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Plantar Heel Pain

Pain in the heel on the underside (the plantar aspect) of the foot is quite common and can have several causes, but the most common of those by far is the one that you are most likely to have heard of: plantar fasciitis. Other possible causes are fat pad syndrome, fracture of the calcaneus (heel bone), neurological problems and rheumatoid arthritis. The correct diagnosis of plantar heel pain depends on several factors, including whether the onset was sudden or gradual; whether pain is felt under the heel on weight bearing; whether it hurts when there is no weight on that foot; whether there are any other associated symptoms, such as weakness or numbness; what makes it worse and what makes it better.



Plantar Fasciitis


Plantar fasciitis is inflammation of the plantar fascia, which is the connective tissue that connects the heel to the toes. The plantar fascia is between a ligament and a tendon in character; it connects bones, but behaves like a tendon. Plantar fasciitis is caused by a strain on the tissue, often from a recent increase in volume of walking or running or from spending more time than usual standing. It can also result from inadequate cushioning for the sole of the foot. One in ten of the population in the Western World develop plantar fasciitis at some point in their lifetime and it is the most common cause of heel pain.


The pain of plantar fasciitis tends to be felt more on the inside of the heel than in the middle of it and it tends to be worse on the first few steps of the day, walking off during the day and returning after sitting rest. If the condition persists for more than three months, it changes from being an inflammatory condition to a failure to heal and is then known as plantar fasciopathy.


Initial management of plantar fasciitis may include:

  • Wearing firm, low-heeled footwear with cushioned soles, which can help relieve the discomfort by taking some of the pressure off the plantar fascia.

  • Applying an ice pack to the area and/or taking non-steroidal anti-inflammatory drugs (NSAIDs) to reduce the inflammation.

  • The use of strapping or taping to support the area.

  • Firm, off-the-shelf orthotics.

  • Stretching the calf and plantar fascia.

  • Massage to relieve tension in the plantar fascia and to promote healing.

  • Steroid injection is another option and is about 50% successful.


Longer term management options include:

  • Stretching as above.

  • Gait retraining (because the pain may have caused changes to the way that someone walks or runs, which could lead to other problems).

  • Warmth over the affected area to stimulate the circulation and healing, rather than to reduce inflammation at this stage.

  • Custom orthotics if the arches of the feet are particularly flat (pes planus) or high (pes cavus).

  • Massage as above.

  • Shockwave therapy, which can be provided by a physiotherapist or osteopath.

  • Ultrasound guided steroid injection, performed by a medical professional (ideally one experienced in treating plantar fasciitis).

  • Platelet rich plasma (PRP) treatment, which is now also available on the NHS.



Fat Pad Syndrome


One in ten people with heel pain have fat pad syndrome, so it is the next most common cause of heel pain after plantar fasciitis. Fat pad syndrome is experienced as a dull ache in the centre of the heel. The pain is only and always felt on weight bearing, is worse barefoot, is usually only in one heel and doesn’t walk off. It is due to age-related atrophy of the cushioning (fat pad) under the heel and so is most common over the age of forty. It can also occur in people with high arches because the pad may be displaced by the one-sided pressure on it. The pad can also be damaged by traumatic injury. A heel spur (a bony lump also known as an osteocyte) can aggravate an irritable fat pad.



Calcaneal Fracture


If the heel pain is caused by a fracture in the calcaneus (heel bone) it may have come on suddenly after a fall or an unusually long walk or run. Being underweight can cause bones to weaken and so will make calcaneal fracture more likely, as can being overweight, which puts the bone under more strain. A stress fracture can also occur in the calcaneus from increased load of impact exercise. Calcaneal fracture results in heel pain even when not weight bearing and there can be pain at night. Heat may make it worse.



Neurological Causes


A problem in the lumbar spine can cause sciatica, referring pain down the leg to the heel. Tarsal tunnel syndrome in the foot (similar to carpal tunnel syndrome in the hand) can cause heel pain because of the restriction of nerves around the ankle. Usually if there is a neurological cause there will be pain elsewhere in the body and associated neurological phenomena (e.g. shooting pains, pins and needles).



