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Abductor hallucis injury vs plantar fasciitis

Discussion in 'Biomechanics, Sports and Foot orthoses' started by footdoctor, Apr 6, 2012.

  1. footdoctor

    footdoctor Active Member


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    Hi.

    Maybe this is nothing new and I apologise if i'm going over old ground but its bugging me.

    How do you differentiate an overuse injury/tendinitis/tear/trauma of the abductor hallucis muscle from plantar fasciitis?

    Got me thinking after Kevin recently posted the emg graphs earlier.

    It showed that abd hallucis fired for longer in the flatfooted subject.

    Aetiologically similar, anatomically similar, symptoms similar. .....

    How often have you been sent a patient with suspected tendinitis of the abductor hallucis vs referral for plantar fasciitis.? I have never even had abductor hallucis mentioned in a referral.

    I know for one that paul connelly believes the majority of suspected plantar fasciitis cases are in fact due to TP's in abductor hallucis muscle.


    Thoughts?

    Scott
     
  2. efuller

    efuller MVP

    Abductor Hallucis and the plantar fascia are treated pretty much the same mechanically. So, in terms of treatment, you wouldn't do too much differently.

    Eric
     
  3. Shane Toohey

    Shane Toohey Active Member

    Thanks Eric,

    Eaxactly as you say.

    Only I'd also like to add that including the release of trigger points, if existing will expedite the recovery. This can be achieved a number of ways including manual means and or by using an acupuncture needle. Follow up with stretching abductor hallucis and heat packs.

    Cheers
    Shane
     
  4. Still intrigued by this concept of trigger points and your response here is bang on Shane: "if existing". Can someone show me the evidence for the existence of "trigger points"- maybe something on MRI, Ultrasound, thermal imaging... anything :pigs: What does a "trigger point" look like under modern imaging, and why can't two clinicians agree on their location? I'll pull the references if you want. Not saying they don't exit, just displaying a healthy skepticism.
     
  5. Shane Toohey

    Shane Toohey Active Member

    I'd say that I have always been a sceptic about most things, Simon, and have a need to prove things to myself as well.

    Can't say that I'm the sort of person who would be using this approach for 20 years if it didn't work. The only reason I bothered was because I wanted faster results and more complete outcomes.
    When I said, 'if existing', just to be clear, I was talking about on a case basis and obviously only treat them when they can be located - no triggers leads to no trigger point treatment. I'd suggest that I'd expect two experienced clinicians who regularly treat TrP's will generally be able to agree on the location of trigger points and I think that there have been trials to this effect.
    Personally, if an experience clinician told me that they can reasonably often obtain a marked (~80%) and sustained reduction in one of the most common presentations of heel pain by releasing tight bands in abductor hallucis in a few minutes by inserting acupuncture needles, I'd be rushing to see someone do it and try it out myself. If I was getting results I'd continue and if not I'd stop.
    There's no harm done.
    Meanwhile, "An Introduction to Western Medical Acupuncture' by Adrian White et al has a chapter on this with references.
    Locating and releasing trigger points is a practical skill, so some are better than others and most get better over time anyway.
    Most practitioners who learn the skills regard the techniques as having caused a revelation in their thinking and clinical outcomes.
    Perhaps one time when in the UK we can catch up with a few patients and do a practical session as I think no matter what I say it won't make much difference and seeing may be more helpful.
    Thanks for your comments.

    Cheers
     
  6. Dananberg

    Dananberg Active Member

    This is an interesting subject. I have differentiated plantar fasciitis from abd hallucis issues for the last few years. On exam, the insertion of the PF is painful when plantar fasciitis is truly present. However, if this is an abd. hallucis spasm, then there is also pain superior to the fascia (from the bottom up) within the muscle.

    For treatment, I have not found anything more superior to manipulation of the cuboid. The lateral column in these feet show extremely resisted dorsiflexion. Once the cuboid is properly mobilized, the lateral column returns to its normal ROM, and the spasm spontaneously resolves. Watching patients stand and exhibit no symptoms immediately is quite the joy.

    At times, both PF and abd hallucis spasm co-exist. For these cases, other methods of care (orthotics, meds, injections) are required for resolution.

