Strengthening Your "Foot Core" May Reduce Injuries

Running injuries are often caused by failure of the stabilizing muscles of your feet that make up your “foot core”. We all talk about how important “core” stability is in preventing injuries, but most of the focus is on our hips, pelvis and back. What about the tiny little “foot core”? There was a really interesting article in this month’s British Journal of Sports Medicine, which make the case that we shouldn't ignore our “foot core”.  In fact, the  authors challenge us to move beyond lifetime orthotic control; and after treating an injury with stabilization and rest with an orthotic, slowly wean the runner away from their orthotics by gradually stabilizing the “foot core”. Interesting paradigm shift! I'm not ready to get rid of my orthotics, but perhaps this is really not so new; but just another way to meet the demands of runners who want to go back to natural running style without the use of corrective orthotics or stabilizing shoes. Hmmm. Sounds like the exercises we presented years ago to stabilize your feet in order to introduce minimalism? I definitely see where this could be helpful in treating all of our runners that don’t have overwhelming biomechanical issues. It certainly can’t hurt!!

So what makes up the “foot core”?

Your feet have extrinsic and intrinsic muscles.  Extrinsic muscles originate far away from the joints that they move.  These are the toe muscles that start on the shin bones and turn into tendons that attach on the ends of the toes.  They can curl and extend the toes, but they do it by crossing over the many small bones and joints of the foot.

Intrinsic muscles originate and attach within the same body part.  In the foot, they originate on the heel bone or long bones of the arch of the foot and attach on the toes.  The intrinsic muscles are like the “core” muscles of the foot.  Because they are deep and don’t cross over too many joints, they can work well in stabilizing and protecting the arch and structures within the foot.  There are actually 11 tiny little intrinsic muscles in your feet, but they have a big job to do. When the foot intrinsic muscles are weak, the foot structures are more prone to increased stress and injury.  Strengthening the intrinsic muscles of the foot is good for people with foot injuries (especially plantar fasciitis) and of course those looking to prevent injury.

So how do we strengthen the “foot core”?

Here are some examples of foot intrinsic strengthening exercises.  They can be done either in sitting or standing, one foot at a time, or both together.  At first, the movement may seem impossible, but if you practice for a few minutes a day, you will start to see the toes working with better control.

1)    “Toe Swapping” – Start with your foot flat on the floor with equal pressure on your heel, the base of the big toe, and the base of the little toe.  Raise up the big toe while keeping the other 4 toes flat and pressed into the floor.  After holding a few seconds, try the opposite.  Flatten the big toe down into the floor and try to lift up the 4 small toes.  Try not to let your whole leg roll back and forth as you swap back and forth between the big toe and the 4 small toes.  You can start by using your hands to hold the toes in place to help your body learn how to isolate the toe movement.

2)    “Playing the Piano” – Start with your foot and all the toes flat with equal weight on the inside and outside of the foot.  Raise the big toe up by itself as in the previous exercise.  Keeping the big toe up, raise up the second toe to join it.  Then add the third toe, the fourth, and the pinky.  Try to make each toe come up separately.  Once all the toes are up off the floor, start putting them back down one at a time starting with the little toe.  Keep rippling them up, and then down, like someone playing scales on a piano.

3)    “Doming” – Start again with the foot flat on the floor.  Try and press the underneath side of the small knuckles of the toes down into the floor.  This should make the main knuckles closest to the foot raise up like a dome.  The toes need to stay long and straight.  When the toes curl under, it’s the extrinsic muscles working, not the intrinsic.

These movements will be a little frustrating at first, but they will strengthen the “core” muscles of the foot.  They also make good party tricks. 

There is a great video on strengthening your feet to prepare for minimalist running (by yours truly) that gives you 6 more simple exercises to strengthen your feet! Check it out! And of course, if you have any foot pain that is not resolving, consult your favorite podiatrist!

