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Hello, I am an Occuapational Health Advisor working in a company where employees have to walk between 6 and 8 miles per day. Generally this is on pavements but can be over rough ground too. There have been cases of plantar fasciitis which leads to long term absence from work and the managment is keen to know what measures can be taken to reduce the risk of this problem developing - particularly thinking about what considerations they should give when purchasing work footwear for the employees. Any advice that you could give me on key factors that should be considered or avoided would be gratefully received.Many thanks
Jeannette
There have been cases of plantar fasciitis which leads to long term absence from work
Who is managing the plantar fasciitis? Someone is running a scam. In the 1000's of plantar fasciitis (including 2 randomised controlled trials), that I have seen .... no one needed time off work.
__________________ Craig Payne
__________________________________________________ ___________________________________ Follow me on Twitter | Run Junkie God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
In my experience in the UK, the GP will routinely sign people off work for 6-8 weeks initially prescibing complete rest. Following that, if the symptoms have not resolved often cortisone injections are given along with orthotics. As a last resort - surgery. I have known GP's sign employees off work for many months with this condition when their job involves walking. On return to work I find many employees cite exacerbations of their symptoms and fail to successfully return to their full walking role. I have been working in other types of industry for some time now and so it is only recently that I have come across this problem again. How is it managed where you are and what advice would you give to an Occ Health Advisor in my position i.e in terms of prevention and management?
Thats not even close to a minimum standard of care.
If its acute, some strapping and they usually straight back to work. If subacute, calf and plantar fasica stretching; appropriate foot orthoses; maybe some physiotherapy .... rarely does the symptoms last past 4 weeks (and they keep working).
For the few that don't respond to that, then there is cortisone, shock wave and surgery. Never tried complete rest as never need to.
Thats the minimum standard of care pretty much worldwide, except for the GP's in your area.
__________________ Craig Payne
__________________________________________________ ___________________________________ Follow me on Twitter | Run Junkie God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
Thanks for your feedback. What you describe isn't at all my experience of the managment of these cases - not just in my area, my company has employees across the UK. Interestingly, a quick search of material on UK sites indicates rest as the first line of treatment. Perhaps prompt access to podiatry/physio at the onset of symptoms would follow the course of treatment and successful response that you describe. Unfortunately, for many conditions that seems to be the exception rather than the rule with the NHS but that is a whole other matter........
It still doesn't help with my question, which was looking for preventative measures that the employer can take with regard to this condition and other foot complaints potentially arising from walking several miles daily. Specifically, any do's or don'ts with regard to footwear. Any specific research with regard to cushioned soles, boots v shoes etc. I have been asked to advise the company and need some sort of evidence back up but am struggling to find anything - hence my post.
Suggest you get them into a good pair of running shoes - some of the running shoe companies have a walking version ---- make contact with the local running shoe store.
Get them into an appropriate pair of foot orthotics and have them do lots of calf muscles stretches...... most should not recur.
__________________ Craig Payne
__________________________________________________ ___________________________________ Follow me on Twitter | Run Junkie God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
Hi Jeanette
In our region of the UK we would use strapping when acute (as Craig has suggested) in conjunction with stretching and appropriate devices. "Complete rest" is the most impractical advice to give anyone, especially some one in employment. Out of interest of those you see who have been signed off work:
How many completely rest during their time off work?
How many are advised to lose weight if that is necessary?
Devices should help 'rest' the tissues by controlling the foot so time off work should not be necessary. If you can persuade your employers to provide appropriate devices then you should be able to keep the majority of the workforce on the go.
many types of work shoes have a very limited motion in the ball of teh foot area. This will be obvious especially with steel toed shoes and other metatarsal type shoes.
When the motion is limited in this area, it will tend to elongate the plantar fascia for a longer period of time. This can start adn prolong plantar fasciitis.
It is best to get your workers into a shoe with a firm heel counter, little to no motion at the midfoot area and full easy flexion at the ball of the foot.
Craig as you know i am conducting a large study on plantar fasciitis. So far there are 58 people involved. All have the classic history of the broken glass on standing etc.
Only three have >4.8mm PF thickness as the radiologists say is PF.
They all have had all manner of therapies the only thing no one has had is the shock wave therapy.
