'Inflammatory' vs 'mechanical' plantar fasciitis

Hi Paul


I just sat down for 10 minutes a tried differentiating the AB HAL, FHL and PLF. What I think I noticed was this;

When I slightly dorsiflex my Hallux I can clearly differentiate the central thickened band of the plantar fascia easily, when I then plantarflex my Hallux I can feel AB HAL contract medial to plantar fascia and easily see it’s short axis expansion on medial side of calcaneus.

If I allow the Hallux to slightly plantarflex against resistance I can feel the FHL pushing against the underneath of the plantar fascia. Best spot seems to be between points 2 and 3 on the attached image.



Any suggestions regarding location of a “sweet spot” in relation to the image?

I will go and look at this with US next week and see how this appears, hopefully be able to identify some tendon motion, I have never tried this before.

If I understand you correctly then subjects with FHL contractures will have tighter than normal palpable FHL tendons and likely absence of AB HAL contraction with resisted Hallux plantarflexion.

Please could you confirm this is your notion?

This being the case, please elaborate on how you see this foot effecting function and how it relates to heel pain, also I did not understand your therapy, are you treating TrPs or somehow treating contractures?

Thanks

Martin
The St. James Foot Clinic
1749 Portage Ave.
Winnipeg
Manitoba
R3J 0E6
Phone [204] 837 FOOT (3668)
Fax [204] 774 9918

 

Paul

In a previous posting I mentioned that after examining over 100 plantar fascia insertions I had yet to come across a single case where inflammatory signs were detectable with power doppler.

Last week I examined my first case of unequivocal chronic plantar fasciitis. What was clinically striking about this was that with physical exam the amount of pressure required to cause pain was very low ( I measured it at around 5 N/cm2, range of pressure thresholds for chronic plantar fasciosis I find to be between 80 and 180 N/cm2).

I was interested to find this firstly because it suggests that US with power doppler is likely sensitive to demonstrate inflammatory change within plantar fascia (as opposed to at enthesis) and also to see how the location corresponded to changes in plantar fascia thickness and also cross sectional changes.

The image, because it only shows a single slice doesn’t illustrate that the entire thickness was effected although this is only apparent with a slow coronal scan through the region.

I am posting several images to illustrate US appearance of normal and typical non inflammatory appearance of plantar fascia. (quality is degredated because of files size limits but still make sense, also had to add one to next post because of restrictions of server)

What I am curious about is that you seem to suggest that these findings are really irrelevant as clinically significant findings.

Although you may be right, I feel the probability that you are is low because typically in cases of unilaterally pain the painful side shows abnormal thickening vs abnormal (ie > 4.8mm) on symptomatic side.

What I find perplexing though is that typically with pain resolution there is, at approximately 4 week follow up, little visible change in plantar fascia measurement with US.

Perhaps you also have some insight into this observation.

One suggestion which has been made is that my US examination is not sensitive to very low levels of inflammatory change which may be undetected in the majority of my PHP exams.

Whilst this may be true, I feel this to be unlikely given that I have been able to detect increased flow using same sensitivity setup in synovial tissues and tendo-achilles which were minimally painful.


Cheers

Martin


sThe St. James Foot Clinic
1749 Portage Ave.
Winnipeg
Manitoba
R3J 0E6
phone [204] 837 FOOT (3668)
fax [204] 774 9918
www.winnipegfootclinic.com

 

Dear Martin

I agree entirely of your 100 hundred findings but not in this case.

May I say if you only need to use the pressures you quote to elicit pain, then you are only compressing the skin, OR more importantly there are referred pains from the Tibialis posterior muscle.

I have seen your wonderful dopplers, but they to me look more like haematoma than tendinitis.

May I stand corrected but please let me know of your thoughts. I have never seen doppler look like this here in the P/F. BUT I am willing to learn . I like new things.

Musmed

 

Dear All

Funny thing. Stanley writes outside the square, ie lateral thinking put into a diagnosis of heel pain and the thread dies. Sad.

I agree with Stanley's diagnostic chart exactly. I would add foreign bodies, fat pad wasting,nerve entrapment by a hypertrophied Abd hall muscle.

I recently performed 15 MRI's bilaterally on 15 patient's with PF.Only 3 showed bony oedema. The PF thickness was only 3.8 mm on average.

I am convinced that PF thickness has nothing to do with the problem. Currently my longitudinal study (which finishes in August 2008) has shown that PF thickness and pain don't matter.

Martin stated at 1 year follow up there is no difference in thickness despite the patient being better. I have some preliminary data that shows there is a difference and the dividing factor is age of the patient.

