Henderson’s foot

Plantar fasciitis is a lot like a tendon problem

Foot prints. Vector watercolor illustration

Liverpool footballer Jordan Henderson is suffering plantar fasciitis. His manager, Jurgen Klopp, is monitoring his progress but cannot confirm whether Henderson will be able to play again this season ~ report here. Lower limb injuries and pain are an occupational hazard for footballers, particularly those who make a career from the game. Here are some important considerations.

Pain and injury

Pain and injury are not the same. Are you injured? Or does it just hurt? An injury can be from an inciting event such as a twist or contact with another player. Or it can a ‘slow burner’ when there is a gradual breakdown of tissue. The point that this is detected by the body systems that protect us and interpreted as dangerous is the pain moment. It can take a long time for this to brew into something conscious. You will note from this that there are at least a few layers of activity before we actually feel pain.

Pain and injury are poorly related. We have known this for many years both scientifically and anecdotally. Yet the predominate message in society through implicit thinking is that pain must be due to an injury. Then the search for a structure begins. Pain is a body state of protection, compelling us to take action. A motivator if you like. Pain is poorly related to the state of the tissues. Consider phantom limb pain when there is no limb yet there is pain in a space. The body systems and our brain, which has a significant role in all conscious experiences including pain, work on a just in case basis. Recognising patterns, drawing on past experiences and predicting what the sensory information currently suggests are all part of the processing that underlies our lived experience. Pain does not have a simple physical basis.

The injury moment

At the point when an actual injury occurs, the context plays a big role in what happens next, as does past experience. In this moment there is a rapid assessment of threat. If the weight of evidence suggests danger, then it will hurt. If something else is more important, such as escape or wanting to win the final, it is quite possible for the pain to be minimal or non-existent.

There are other factors that play a role in the processing: where am I? What am I doing? How am I feeling? Who am I with? Have I been here before? What does this mean?

The meaning of foot pain to Henderson is very different to the meaning for me. For me it would be unpleasant, inconvenient and prevent me from being as active as I might otherwise be. For Henderson, it means he cannot work, therefore impacting upon his career. This then, would be far more threatening and hence create a context for more protection. It would be similar if a violinist injured his or her left hand compared to the right. Meaning is key and must be considered.

Persistent pain

Problems that involve tendons, and we can include plantar fasciitis here, typically go on for months. There has been huge amounts of research and work undertaken to look at this problem, most of which has focused upon the tissues themselves. Whilst tissue health and tolerance for force is important, a much wider approach is needed starting with recognition that it is the person who feels pain. This being a fact, it points us towards addressing the person as much as the condition, and even more so thinking about how that person uniquely interacts with the condition. There is a key interface.

Most of the biology of pain is not where the pain is actually felt. Much like the film you watch in the cinema involves much more than the screen. The adaptations that occur in chronic pain are in the emotional centres of the brain, the connectivity between the thinking and planning areas and emotional centres, and in the sensory areas. We are more than a brain of course and all the habitual changes we observe and those that occur in the dark (e.g. neuroimmune) somehow emerge as a lived experience. This delves into questions of consciousness and self.

To address plantar fasciitis then, we need to think about a range of factors, beginning with the person’s understanding of their pain. This understanding sets the scene, reduces fear and promotes engagement in the training and practices needed to overcome the problem. We have to create the conditions for this to happen, which is why the person needs to focus on a clear direction and the means to achieve this. Fears, worries and anxieties will of course intervene, but the more quickly this energy can be transformed into the practices of well-being and specific training, the more efficient will be the recovery. Just as an insight, practices would include body sense training, proprioceptive training, nourishing movements and mobilisations, sensorimotor training, mindful practice, graded exercise (strength, endurance etc). But this is all based upon a mindset focused on success, so the practices of resilience and attention come into play. The aim is sustained learning and change to overcome the problem by facing it and transforming it, not trying to get around it by just using pills, injections and other means of avoidance.

Looking back through the story and knowing the person creates the opportunity to understand how the problem emerged in the case of a slow burner. An acute injury can also be analysed to discover if there were any factors increasing the vulnerability to injury and indeed vulnerability to develop a more persistent problem.

In summary, the bigger picture is always important. Considering the person as much as the condition and ensuring that pain is understood. Understanding pain is the key.