weeks and then gradually managing their load through the feet, potentially over a few months, before you're safe and before you can say, I've done my rest protocol or my rest period for a prolonged period of time, but it's still not getting better, then I can go into these other options as well that Paul goes through.

SPEAKER_00: 10:19

Want an easy way to improve your assessment and treatment skills? Introducing practicals, where you can watch video recordings showing exactly how top experts assess and treat a range of conditions. It's the fastest way to develop your practical skills and enhance your clinical reasoning. Treat your patients like the experts do with practicals by Physio Network. Click the link in the show notes to try it for free today. In the book, Paul talks in great detail about many, many different treatment options, which is really useful because I think I always a great believer of every patient that comes to you is going to be very different and was likely to respond to different things, and finding those things is part and parcel of the fun of being a physio, I think. What sort of things have you taken away from the book, Luke, in terms of those treatments, those actual sort of modalities that we might have on offer?

SPEAKER_01: 11:09

Yeah, so there's a lengthy list, as you said, there. So he goes through the ones, he highlights the ones that are probably the most common. So he obviously mentions, as we said, rest. He talks about using the boots and potentially using like night splints as well. Knight splints are something that people are using less frequently, but actually he tries to use them more with his patients because if something like a simple stretch, like a calf stretch, whether you're stretching your Sileus or your gastroc, if something like that gives somebody relief, it's not targeting specifically the plantar fascia, but it's getting them some sort of stimulus into that ankle and foot complex that's giving them some sort of relief. So then we can double down on that by using night splints overnight, and we're getting whatever six, seven, eight hours of lengthening into the calf and that potentially having a beneficial effect. We know that stretching will loosen up tight muscles associated with the actual problem of plantar fasciitis, but we don't know if tight muscles are causing it, and we don't know if treating tight muscles is going to cure it. We know that it's not going to really do any damage in that ankle-foot complex. So if it's something that the patient finds useful, if you started to trial some of those things, then it may be something to incorporate as part of that sort of symptom management or damage control thing as well. So we're sort of lumping in night splints and stretching into one category and then that having potentially some beneficial effects for plantar fasciitis. He then goes into stretching the plantar fascia itself, and he basically summarizes that whether you're trying to stretch the plantar fascia or not probably doesn't matter. So I think that's a really interesting one from like a social media perspective. Even myself, I've posted stuff on social media to stretch the plantar fascia. I think it was there was a systematic review out in 2021 by, I think it was Dylan Morris and colleagues. I might have the year wrong, but they had stretching as like the core component to their management of plantar fasciitis. So that was a big part of what I did as well. But then Paul has gone through research within the book that highlights maybe it's not the specificity of the stretch to the plantar fascia that's actually useful. And we can keep it more generic. We can stretch the calf, we can stretch the plantar fascia, but we need to be realistic. That's probably not going to yield massive benefits in terms of a huge reduction in pain. But if it helps this person to manage the problem, then why not? Why not do it? It's very easy to do and it's low cost. And if it gives them a bit of a reduction in their pain, then why not? But we need to be very clear with the patient that it's probably not going to be a cure for their problem. The next one that I took an interest in was strengthening as well. Obviously, that's another one that was part of a lot of people's management of plantar fasciitis, and it's a probably a go-to for an awful lot of us that are biased towards exercise prescription and the likes. And he says that of all the treatments within rest, stretching, knife splints, strengthening is probably the one where you're getting best bank for buck. But why you're getting best bank for buck is very up for debate. Is it because you're just getting more stimulus through the area, you're getting more of a stretch through the area, or is there something else happening where we're building up the capacity and that's having some sort of an analgesic effect over time? So he highlights different research from 2015 by Raffleff and colleagues as well that goes through the uh comparison of stretching one group and strengthening another group and looking at the outcomes in terms of reduction in pain and increase in function. And the strengthening group had a statistically significant improvement with their pain and their function. So that might lead you to do more simple calf strengthening. It might lead you to do more eccentric work through the calves as well. And what type of strengthening you choose probably doesn't matter a huge amount. So you're going to tailor it to the person and monitor their symptom response to the type of strengthening protocol, whether you're using isometrics, isotonics, eccentrics, whatever you're going for. There are some other notable mentions as well. So I often think about like older patients that I see, and they always come in with the question of do I need to get it injected? I don't know where that comes from, whether it's like doctors in the past or orthopedic doctors or wherever or physios were promoting getting steroid injections into the plantar fascia to help with symptoms. And Paul has basically outlined that the potential cons outweigh the benefits that you're likely to get in the long term. Like the risk of plantar fascia rupture is a lot higher with repeated injections of the steroid injections into the plantar fascia. And you may only get a small, negligible improvement in pain over time. So it's not recommended as part of Paul's treatment. But if somebody had exhausted all the other options, he may consider it as like a last resort. So he keeps everything on the table and uses different things depending on how people are responding to the treatments over time. We could talk for ages because there's so many. He goes through surgery, he goes through dry needling, he goes through orthotics, he goes through stem cell therapy. There is so much juicy information that you have in the book to get stuck into. If you want many options, his book outlines all the options that's some of them that I've never even heard of myself. So if you're stuck in terms of your treatment choices for this type of problem, then it's definitely the book to give you many strings to your pantrophasciages management bow.

SPEAKER_00: 16:34

Brilliant. Thanks, Luke. Thank you. As you say, we would easily spend an hour or so talking through some of these treatments and still just brush to the surface. Before you go, and we do have to go this second, and I don't want to go into detail on these, but just to make sure, does he cover shockwave and taping?

SPEAKER_01: 16:50

Oh, so much. Good.

SPEAKER_00: 16:51

That's all right then. Excellent.

SPEAKER_01: 16:53

Shockwave, taping, all the different types of taping for the plantrofascia. And as I was saying, like the stem cell therapy and surgery, the different types of surgery, like it's quite incredible the detail he's got into.

SPEAKER_00: 17:06

Brilliant, brilliant. So, listeners, listening to this, I'm sure you probably want to get more of this. And you can indeed do that by getting hold of Paul Ingram's ebook. And all you've got to do is sign up for the Physio Network Practicals, and you can do that by clicking the link in the show notes. But you do have a limited time, so don't hang about. Click on the link and get yourself signed up for practicals. And personally, I can't recommend them enough. I use them an awful lot in my practice. The practicals are fantastic. I use them with staff, and it's just brilliant for another resource to see how the experts do their thing in practice with their patients. Luke, thank you very much for your time, and I'm no doubt we'll speak to you again soon. Thanks for having me. Cheers, Luke.