    Howard
     
  7. Yep, great Shane, I guess you're selling courses in the UK at the moment? In the meantime: because "it works for you"; I don't think that is good evidence... I got patients who swear by homeopathy. Any way, I was asking about references which show the existence of "trigger points" using modern imaging? Since, I'm guessing, you are providing courses on "trigger point therapy", could you provide references in which "trigger points" have been positively identified using modern imaging technology?
     
  8. musmed

    musmed Active Member

    Dear Scott
    How often does one blame muscles for anything! I read a paper yesterday stating that lumbar spine muscles when probed NEVER hurt! Crap.
    When in medical school 45 years ago it was drummed into your head that 2 words you must not use are never and always because they will come back to bite you.
    Some of the most tender and sorest muscles I see are the quadratus lumborum when prodded with an acupuncture needle.

    When I bring up the abd hall's thing in radiology practices the staff have to get out the anatomy books to look it up although they have been imaging the PF for 20+ years or more. Funny or sad, but true.

    Your eye will only see what your brain will allow.

    The abd hall only fires when the 1st MET base hits the ground. The only foot muscle to do so. All the rest aim to drive the 1st MET into the ground.

    Forget about abd hall's name. It is an anatomic name. Too many out there try to use (or never think about things) in a biomechanical sense. If you want to get good at this topic, start thinking along these lines.

    The abd. hall has multiple functions, the least of which is great toe abduction. The only people I know who can abd the great toe are beach sprinters. They can move it like a wind screen wiper. The control is about 30 degrees. Quite strange to see this.

    Now: if the abd hall fires when the great toe hits the ground what is it going to do?
    It is trying to pull the great toe to the calcaneus.
    This then puts the PF on slack,
    The muscle eccentrically relaxes and thus slowly puts the PF on stretch and thus stops damage to it.
    I have yet to see a case of PF where the patient has total control of the muscle.

    Thus a flat foot will take longer to elongate and thus have a longer EMG firing pattern.
    It would be nice to repeat such a show on normal and flat footed people who have PF.
    I can bet the image would be totally different.
    maybe some one out there is after a PHd and here is one.

    Regards from an early winter (snowing in the Alps)
    Paul Conneely
     
  9. Shane Toohey

    Shane Toohey Active Member

    Simon,

    Who do you think you are?

    I arrive next week. I don't expect more registrants. Overall the workshops are full. May come back in 12 months or so. Feedback has been positive from previous workshops with folk being happy with improved outcomes.

    I see no possibility of you ever engaging in a discussion in good faith :pigs: so will not bother ever engaging.

    Shane
     
  10. A podiatrist, scientist and skeptic who doesn't buy just anyone`s cockatoo, with no vested interest in "trigger point therapy"... and you?



    Travell and Simons defined trigger points as the presence of exquisite tenderness at a palpable nodule in a taut band of muscle. The problem is that inter-rater reliability is generally poor in identifying where these "trigger points" are supposed to be:

    http://terapiamanipulativa.com.br/Myofascial trigger points.pdf

    I quote:

    "In summary, the diagnosis of trigger points relies on finding a local tender spot within a taut muscle band, reproduction of recognisable symptoms, and a local twitch response to snapping palpation or needle insertion.
    There are, however, several caveats to bear in mind when establishing examination findings, not the least of which is the lack of a gold standard for assessment of trigger points. This lack of standardised assessment makes validity studies near impossible, although reliability trials have been performed. Wolfe et al. (1992) examined patients with chronic myofascial pain or fibromyalgia, and the most common finding in their subjects was local tenderness and taut muscle bands. Reliability of examination for taut bands, muscle twitch, and active trigger points, however, was problematic.
    In a blinded trial of physiotherapists experienced in treating lower back pain (Nice et al., 1992), the reliability of assessment for the presence of three trigger points described by Travell and Simons was poor and it was noted that issues as simple as patient positioning, palpation technique, and the amount of force applied significantly influenced results. Of interest, reliability was not improved when the sample was reanalysed for only those therapists reporting the use of trigger point examination in their routine practice.
    In a more recent study, Lew et al. (1997) found that both inter and intra-rater reliability, using two highly trained examiners for assessment of the presence and number of trigger points in asymptomatic patients, was poor. In a study by Gerwin et al. (1997), it was found that extensive training of four clinicians together resulted in improved reliability of identification of trigger points. In a study by Hsieh et al. (2000), it was reported that localisation of trigger points was unreliable in untrained examiners, and only marginally more reliable in trained examiners. Further, Hsieh et al. (2000) found that taut band and local twitch responses could not be reliably assessed, and examination for referred pain had low reliability when extensive training had been undertaken, but was not at all reliable without this. Another study has shown moderate reliability for the presence of local tenderness and production of recognised pain, but poor reliability for twitch responses and the production of referred pain (Njoo and Van der Does, 1994)."

