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Muscle strain or plantar fasciitis

Discussion in 'Biomechanics, Sports and Foot orthoses' started by scotfoot, Sep 2, 2019.

  1. scotfoot

    scotfoot Well-Known Member


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    Pain from intrinsic muscle strain and from plantar fasciitis . How do you differentiate between the two and is there a difference in the treatment prescribed ?
     
  2. scotfoot

    scotfoot Well-Known Member

    In some instances it might be quite easy to differentiate between muscle pain and pain from the fascia .

    My understanding is that foot pain is often at its worst for the first few steps after getting out of bed in the morning , so that may be the best time to have the test ( carried out by the patient themselves but only after diagnosis and instruction by a suitably qualified individual ) .

    The test ? Dead easy . You would need a simple board for the foot with a raised ,ramp section at one end for the toes and a non elastic leather strap to hold the foot in place . Before taking those first few steps the patient would place their foot on the board ,located on the floor , with the toes inclined on the ramp . The leather strap would go round the board and the foot , and be fastened to hold the foot to the board . The patient now presses the toes against the ramp section so that the ball of the foot tends to lift off the board but is held in place by the rigid leather strap . The fascia is being unloaded here , whilst the intrinsics are contracting . Pain means a muscular pain source .

    Once again you would carry this out only after expert instruction but in essence its pretty simple once you know how .

    No ?
     
    Last edited: Sep 2, 2019
  3. scotfoot

    scotfoot Well-Known Member

    With regard to the above , it will be understood that if a patient has marked pain with the first few steps in the morning , but the technique outlined does not produce pain when the intrinsics are contracting ,then it is likely to be a fascia based problem .

    Toe curling type exercises are unlikely to be of any use in the test since they principally concern the extrinsics .

    How often is intrinsic muscle damage or insertional tendonitis mistaken for plantar fasciitis ? Given the number of muscles in the foot and the job they perform during the latter part of stance , I would imagine the misdiagnosis happens frequently .

    Any thoughts ?
     
  4. efuller

    efuller MVP

    The first toe long flexor attaches to the distal phalanx. The intrinsics insert, through the sesamoids, into the proximal phalanx. One could theoretically differentiate between them by testing flexor strength with the resistance on the proximal phalanx.

    In regards to misdiagnosis and treatment: The external forces that cause strain on the intrinsics that attach to the sesamoids of the first mpj and the forces that strain the plantar fascia are the same. So, treating one is very likely to help the other, no matter what the diagnosis. Rest, ice, anti inflamatories and an orthotic device designed to reduce force on the first ray would all help both problems.
     
  5. scotfoot

    scotfoot Well-Known Member

    A muscle strain might initially be treated with rest and ice , but progressive strengthening exercises would normally also be involved ,as soon as symptoms began to resolve . Physiotherapists would normally routinely recommend targeted, strengthening exercises for skeletal muscle strains .

    With the foot , I can see some value in being able to differentiate between muscle and "fascia related " problems .
     
  6. scotfoot

    scotfoot Well-Known Member

    Eric ,
    How would you differentiate between heel pain caused by insertional tendonitis /tendonosis and plantar fasciitis ? Also , would you accept that strengthening exercises are a good idea for muscles involved in insertional tendonitis /tendonosis ?
     
  7. efuller

    efuller MVP

    Clinically, the short answer is location. However, that becomes difficult when you look at the location of attachment of the plantar fascia and short intrinsic muscles of the foot. Looking at toe flexors, you could have the patient plantar flex their inter phalangeal joints. Theoretically, if it hurt with the activation of the muscle, it would be the muscle instead of the fascia.

    Thinking towards treatment: injury of the attachment of the flexors versus attachment of the fascia... After reducing stress and pain, I would want to strengthen the intrinsic muscles for both plantar fasciitis and intrinsic muscle attachment pain.
     
  8. scotfoot

    scotfoot Well-Known Member

    Eric ,

    From reading , it seems to me that plantar heel pain on the medial aspect of the calcaneus often bears a striking similarity to medial epicondylitis at the elbow ( golfers elbow ) .

    As you are aware , the intrinsic foot muscles are fairly small , and so it seems to me that they may be more susceptible to damage than the fascia itself ,especially from repeated loading /overuse injury .
    I am starting to suspect that medial plantar heel pain might be due to insertional tendionitis /tendonosis more often than not .

    You said "I would want to strengthen the intrinsic muscles for both plantar fasciitis and intrinsic muscle attachment pain. " and that seems like good sense to me . In particular though , I believe that targeted strengthening and stretching of the abductor hallucis , in combination with the other treatment modalities you have mentioned , may give the best results .