On a side note: The quest to run 2015 miles in 2015 is still moving forward! We hit 400 miles this weekend at the Dallas Athlete’s St. Patrick’s Day Triathlon! Fun Times…..Now 1615 miles to go…..See you at the Dallas Rock & Roll Half Marathon this weekend! 

Chronic Heel Pain Responds to Night Splint

Plantar Fasciitis a.k.a. Plantar Fasciosis (PF) is an extremely common foot injury usually described as heel pain. The pain is usually first thing in the morning and after rest. PF is by far the most common injury I see in my North Texas sports medicine clinic. PF is seen in most athletes, and is one of the most common running injuries. One study described PF as affecting 8% of habitual runners. 8%! When you calculate that approximately 2% of the US population runs on a regular basis (based on a survey of how many people ran a marathon in their lifetime). That is a lot of people. Actually the rough estimate is 6.2 million runners in the US alone with about a half a million suffering from heel pain. Wow! Oh my aching heel!

Why is there so much heel pain in runners? Too much, too soon, too fast syndrome. In other words, we want to be in shape way before our bodies are ready. The rule of adaptation states that our bodies become stronger with small incremental increases inn stress, but we break down with large incremental increases in stress. This is why PF is described as an overuse injury.

So how do we treat is? A protocol approach that starts with simple, stupid and follows a stepwise pattern that ends with 85% of runners having complete resolution with conservative therapy and 15% going on to move invasive surgical procedures.

Mainstays of treatment: orthotics, better and/or different shoes (that is an entire article in and of itself), lots and lots of stretching, night splint, anti-inflammatories, physical therapy, extracorporeal pulse activated treatment (EPAT), and in some cases, injection therapy (always a debate in athletes).

Simply reducing pain and inflammation alone is unlikely to result in long term recovery. Rest is usually not enough. The minute the runners gets back to activity, their pain is back! I find that most runners, especially over the age of 40, desperately need to stretch their Achilles tendon and plantar fascia. The plantar fascia tightens up making the origin at the heel more susceptible to stress. The best way to do this is a combination of dynamic stretching throughout the day (see my video on Youtube) and a night splint. A plantar fascial night splint is an excellent product which is worn overnight and gently stretches the calf muscles and plantar fascia preventing it from tightening up overnight.

Why does a night splint work, especially in athletes?

The plantar fascia is the ligament that holds up your arch. It is a thick band of fibers that go from the heel of the foot across the bottom of the foot to the toes. Plantar fasciitis is considered to be an inflammatory process following micro tears in the fascia. Plantar fasciosis is a degenerative process that occurs after several months of chronic plantar fasciitis. The reason PF causes so much pain in the morning, is that during the night the foot is relaxed and drops so the toes are pointed downwards. In this position the plantar fascia is relaxed, healing of the micro tears occurs overnight, but when the foot is put to the floor in the morning the fascia has to stretch to a longer position and this tears the new healing. Think of ripping a scab off every morning! Ouch! The idea of a night splint is that the foot is held overnight with the toes pulled upwards and thus the healing occurs with the fascia in its stretched position.

Many research studies have looked at night splints and the treatment of plantar fasciitis. There have been some mixed results due to the construct of the studies, but overwhelmingly the whole body of evidence suggests that night splints can help ease pain and assist healing, and this is especially true for people who have been suffering from plantar fasciitis for several months or more (truly plantar fasciosis).

Night splints do generally have to be used consistently for at least one month or more before significant improvement is seen. If you are a light sleeper, just make sure your wear it at least 4 hours a night.

A number of good night splints are available, and the fit and comfort is important given you will be wearing it for at least 6 weeks AFTER your symptoms resolve. A dorsal night splint will allow you to walk to the bathroom in the middle of the night without taking it off. A posterior night splint usually is better tolerated long term.

Got an aching heel, seek out a running podiatrist to get you back on the roads in better shape than you left them!