Finally here is a paper I wrote on Complex Regional Pain.It has been abridged down to a few pages from the 50 odd it was.

Hope this helps one understand the difference between allodynia and hyperalgesia and the role in complex regional pain syndrome.

Regards
musmed

 

Dear Martin

Second go.First went to the ethers...

I am treating short muscle. I presume the FLH increases it's tone (what ever this is) so as to help pull the foot up on the medial side.

Palpation is always tender. Yes the FLH will be tender and taut in these with no action by the abd. hall.

The U/Sound wills how the FLH very nicely along your 2-3 markings in the diagram you posted.

The treatment protocol is to
1. sit facing the patient leg near the foot. eg for right foot.
2. use a cold spray eg ethyl chloride, spray from origin to insertion.
3. rapidly with your left hand,grasp the toe
with your right hand grasp the dorsum of the foot.
4. pronate and plantar flex the foot
5. quickly dorsiflex the great toe to end range
6. move the foot into full dorsiflexion and supination.

Basically you have placed the muscle on full stretch.

Yes I hear you all .You are saying I am stretching the PF. Am I?

Do this twice and retest. You will find their foot pain gone.

These people are not in my PF study (despite their story being consistent with PF). It is up there with the commonest cause of heel pain I know.

Try it and let me know of your wins!

musmed

 

Kevin

If you slighty dorsiflex the foot and do as I have written, the PF is not tight the FLH is in these patients.

Try doing what I said in a range of patients. You will find those that have no palpable band while in others it will be easily palpable and often visible when the patient's foot is looked at during inspection.


I have been doing this for years and teaching it a recently as last weekend in Canberra. The podiatrists there agreed with what I am saying. There were two people with this problem and both had cessation of foot pain after performing what I have posted to Martin.

Regards

musmed
Paul Conneely

 

Hi Paul

I took the liberty of starting a new thread to seperate out your ideas from those before since I felt this benefited a seperate discussion. Unfortunately your further reply crossed over mine - anyhow I will add the new stuff (Craig I hope I am not stepping in your toes here) and carry on FHL specific topics there once I have mulled your additions over.

New threat is called

"plantar heel pain and Fl Hal Long Dysfunction"

As far as my ultrasound images are concerned

I do not think this case demonstrated a haematoma because:

the power doppler (PDI) showed pulsitile motion suggesting that vessels were being detected not a static pool of fluid.

the imaging was done several weeks after onset of pain

with compression the PDI signal almost disappeared, again suggesting imaging of neovascularised vessels.

the pattern of PDI signal was very random when scanned both saggitally and coronally and confined to plantar fascia. My expectation of a haematoma in this region would be as simple anechoic or compex hypoechoic reflection which would be less minutely dispersed and not confined so neatly to the plantar fascia boundries.

Also there was no hint of ecchymosis visible.

Interestingly I saw another case today which I regarded as true fasciitis with what I interpreted as visible neovascularisation within the plantar fascia.

I have recently started imaging transverse sections which I have not seen done in the literature.

My idea was to try and get a better 3D appreciation of calcification and it's relationship with FDL and ADD Hal.

I captured a very clear image which showed Add Hal with the laterally adjacent central band of the plantar fascia with focal degenerated portion with vascular elements. I will post this for your scrutiny

cheers

Martin'

The St. James Foot Clinic
1749 Portage Ave.
Winnipeg
Manitoba
R3J 0E6
phone [204] 837 FOOT (3668)
fax [204] 774 9918
www.winnipegfootclinic.com

 

Paul



Just a correction here

The US follow ups I mentioned are generally at one or two months, I have no observations to report for one year.

Also I am curious with your MRI findings which are different, as a generalization, from what I am seeing on US.

Most people I see with unilateral plantar heel pain have a very typical unilateral fusiform thickening (> 4.8mm) of plantar fascia compared to asymptomatic side (range 2.5 - 4.8mm) which is entirely consistent with many published papers in terms of appearance and measurement.

What is lacking in literature are studies which include power doppler imaging for plantar heel pain.

Whilst I agree it is possible that the appearance and thickness may be incidental to the pain generator I feel that the corellation seems uncomfortably high for this to be likely.

great to compare notes with someone doing some soft tissue imaging for plantar heel pain

cheers


Martin


The St. James Foot Clinic
1749 Portage Ave.
Winnipeg
Manitoba
R3J 0E6
phone [204] 837 FOOT (3668)
fax [204] 774 9918
www.winnipegfootclinic.com