    Even for those who do not believe that strengthening the intrinsics will make a significant difference to plantar fascia loading during gait , and there seem to be many , it must surely be recognized that if medial heel pain is being caused by muscle insertion pathology , then muscle strengthening and stretching exercises should be included as part of any treatment plan .
     
  9. efuller

    efuller MVP

    It doesn't logically follow that since the muscles are small they are more likely to be injured. They are more likely to be injured when the load applied is greater than the load they can handle. Noting that they are small is more likely to support the idea that they are less important than other muscles for locomotion.

    I do agree that strengthening the intrinsics can theoretically reduce load in the plantar fascia. So can strengthening the extrinsics like the posterior tibial muscle.
     
  10. scotfoot

    scotfoot Well-Known Member

    "It doesn't logically follow that since the muscles are small they are more likely to be injured " .

    And yet physiotherapist tell us that stronger muscles are less injury prone than weaker (smaller muscles ) . Yes injury does , as you say ,depend on loading ,but let's not forget that the intrinsics operate in a very high load area and they do so with considerably less functional redundancy than the plantar fascia .

    "I do agree that strengthening the intrinsics can theoretically reduce load in the plantar fascia. So can strengthening the extrinsics like the posterior tibial muscle."

    Agreed , and I would think that of the two groups , strengthening the extrinsics would better support and protect the fascia . However , if pain is being produced by tendonitis at the insertion of the abductor hallucis , then above all others this is the muscle that should be subjected to strengthening exercises .

    From post #2

    The test ? Dead easy . You would need a simple board for the foot with a raised ,ramp section at one end for the toes and a non elastic leather strap to hold the foot in place . Before taking those first few steps the patient would place their foot on the board ,located on the floor , with the toes inclined on the ramp . The leather strap would go round the board and the foot , and be fastened to hold the foot to the board . The patient now presses the toes against the ramp section so that the ball of the foot tends to lift off the board but is held in place by the rigid leather strap . The fascia is being unloaded here , whilst the intrinsics are contracting . Pain means a muscular pain source .

    Once again you would carry this out only after expert instruction but in essence its pretty simple once you know how .

    No ?
     
  11. scotfoot

    scotfoot Well-Known Member

    From above :

    However , if pain is being produced by tendonitis at the insertion of the abductor hallucis , then above all others this is the muscle that should be subjected to strengthening exercises .

    The rational behind this is that muscle damage , or in this case muscle tendon insertion pathology , is known to heal most quickly if the muscle involved is subjected to a programme of stretching and progressive strengthening .
     
  12. scotfoot

    scotfoot Well-Known Member

    Eric , in post #7 you said
    Thinking towards treatment: injury of the attachment of the flexors versus attachment of the fascia... After reducing stress and pain, I would want to strengthen the intrinsic muscles for both plantar fasciitis and intrinsic muscle attachment pain.

    What exercises would you use to strengthen the intrinsic muscles ? ​
     
  13. scotfoot

    scotfoot Well-Known Member

    Plantar fasciitis . Caused by a degenerative change in the fascia or perhaps , in some cases , as follows ?

    Tendon insertion pathology of an intrinsic muscle at the calcaneus -> pain at push off -> gait changes to avoid push off -> reduced strain on the plantar fascia over a prolonged period of time -> degenerative change of the fascia . Is this sequence of events plausible ?
     
  14. scotfoot

    scotfoot Well-Known Member

    Still on the subject of possible links between heel pain ,the plantar fascia , and the intrinsic muscles , reduced muscle strength has been linked to plantar fasciitis /plantar fasciopathy . But which comes first ?

    Plantar fasciitis occurs more often in the diabetic foot than the non diabetic foot . In the development of diabetes related foot pathology , muscle atrophy develops early in the disease process . So muscle atrophy and then heel pain ?

    One study has already demonstrated that intrinsic muscle atrophy can be reversed in the intrinsic minus foot . Could this restrengthening of the intrinsics reduce heel pain ?
     
  15. stevewells

    stevewells Active Member

    Having had a conversation with a superb physio/anatomist/anatomy lecturer and biomechanist on a cadaver based US guided CSI day it would probably be almost impossible to differentiate by testing as the fascia is so strongly attached to the FDB - in fact he made a point of describing to me how difficult it was for him to detach the fascia from the FDB when he prepared the prosection that he was showing me. (Whether that has anything to do with age we didn't discuss).
     
  16. scotfoot

    scotfoot Well-Known Member

    Hi Steve ,

    Fair enough , but since most plantar heel pain is on the medial aspect of the calcaneus and is therefore likely to be , if muscular , at the insertion of the abductor halluces , the FDB need not enter into the equation if only the hallux is tested .

    Still worth looking at on that basis .

    Gerry
     
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