EPAT Treats Chronic Heel Pain

EPAT is the most advanced non-invasive treatment for musculoskeletal pain. Extracorporeal Pulse Activation Treatment is a new way to conquer chronic heel pain. Pressure waves stimulate the metabolism, enhance circulation and accelerate the healing process without surgery. Dmaged tissue of the plantar fascia or Achilles tendon gradually regenerates and eventually heals. Here are the top 16 frequently asked questions about EPAT.

The Top 16 FAQ’s About EPAT Therapy for Heel Pain:

1. What Is EPAT?

EPAT is an acronym for Extracorporeal Pulse Activation Technology. It is a highly effective non-invasive office based treatment method that accelerates healing of injured tissues.

2. How Does EPAT Work?

The treatment utilizes a unique set of acoustic pressure waves that are delivered through the body and focused on the site of pain/injury with a special applicator. These pressure waves stimulate the metabolism, enhance blood circulation and accelerate the healing process.

3. How is the Treatment Performed?

Ultrasound gel is applied over the skin of the treatment area to enhance the transmission of the pressure waves. The pressure waves are applied using a special applicator tip. The tip is moved over the injured tissue using circular motions.

4. How Long Does the Treatment Take and How Many Treatments are Required?

Treatment sessions take approximately 15 minutes per site and vary slightly depending on the site to be treated. Generally 3 treatment sessions are necessary and are performed on a weekly interval. If you are improving, but not completely better; up to 5 treatments can be performed.

5. What Conditions Can Be Treated With EPAT?

EPAT can be used to treat many painful soft tissue injuries. Including: plantar fasciitis, Achilles tendonitis, tendon insertional pain, acute and chronic muscle pain, and myofascial trigger points.

6. Is EPAT Safe?

EPAT is a safe treatment with virtually no side effects. It was originally developed in Europe and is currently used around the world.

7. Is EPAT Safe for Pregnant Patients?

EPAT is a safe treatment, but has never been tested on pregnant patients. Patients are advised to wait at least 3 months post partum before treatment, as many foot pains subside after weight loss and hormonal equilibrium is reached.

8. Is EPAT FDA Approved?

Yes, the machine is FDA cleared for usage.

9. What are the Expected Results?

Most people will experience pain relief after 3 treatments. Some patients report immediate pain relief after the first treatment, but maximum relief can take up to four weeks after the last treatment to begin. Over 80% of patients treated report to be pain free or have significant pain reduction.

10. Are There Any Special Aftercare Instructions?

All patients receiving EPAT therapy should be off all anti-inflammatory medication for a minimum of 2 weeks prior to the procedure and 4 weeks after. This includes common over the counter medication such as, ibuprofen (Motrin, Advil), naproxen (Aleve) and aspirin. Your doctor will provide you with detailed after care instructions.

11. What are the Possible Side-Effects or Complications?

EPAT is a non-invasive treatment and has virtually no risks or side effects. In some cases patients may experience some minor discomfort which may continue for a few days. On rare occasion, the skin may become bruised or red after the treatment.

12. Who Should not Have EPAT?

EPAT should not be used in people who have deep venous thrombosis or malignancy. It is also best to avoid the procedure if you are taking blood thinners.

13. Why Consider EPAT?

EPAT has a proven success rate equal to or better than traditional treatment methods (including surgery) without the risks or lengthy recovery time. It is performed in your physician's office without the need for anesthesia.

14. Does My Insurance Pay For EPAT?

No, unfortunately insurance companies do not pay for EPAT, though the cost of EPAT can often be reimbursed from a qualified health savings account. Non-covered services and/or procedures without billable terminology are paid to the office by the patient at the time of service; a claim will not be submitted to the insurance, though our office can provide receipts for reimbursement accounts to consider.

15. How Much Does it Cost?

EPAT is an affordable alternative to invasive surgery, lengthy physical therapy and other costly treatments. The first 3 treatments are bundled at a cost of $500 for the procedure, but you are still responsible for any co-pays or costs associated with the initial and/or any follow up office visit. If a 4th or 5th treatments are deemed necessary, these cost $150 per treatment.