Rheumatological Causes


If heel pain is caused by a rheumatological condition, it will usually be in both heels, with stiffness as well as pain. There will usually be a family history of rheumatoid arthritis or other enthesopathies (pain where a tendon inserts into a bone), so those over the age of thirty will usually have been screened for the condition or diagnosed already.





If you experience heel pain, no matter the possible cause, it is advisable to consult with your GP as soon as possible for a diagnosis and for advice on the most appropriate treatment for your condition. They will also be able to refer you on if necessary for the most suitable ongoing support. And if you are heel-pain free, I hope that you have learnt something here to help you stay that way.

The Top Ten Principles of Qigong

There are several principles of qigong, and in class I tend to focus on one per session, although all of the principles are involved in every class, as one principle feeds into another. The top ten principles that I am going cover here are:

  1. Relaxation
  2. Concentration
  3. Alignment
  4. Coordination
  5. Breathing
  6. Centring
  7. Soft and gentle movement
  8. Balancing
  9. Duration of exercise
  10. Practice.

Relaxation

One aspect of relaxation is to notice tension in the body that we can feel and consciously release, whether that is by sequentially scanning through the body, top to toe, one joint at a time or as we work, regularly checking in with the body. The shoulders can be particularly prone to wander up towards the ears.

Another aspect of relaxation is known as ‘sung’ and is the sense of sinking the weight down through the body, as if hanging from a bar. Peter Wayne in The Harvard Medical School Guide to Tai Chi describes it as the opposite of being uptight “The Chinese character or pictogram for Sung depicts hair contained in a tight bun letting go and hanging freely.”



Concentration

In qigong, concentration should be relaxed, not forced. It is about observing sensations in the body and having moment-to-moment awareness. As such it is a mindful practice. It is through concentrating on what we are doing that we develop body awareness and improve our practice.



Alignment

Alignment is all about minimising effort in any given posture or movement so as not to waste energy or strain the body. This is epitomised in the standing meditation known as wuji, which roughly translates as extreme nothingness. In wuji we imagine hanging from a thread attached to the very top of the head; jaw relaxed; shoulders relaxed; arms relaxed with a natural, slight bend in the elbow; shoulders balanced over the hips; a slight bend in the knees as we feel the weight sinking down through lightly flexed ankles and evenly distributed across both feet. I think of it like pebbles balanced one on top of the other on a beach.



Coordination

I often feel like a puppet on a string when practising qigong and I love the sensation, for example as a wrist and ankle lift together or an arm and leg circle simultaneously. We can coordinate a sense of sung with movements, for example we can feel our weight sinking down through the body as we lower our hands from overhead, either to the side of the body or in front.


Breathing

When we are focused on other things we can forget to breathe, which is why coordinating movements with the breath can be helpful. It can also help keep movements slow and smooth. As Kenneth Cohen explains in The Way of Qigong “One of the ancient names for qigong, tu gu na zin, ‘expelling the old, drawing in the new,’ sounds like a modern description of the gaseous exchange that occurs during respiration… One of the goals of qigong is to maintain the balance and efficiency of this exchange, so that the entire body receives the energy it needs.”



Centring

In qigong we work with three energy centres in the body: the lower dantian in the abdomen between the navel and pubic bone, the middle dantian in the chest near the heart and the upper dantian in the head between the eyebrows. The lower dantian is the most significant of the three in qigong and is the body's center of gravity. “The dan tian both stores qi in the body, like an energy reservoir, and propels qi through the body, like a pump. Dan tian means, literally, the elixir (dan) field (tian), the field of the elixir of long life and wisdom. The qigong master learns to cultivate, nurture, and harvest qi by concentrating on this energy centre,” Kenneth Cohen.



Soft and Gentle Movement

As well as coordinating movements with the breath as mentioned above, we can use visualisation to ensure soft and gentle movement. We can imagine moving through something with more resistance than air, like water or even treacle. It also helps give grace to the practice.



Balancing

When balancing on one leg, whether fully or partially, we employ sung to sink our weight down into the supporting leg, bending the knee and ankle a little more (like a spring being compressed) so that our centre of gravity is lower and our position more stable. We also play with shifting our weight around so that the body gets used to rebalancing even from random or unexpected movements.