They range in duration from 10 weeks to 330 with a geometric mean of 98.8 weeks.
There was a 5 year follow up of PF treatments on 560 odd souls published in the Nov'06 edition of the American Journal of foot and ankle surgery and 18% of participants still had no relief.
So pray tell, where do you get the 4 weeks from?
All manner of therapy = orthotics, stretching exercises, steroids, massage, U name it. All came to a zero in each case.
I agree, none took time off work.
Maybe PF is UK's answer to our RSI of the early 1980's
Thats not even close to a minimum standard of care.
If its acute, some strapping and they usually straight back to work. If subacute, calf and plantar fasica stretching; appropriate foot orthoses; maybe some physiotherapy .... rarely does the symptoms last past 4 weeks (and they keep working).
For the few that don't respond to that, then there is cortisone, shock wave and surgery. Never tried complete rest as never need to.
Thats the minimum standard of care pretty much worldwide, except for the GP's in your area.
In the RCT's we done, we do the first outcome assessment at 4 weeks. Pretty much all (except a couple) show some degree of improvement at 4 weeks ..... so we just expect to see at least that clinically as we intervene more aggressively clinically than in the RCT when only one modality is manipulated.
__________________ Craig Payne
__________________________________________________ ___________________________________ Follow me on Twitter | Run Junkie God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
In the RCT's we done, we do the first outcome assessment at 4 weeks. Pretty much all (except a couple) show some degree of improvement at 4 weeks ..... so we just expect to see at least that clinically as we intervene more aggressively clinically than in the RCT when only one modality is manipulated.
In future, I think that anyone presenting with foot pain / PF symptoms would be best referred by the company to a podiatrist for specialist advice and treatment.
I agree that to be signed off work for complete rest is very impractical and I am very much encouraged by what I hear on this site.
Thanks
Craig;
this is off topic. I've tried to email you a couple of times, but can't seem to get thru. Drop me an email if you will, bwilliams@breakthroughpodiatry.com
Thanks.
Bruce
I have patients who wear work boots and that exacerbates the symptoms.My query:Since they must wear the boots to work,is this not a catch-22?Think of it:The boots aggravate the fascitis but they have to wear boots.
Any advice here?
Having just spent the weekend running through the themes on plantar fasciiitis from Podiatry Arena (most excellent resource) I put together a summary sheet to use with clients.
My understanding of the current literature is no matter what non invasive treatment is prescribed greater success is likely to be found where patients prepare themselves for the first step by toning muscles (calf); and cyclically stretching the fascia.
I would suggest as a preventative measure the simple exercises are ideal as a means of preparing people to stand and walk for long periods on hard (and hot surfaces).
Provided the workboot fits the feet and are designed for the terrain and offer comfort then I cannot think of anything else that could be done.
In good faith I have appended the barebones of the broadsheet for your perusal.
Cheers
Cameron
Sore Heels
If there was ever to be a league of pain then sore heels would need to be close to the top. As anyone who has suffered can attest it is the most debilitating ailment and all the more frustrating because it does not always respond to initial treatment. Proximal plantar fasciitis is the most common cause of heel pain and is now thought to be a degenerative process in soft tissue around the bone. Micro tears in the facial bands are initially unable to heal quickly due to a poor circulation in the surrounding area. Treatments vary with different doctors and 50% of cases get better within 18 months. According to research, that figure can improve to 70% success when patients are willing to participate in a simple set of exercises. Unlike a straight forward injury, heel soreness is a repetitive stress injury complicated by delayed healing and combined with the need to walk. The pain presents at the base of the heel on the sole of the foot. It is often on the side of the arch but not as far as the instep. Rarely is there a specific cause or injury and the condition is likely to arise in fit and healthy individuals who may temporarily change their walking habits e.g. standing for longer than usual or walking on rough uneven surfaces. In some people facial bands tear microscopically due to weight bearing. The planar fascia is a complex collection of fibrous bands which helps support the arch of the foot. At first the damage is often without symptoms and continues until a painful event arises such as changing walking habits. This means damage has been done long before people are aware of pain or seek treatment and this accounts for why the condition does not always respond to initial care. Classically it is the first step in the morning that triggers the pain cycle for the rest of the day. Most try to bravely walk through the pain but this only further aggravates symptoms. With sore heels nature tries to solve the problem during periods of rest and floods the injured area with blood causing it to swell, at the same time connective tissues contract when we sleep. In the morning muscle tone is low and when the foot and leg stretch with the first step of the day tension over the damaged area triggers pain. The same can happen after sitting or after a short period of rest. In recalcitrant plantar fasciitis (a long standing chronic type) the pain gets worse as the day goes on and intensifies at night. Many people have an x ray or MRI of their foot only to discover there is a heel spur (bony outgrowth) sometimes the shape of a miniature Viking horn coming from the base of their heel. In the vast majority of cases this causes no pain, nor is a bony spur directly associated with plantar fasciitis. Both may be caused by the same physical action of stretching the foot but the spur usually lies too deep to become involved with the superficial facial band. Heel spurs can be surgically removed (if painful) otherwise they are left alone. Unlike a straight forward injury, heel soreness is a repetitive stress injury with delayed healing combined with the need to walk and so attention must be paid to tone up the muscles and gently stretch the facial bands before taking the first step, after rest. The following set of simple exercises help prepare the foot to take weight bearing.