16. How Can I Get More Information About EPAT?

The physicians at FAANT all have experience in providing EPAT treatment and are the best people to speak with if you have additional questions regarding the procedure. Call or contact our office for a consultation.

There is also much more extensive information available at http://www.curamedix.com/

Why is There an Epidemic of Heel Pain?

Why does it seem like there is an epidemic of heel pain in the United States? Everyone I talk to has had plantar fasciitis or at least has heard of it. Many can even spell it correctly. (Isn't that scary!) Most people suffer for months and even years before they seek medical attention. Even those treated with traditional methods seem to take just about forever to get better. And there are more voodoo treatments available than Carter has liver pills. Why is that? Seems to me that there is a lot of money in heel pain!

So let's take a closer look.

What is plantar fasciitis? Simply stated, it is inflammation of the ligament that holds up your arch, also known as your plantar fascia.

What causes heel pain or plantar fasciitis? Most experts agree that plantar fasciitis is caused by too much stretching of the plantar fascia, usually because of excessive pronation or flattening of the arch of your foot while you walk. Some people just have excessive stretch because they have flat feet. Others have really high arches and their fascia is under a lot of stress in normal walking. Some are just too heavy. It can be triggered by an injury like simply falling off a curb, excessive stress by a new exercise program, poorly supporting shoes, and many other increases in stress like a new job or carrying heavy objects. There is even one theory that states that plantar fasciitis is caused by weakening of the muscles of our feet from wearing shoes all of our lives. Hmm...Will have to look at that a little closer in the biomechanics lab.

Why does it afflict so many people? Let's think...oh yeah...most of the United States is overweight. Most people choose absolutely awful shoes to wear due to their sense of fashion. Slaves to fashion usually have painful feet! And the flip flop phenomenon has accelerated the epidemic! Those that aren't fat and in poor shoes are usually crazy obsessive exercise-aholics.

Now that we know why it seems that everyone suffers from heel pain at some point in their lives, how can we treat it without breaking the bank? Let's start simple. Better, more supportive shoes are the key to success. Arch supports if the shoes aren't enough. You need to stop the stress that caused the arch to strain in the first place. Then treat the inflammation with over-the-counter anti-inflammatories, if you can tolerate them, and lots and lots of ice. Slow down. (That's tough for more people) And gently stretch the arch of your foot and your Achilles tendon.

When should you seek medical attention? If you have arch and heel pain for more than three or four weeks, and you have done the simple things to alleviate the pain; it's time to see your podiatrist. Not time to go to the shoe store and spend a bizillion dollars on off-the-shelf inserts and funky "proven to work" shoes. Not time to go to the pharmacy for hundreds of dollars worth of gadgets and creams. Time to see your podiatrist, who is the expert in heel pain.

How will your podiatrist treat your heel pain? Every case of plantar fasciitis is different, but some standards of care do exist for treatment protocols for heel pain.

First order of business: You need to rule out anything else by taking an x-ray to make sure it's not a stress fracture or tumor in your heel bone. A physical exam is also needed to assess why you have heel pain.

Then your podiatrist will usually assess your shoes and possible prescribe arch supports or orthotics if your need them. An injection or two of an anti-inflammatory into the heel is often used to break the pain cycle. Physical therapy is also often helpful. A night splint or brace is sometimes used. And if all else fails, you may be put in a cast to rest the area.

Contrary to popular belief, you do not have to suffer from plantar fasciitis forever. Most patients (>85%) will get better with aggressive conservative treatment. It is tedious and frustrating, but the diligence and consistency in the treatment protocol yields excellent results.

Here is the bottom line: if you seek the attention of your podiatrist early, you will get better faster and your treatment will not break the bank. Procrastinators will end up spending a lot more money and the chance of needing surgery to alleviate your pain goes way up!