Duration of Exercise

All things in moderation as they saying goes and that applies to qigong too. “Each practice should be done over a long enough period so that the body can relax into it - but not so long as to exhaust the physical or mental energy,” Karel and Eva Koskuba.


Doing one practice, whether that is a standing meditation like wuji, a breathing meditation or a moving exercise for 10 minutes has value. You don’t have to spend an hour doing qigong if you don’t have the time or inclination for that. Probably more important is regular practise, ideally at the same time of day. And play around with that to find what time of day works best for you.



Practise

The variety of practices in a session can seem bewildering and impossible to remember, but if you remember just one or two exercises from each class and practise it or them for just a few minutes each day, you will soon build a repertoire and improve over time. You will find that you recognise them in class and pay close attention to them, which will help refine your technique.    




All of these principles are inextricably linked, like organisms in an ecosystem. If this has piqued your interest and you would like to put these principles into practice, you are welcome to join one of my classes, details of which are on my website. Call me on 07528 708650 or email wendy@rookeholistic.co.uk to register your interest.


How to Maintain Safe Levels of Vitamin D All Year Round

In my previous blog post in July, I talked about staying safe in the sun. As mentioned in that post, here I will talk more about vitamin D and how to maintain healthy levels safely.


Vitamin D is important for bone health and muscle strength. It is also linked to immune function. Very low levels have been associated with health conditions such cancer, diabetes, dementia, heart disease and multiple sclerosis.


As SKcin (the Karen Clifford skin cancer awareness charity) explains “Exposure to UVB radiation is the most efficient way for our bodies to boost our vitamin D supply. So, whilst some sun is definitely good for us, over-exposure to UV is a serious health risk, it’s therefore important to strike the right balance.” The sun emits three types of ultraviolet rays: UVA, UVB and UVC. UVA can reach the middle layer of the skin where they can cause skin burn, skin cancer and premature ageing. UVB rays (often referred to as the ‘burning rays’) affect only the outer layer of the skin and are the main cause of sunburn and skin cancer, but also stimulate the vital production of vitamin D in the skin. UVC rays do not reach our skin unless there is damage to the ozone layer.

From the end of September until the end of March, UVB light ray levels in the UK are insufficient for us to make healthy levels of vitamin D in our skin, so we need to supplement with the vitamin, unless our diet already provides adequate levels. It is worth checking labels because a lot of plant milks, margarines and cereals are fortified with vitamin D now, as well as some juices. The NHS recommends that 10 micrograms a day of vitamin D should be sufficient for most adults and children over the age of four. Some health conditions can affect the safe dose, so it is worth checking with your doctor if you are unsure, as too high an intake can be harmful.


From April until September most of us can produce sufficient vitamin D in our skin from unprotected exposure to daylight: from 10 minutes for paler skins and up to 45 minutes for darker skins (the important thing is not to burn). Don't worry, you cannot overdose on vitamin D from light exposure. People unable to ensure adequate sun exposure over the spring and summer are advised to supplement with vitamin D as above.


For more information about vitamin D, you can visit the NHS Choices website or listen to the ‘Get Some Sun’ episode of Dr Michael Mosley’s Just One Thing podcast. Keep well and do get in touch on 07528 708650 or email wendy@rookeholistic.co.uk if I can support you with your health and wellbeing through holistic therapies or qigong.


Five Ways to Stay Safe in the Sun

Having recently trained in the early detection of skin cancer, I wanted to share some of my new-found knowledge with you in the hope of helping you avoid the disease. Skin cancer is the most common cancer in the UK and rates are increasing. The good news is that 86% of skin cancers are preventable and there are a number of simple actions that we can each take to stay safe.


There are several types of skin cancer, some of which are more serious than others. Melanomas (e.g. nodular, acral lentiginous, subungual) are dark tumours that start in melanocytes and are easy to see on the skin or under nails. If left, they spread elsewhere in the body and early detection is key to successful treatment. Non-melanoma skin cancers (e.g. basal cell carcinoma and squamous cell carcinoma) tend to be slow growing and are usually disfiguring rather than fatal, but still require medical attention.


The ultraviolet radiation (UVR) emitted by the sun is carcinogenic to humans and nearly all skin cancers are caused by over exposure to it. The damage is cumulative and has a premature aging effect (wrinkling, sagging and blotching of the skin) as well as increasing the risk of skin cancer. Sunbeds emit the same harmful rays as the sun, but at an even higher intensity, so are not a safe tanning option. A tan anyway is a sign of over exposure to UVR.