    And moreover, why should something that is "palpable" be pretty much invisible to modern imaging?

    "Currently, there is no gold standard pathological test for the identification of trigger points. Therefore, much of the research into the pathophysiology of trigger points is directed towards indirectly verifying the common theories for their formation. Histological studies have been inconclusive, with either non-specific changes of fibrosis and absence of inflammatory cells, or negative findings (Yunus et al., 1986). Imaging of trigger points has not been shown to be reliable with thermography (Diakow, 1988; Swerdlow and Dieter, 1992), or ultrasound (Lewis and Tehan, 1999)."

    Now, the review paper I quoted from is a little dated, perhaps Shane you could provide newer references which have demonstrated a reliable "gold standard" pathological test for "trigger points"? As it stands it seems that no-one can provide validity studies, because trigger points are "invisible" and two independent "highly trained" clinicians can't agree on where they are supposed to be located. As you know, "improved outcomes" can occur for many reasons, one of which being that the patient wants you to stop sticking needles into them.

    Here's the Cochrane review for the acupuncture treatment for pain: http://www.bmj.com/content/338/bmj.a3115.full

    It concludes: "A small analgesic effect of acupuncture was found, which seems to lack clinical relevance and cannot be clearly distinguished from bias. Whether needling at acupuncture points, or at any site, reduces pain independently of the psychological impact of the treatment ritual is unclear."

    Viz. when something has questionable clinical validity, reliability and efficacy, I believe we should all be sceptical. I am; especially so when someone is selling something based on this. I hope your courses go well, Shane.

    "16th of June 9:05, door bell rings, man at the door says if I want to stay alive a bit longer, there`s three things I need you to know...three! Coming from a long line of traveling sales people on my mother's side, I wasn`t gonna buy just anyone`s cockatoo, so why would I invite a complete stranger into my home?...would you? These days are better than that, these days are better than that..."

    http://www.youtube.com/watch?v=xGurpsGKPCg
     
  11. Lorcan

    Lorcan Active Member

    I also was very skeptical of dry needling until a patient with a PF I couldn't sort over 3 months was resolved by 2 appts with an acupuncturist. This got me intrigued and I did a course with a dose of skepticism. This was dispelled when I was able to resolve another PF over 8 days that I couldn't over the previous6+ months.
    Use it still combined with classic podiatry mobs etc.
    My pts don't care whether I have a reference or not, all they want is to get better and that's what I want too, if there is a ref great but not a deal breaker. I recommend anyone who hasn't tried it to give it a go with a healthy dose of skepticism as Simon suggests. You may be surprised.
     
  12. Shane Toohey

    Shane Toohey Active Member

    Simon, you continue your personal attack on me, which I find offensive.
    I do provide practical training in various skills with the only pity being that it is to small groups. I could definitely make far more income by staying in clinic and pumping out orthoses all day to every person who walked in the door instead of providing the generally low cost treatment that I provide.

    When confronted with heel pain ("plantar fasciitis"), I must admit that aprt from attempting to release the trigger points that I find and which may be involved, I do also often use manual therapies and orthoses, sometimes even custom made devices. This is despite the fact that Cochrane does not support the use.

    So I am doubly blighted or even worse.

    As mentioned previously, I treat my punters as single case studies and treatment proceeds according to the particular presentation and involves a variety of modalities and changing direction/thrust according to the response. This may even sound a little 'scientific'. I'm commonly treating the ones who have had very prolonged ineffective treatments.

    The article you quote is a literature review by a physiotherapist, published online in 2003 and quoting quoting studies from the 80's and 90's. You have selectively quoted form some of these.
    The final conclusion of the article stated:

    I'm done! Life's too short.
     