Before taking the first step in the morning
Lie flat on your tummy in bed and catch the forefoot of the sore foot at the end of the mattress, gently pull up against the resistance of the mattress and feel the stretch on the tendo Achilles. This will tone up the calf muscles.
Hold the stretch for the count of ten then rest the foot. Repeat the same cycle about ten times. This action stretches the fibres and like a sportsperson warming up, gets you ready to take the first step. It helps is you have a pair of heeled shoes or wedged slippers or thongs ready to step into. This will help with the first step and delay the trigger for pain.
After a period of sitting.
Cross your legs, sore foot over the other knee and with your hand pull your toes gently up towards the shin of the same leg. (this will stretch the tendo Achilles). Hold that position for a count of 10 then let the foot relax. Repeat ten times before you take the first step.
Alternatively when sitting, you may slip your forefoot under the handle of a handbag/carrier bag and gently lift the fore foot against the weight of the bag until you feel the stretch on the tendo Achilles, hold for the count of ten 10. Repeat cycle as above.
Continue to do these stretches three to five times per day.
Unless otherwise advised by your doctor or health care professional incorporate these stretches into your daily activities and this will accelerate healing of sore heels and prevent reoccurrence.
Flexible custom insoles can provide an enhanced fitting and comfort solution which is particularly positive in preventative foot health. They can also contribute to a solution to other issues such as yours [nb I am not a medical professional].
However, in your client's case ensuring correct fit [and ankle stability for rough outdoor surfaces] also plays a substantial role in outcomes, as does sole type. For example elastic sided boots are totally unsuitable in many situations [and have increasing fit / stability issues with boot age]
As both a specialist retailer of Work and Safety Footwear and the Australasian Distributor of the Amfit Computor Orthotics System I have substantial experience across both these areas.
Annual Foot health assessments incorporating precise computer foot shape assessments are also a good preventative and recording tool for any situation where issues may arise. Amfit measures in 1/10mm [actual pin contact] increments - by far the most precise system in the world
We have trialled [and continue to promote] a foot health assessment regime where annual medicals are supplemented by a separate annual foot assessment by a Podiatrist including an Amfit scan and 'prescription' for type of work footwear [and any resulting Amfit custom EVA insoles or Amfit EVA flexible orthoses].
The majority of the trial particiants simply required good quality workwear fitted and all were very positive about it.
Considerations included last /foot type, width, toe space [and nail health!], lining [incl. wicking, breathability and waterproof aspects where appropriate], socks [Big and very understated role, also involves fitting], insole type and charateristics, sole construction and characteristics, overall flexiblility, weight and use. Heating of the foot from strident activity can be a consideration in fitting. Amount of user travel has a substantial effect on type choice in all these regards. Some good workwear is simply not good distance walking footwear.
** General comment - after nearly 20 years in footwear I remain gobsmacked about the number of people who don't bring their orthotics to fit shoes or workboots, and how old most orthotics are. This suggests that many people see them as a one off, where I would like to see people regard podiatry visits like those to dentists. Yes, annual preventative checkups rather than issue visits. I don't know if there is any research on old orthotics by Pod. Associations but it is worrying and could be quite telling.