Our skin needs some exposure to sunlight to produce vitamin D, but 15-20 minutes a day is sufficient over the spring and summer months, ideally before 11am or after 3pm when UVR levels are lower and less harmful. I will talk more about vitamin D in a later blog post.

 

Prevention is always better than cure and, as I mentioned at the beginning, most skin cancers are preventable. I love the alliteration of the five Ss of staying safe in the sun:

  1. Slip on a top to cover your shoulders as they are most at risk of sun damage, so it is best to keep them covered in direct sun (close-weave fabrics are more effective than thinner ones and fabrics with a high ultraviolet protection factor are better still).
  2. Slap on a broad-spectrum sunscreen with a sun-protection factor (SPF) of at least 30 and with a minimum of four-star UVA protection 20 minutes before sun exposure and re-apply every two hours or after swimming - remember to protect your lips too with SPF30+ lip balm.
  3. Slop on a wide-brimmed, close-weave hat, ideally made with a ultraviolet protection factor (UPF)-rated fabric, to protect your face, neck and shoulders (baseball caps don’t provide sufficient coverage).
  4. Slide on a pair of sunglasses that have a CE mark to ensure a safe level of protection.
  5. Seek the shade, especially between 11am and 3pm and don’t rely on it solely for protection, use the other measures above too.


It is easy to become complacent about sun protection, but it is something that we need to keep working at all through life and it is a crucial part of our self care. As a therapist, I see a lot of people regularly, so I am in a good position to look out for signs of skin cancer, which is why I have done the skin surveillance training. Early detection is key to successful treatment. Better still is prevention.


I have a sun safety booklet available that I can email to you, so do get in touch if you would like a copy (wendy@rookeholistic.co.uk). It is an invaluable resource including advice on both the prevention and detection of skin cancer.


Long COVID-19 and Post-viral Fatigue

There are estimated to be up to 80,000 people with long-COVID in the UK and we are all familiar with the term, but perhaps not that there are different forms of it: post traumatic stress disorder (PTSD) from the experience of intensive care; lasting organ damage; symptoms that vary around the body and post-viral fatigue. It is post-viral fatigue that I am going to focus on here because that is what we can have most control over and even prevent in terms of COVID-19 and other viral infections.


Post-viral fatigue (PVF) is most closely associated with infection with Epstein Barr Virus (glandular fever), H1N1 (swine flu) and more recently coronavirus (COVID-19). Post-viral fatigue is similar to chronic fatigue syndrome (ME) and fibromyalgia.


Symptoms of long-COVID PVF, chronic fatigue syndrome and fibromyalgia include:

  • Unexplained tenderness or pain in muscles

  • Pain in several joints

  • Feeling worse after exertion

  • Sore/tender lymph nodes

  • New headache

  • Palpitations

  • Intolerance to alcohol and/or caffeine

  • Bloating/abdominal pain/IBS

  • Racing mind/unable to switch off

  • Excessive worry

  • Impaired concentration and memory

  • Non-refreshing sleep

  • Insomnia

  • Fatigue.



As self-help author and speaker Louise Hay said, ‘The problem is rarely the problem.’ The symptoms that are perceived as the problem are just the tip of the iceberg; it is the underlying causative factors that are the real problem, and not just in post-viral fatigue, but so many other health problems. It is the adverse childhood experiences, the trauma, the unprocessed loss, the lifestyle and career choices, the toxic relationships, the stress that are the real cause of dis-ease and something like a virus that is the tipping point...


The NHS is increasingly employing health coaching based on the biopsychosocial model to help patients recover from PVF and other fatigue conditions. Role-model medicine also plays a crucial part in recovery as it is important to see that others have recovered and to learn how they did it. Self-care is so important to the prevention of and recovery from PVF and requires a multi-faceted approach to address the causative factors. Gentle exercise, like qigong, and treatments can be a part of that. For more about the qigong classes that I run, see the qigong section of my website. If you would like to schedule a massage or reflexology treatment, you can book through the Formula Health website or on 0118 418 1825.