  13. It also said "Studies of invasive treatment utilising a placebo intervention have not found the active treatments to be any more effective." but I guess you selectively skipped that bit.

    Quite frankly I find your "who do you think you are?" pretty aggressive and somewhat offensive too, Shane. I asked if anyone knew of references which validated the existence of trigger points using modern imaging.... I guess there still are none. By the way, the paper cited was published in 2004, the date is at the top.
     
  14. Shane Toohey

    Shane Toohey Active Member

    Nothing more to add Simon, pointless, other than you threw the ****e first.
     
  15. PodAc doc

    PodAc doc Member

    Ballyns JJ, Shah JP, Hammond J, et al. Objective Sonographic Measures for Characterizing Myofascial Trigger Points Associated With Cervical Pain. Journal of Ultrasound in Medicine 2011;30:1331-40.

    I am sure there will be more, when people open their minds to possibilities beyond the familiar, and fund the relevant research. However, my understanding of a trigger point is that it is a functional abnormality, not a structural one, so I would not expect instrumental imaging to be definitive.

    While Plantar Fasciitis is a notion that has become reified by academic habit my clinical experience suggests that PF is not a unitary phenomenon. It seems to me that the syndrome we label as PF (or PHP for preference) can result from a variety of causes, which are not mutually exclusive. Like the stress response, it is a complex phenomenon, and those who expect a simple cause-effect relationship are likely to be disappointed. This does, of course make it harder to research.

    However (to be reductionist for a moment) one relevant factor is the presence of TPs in the AH muscle. If they are present then treating them is likely to be effective (and, as Shane says, you need to address the causes as well, for sustained benefit); if they are not there, then one needs to look further.

    I guess we will know more when Cotchett et al publish their results:
    Cotchett MP, Landorf KB, Munteanu SE, et al. Consensus for dry needling for plantar heel pain (plantar fasciitis): a modified Delphi study. Acupuncture in Medicine 2011:11pp. doi:10.1136/aim.2010.003145.
    Cotchett MP, Landorf KB, Munteanu SE, et al. Effectiveness of trigger point dry needling for plantar heel pain: study protocol for a randomised controlled trial. J Foot Ankle Res 2011;4:5.

    Richard
     
  16. PostMortem

    PostMortem Active Member

    Hi all

    I have posted very few times on Pod Arena, shy and retiring type! But I have thoroughly enjoyed following some of the topics that have been discussed and have learned a great deal.

    Initially I was excited to see this topic being raised for discussion. I have been very suspicious of the PF Dx as this is an area of the foot that is very complex both in its structure and function, why, when there are so many structures in this area would the PF be the only structure to be so severely affected?

    I am not an academic, some of the discussions on Pod Arena make my brain hurt! I like to be able to convey to my patients, in terms they can understand, what is happening and why. Much of which severely simplifies the complex mechanics and pathology that is going on, but I don’t think my patients care. What they do care about is having some understanding of what is going on, so the Tx makes sense for them to follow and persist with, especially if rehabilitation of an injury requires hard work!

    So, I was very disappointed to see this discussion descend so rapidly into a kinder level mud slinging match. Shame on you!! Some of the most knowledgeable and respected practitioners within our profession behaving like toddlers, it’s embarrassing. :craig:

    Simon, where’s the evidence? This is a very relevant question and should be asked and acknowledged, but if every subject of podiatry and a great deal of medicine was required to provide the level of evidence you continually ask for before useful discussion or implementation then we would be out of a job cause we would be able to do very little! That is not to say we should not strive to get the evidence.

    Shane, as an educator of a technique that is wobbly on evidence, be up front and put it out there, what are the theories/hypotheses on what trigger points are? How is the specific treatment you use, in theory, impacting on the soft tissue?

    It took less than 10 post to hijack the original question, either go to your room and don’t come out again until you can behave like grown ups, or get back on topic and make this the exciting discussion that it could be. :bang:

    Speaking to a physio colleague, there is an acknowledged lack of evidence for what Trigger Points are, but apparently it is being worked on. Until then, can we theorize/hypothesize about the influence of focal areas of pain that can be found in soft tissue (trigger points, for want of a shorter term) that respond to physical therapy? While we are at it, what about the influence of Flexor Dig Brevis or Adductor Hallucis in this equation? And are the short/medium/long term treatments the same or muscle injury and ligamentous injury?