Substantial Reductions in Workers Comp. Insurance premiums can be achieved for many workplaces with this regular checkup approach, in effect, almost paying for the whole process including the ongoing assessment.
"Management" [often a contradiction!] time with foot / footwear issues is also minimised and review to other professionals is simplified by foot scans being included, as is ongoing case management by including repeat scans. Employee downtime is significantly reduced and workplace health enhanced.
Not so long ago, workwear was always determined by the purchasing officer who simply looked for best $ deal on cheapest work footwear, a false and timebomb economy. For example, until recent years many small factories had assembly workers standing on concrete floors all day in unsupportive footwear. If protective was not required packers often wore their own which was entirely unsuitable. Cold temperature transmission was also a notable issue, mostly overlooked.
The message is now getting through - many companies today use a OC&S adviser like yourself to oversee this and have in the process have realised that buying good quality work footwear and fitting same is in fact cheaper than not on a number of indices. It also has great workplace relations benefits, leading to positive performance / opinion scores in many areas.
We've found substantial success with an employer funded footwear voucher system where the employee presents themself in a defined time period [often on their own time as part of the new arrangements ...] and gets fitted to the specifications on the voucher to a healthy $ limit [part of the new arrangements] and charges the shoes to the account, making up the cash difference if they wish to by premium brands [eg Catapillar - popular amogst the younger males].
Employees love being given choice and this leads to demonstably happier and easier workplaces. It is a regular and loyal market yet to be fully explored by health professionals, but the workplace requires systems and technology.
Craig Payne is spot on when he suggests good quality running footwear [if workplace suitable] because this does involve substantial reduction in plantar pressures.
A paper was done some time back at UWS [Bob Kidd/ Mandy McDonald] which used the Amfit system and the Uni's FScan assessment on just this and concluded notable reductions and benefits in using custom flexible EVA insoles and orthotics in workplace footwear.
If you would like to see this email me off page and I'll dig it out for you. TekScan and Amfit can and do work together in some environments and this is a good example. Bruce Williams [USA] is a recognised International specialist in combining both technologies and visited Australia and spoke at Latrobe in 2005 on this.
However, policy for all this needs to be carefully developed as employees given petty cash will just go to K-Mart and buy inappropriate. Again, a decent value voucher with a suitable qualified supplier is often the best simple solution as OHAS officers then have control, feedback, records and a solid insurance reference if issues arise from non compliance.
Trust all this is of some assistance. I provide it for the benefit of the forum, not commercially, although in this context it is unavoidable some may choose to see it as such.
I might be new at this but in my short time as a pod I have found that a combination of orthotics and stretching exercises has a positive response.
I also like the idea of wearing trainers or shoes with cushioning soles and an arch support.
I was doing a Google search on "Work Boots + Plantar Fasciitis" and came across this thread.
The problem we have encountered with many brands of work boots is that they lack sufficient depth to accept custom or OTC orthoses. If you manage to get the device inside the boot, there isn't sufficient room for your foot.
The USA work boot marketplace is dominated by brands like Red Wing, Wolverine, Timberland, etc. I was at the National Safety Council Show in Chicago a few years ago and walked the floor with a pair of orthotics in my back pocket. I tested several brands, and found most to be very uncomfortable once my orthotics when I replaced their insoles with my orthotics.
Then I came across Europe's best-kept secret - Cofra work boots from Italy. Plenty of depth to accept my orthotics, and much safer than most of the US brands. If you are aware of Cofra boots, then you know how beneficial they can be for foot health and occupational safety. For those that aren't aware of Cofra, it's a brand well worth knowing about. Here's a link to my blog antry and a short video about Cofra:
If you want to prevent these issues we have found the best course of action is to get them in lace up boots or shoes that is lite and fits correctly, meaning no slip and a snug fit all round.
The Bata range, which is available world wide, the style l would recommend is the "Kepler" this product is an ankle boot that looks like a runner and the weight is about half of a normal safety boot as is the price, we sell it here for $95.00.
The shoes on this link are safety(Steel cap) footwear, the top two are the Bata product and yes it is a Dunlop volley steel cap there also
Excluding the Dunlop volley all of these will take an Orthosis with comfort
Work shoes and plantar fasciitis
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