    My apologies if this seems a bit OTT, but so many useful discussions recently have been hijacked in this childish way, I don’t know whether to quit Pod Arena or put it forward for its own TV show, can see it challenging Days of Our Lives!!
     
  17. Shane Toohey

    Shane Toohey Active Member

    Fair comment Post Mortem,

    I made a small contribution to the discussion and was immediately slurred and insulted.
    I defended myself and am still annoyed about it being required.

    I'm willing to have a discussion in good faith but have got better things to do than have a slang.

    The evidence is not gold standard and there is incredibly little of that kind of evidence for almost everything that podiatrists do. So we can face up to that or not. Whoever said that trigger points can be proven through imaging.

    The punter comes in with a painful problem that is seriously affecting their health and quality of life. I think we use every bit of information and techniques that we have to help solve the problems.

    If we only used evidence based treatments then we would not be allowed to do anything other than talk to them.

    I am a clinician and teach practical skills and am continuously trying to expand and refine what I do.

    So, if you are interested in my opinions I'm happy to discuss them and you can think about them. Most of the time we are working with hypotheses and they are subject to modification or even outright rejection over time.

    Anyway, cheers
    shane
     
  18. davsur08

    davsur08 Active Member

    Ballyns JJ, Shah JP, Hammond J, et al. Objective Sonographic Measures for Characterizing Myofascial Trigger Points Associated With Cervical Pain. Journal of Ultrasound in Medicine 2011;30:1331-40.

    Just a thought, wonder how a radiologist will interpret this "large mass with increased vascularity" what the authors defined TrP? certainly not as a trigger point. Shah et al published this review https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4508225/pdf/nihms-695755.pdf in which he stated and i quote "To date, the pathogenesis and pathophysiology of MTrPs and their role in MPS remain unknown........ Investigators also demonstrated that dry needling provides symptom relief and change in the status of the trigger point, although the mechanism by which this works has not yet been demonstrated."

    The day we stop asking questions is the day we stop learning.
     
  19. musmed

    musmed Active Member

    Dear David
    I first took dry needling to the UK in 2004 and Shane and I were packed out.
    The Pod society told us that we could not teach above the lateral malleolus. I hope they have improved their scope of vision since.

    I spent over 3 years dry needling the abd hall in patients that had the classic history of getting out of bed one day - spent 7-8 steps to stop the pain while at noon it only took 3-4 steps. that was the criteria. We ultrasounded their feet at about 8am and 12 noon. What we found was that it took 7-8 steps at 8am to activated the abd. hall. while at noon 3-4 steps.

    iIwondered why. I looked at the work by Vladamir Janda and there was the answer. Muscle tone. it is lowest when we get up and improves to a maximum when we are what we call fully awake plus 30 mins. By this I mean when you feel you are fully awake.

    I looked at the abd. hall and we needled the muscle- we took measurements at 0 mins when the muscle was needled and every minute till 10 and when they returned at 3-4 weeks for follow up.

    68% immediately lost their pain- the same results as shockwave therapy and Adjervic (sorry for the spelling) medicine.

    The abd hall not only changed colour from a deep-grey-black to normal (school boy grey colour) in those 10 minutes but also reduced its cross sectional area (between the medial malleolus and navicular) on average 12.8% in those 10 minutes and at follow up another 2.4%.
    I had radiology experts view the films and they agreed that the changes were not due to oedema fluid loss from the muscle abd hall.

    I still have all these results. my website www.musmed.com.au has graphs there on what happened.

    Yes trigger points do exist and are treatable with immediate results- not later but immediate. as Janet Travell the founder said the reason why people do not find trigger point is that they never put the muscle upon enough stretch. Once stretch is added the triggers arise and are easily found.

    Do not worry, as Galileo said, 'if they would only look down my telescope and they would see.'

    When I first took this to the globe outside of US, I was put down by the 'experts'.
    For something that the 'experts' say does not work, it is amazing how many people will travel the globe from Europe to Sydney Aus. to see me for something that does not work.

    All the best,
    Paul Conneely
    www.musmed.com.au
    0 degrees last night for the first time ever, with a nasty frost.
    exactly what global warming said would happen.
     
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