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Effect of different orthotic concepts as first line treatment of plantar fasciitis

Discussion in 'Biomechanics, Sports and Foot orthoses' started by NewsBot, Feb 19, 2013.

  1. NewsBot

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    Effect of different orthotic concepts as first line treatment of plantar fasciitis
    Markus Walther, MD, Bernd Kratschmer, Joachim Verschl, Christoph Volkering, Sebastian Altenberger, Stefanie Kriegelstein, Marc Hilgers
    Foot and Ankle Surgery; Available online 19 February 2013
  2. Admin2

    Admin2 Administrator Staff Member

  3. Petcu Daniel

    Petcu Daniel Active Member

    Title : Effect of different orthotic concepts as first line treatment of plantar fasciitis
    Background: Evaluation of the effectiveness of three different types of prefabricated foot orthotics in the treatment of plantar fasciitis.

    concepts = types ?

  4. cpoc103

    cpoc103 Active Member

    Ok so I'm probably going to get slated here but I have to comment on the paper, finally had a chance to read and digest the info..

    I have a couple of issues with the paper, 1) plantar fascia attachments are made up of deep fascia fibres the last time I checked these fibres are inelastic fibres.
    2) three different types of orthotics were chosen which represent the different mechanical approaches to treat P/F.- How does prefab orths represent any mechanical theories currently used in podiatric biomechanics??
    Last I checked most prefabs are mass produced in a factory with very little or no correction, my understanding is these devices are for support rather than actually correcting mechanics! So how is this latest research '2013' showing the latest theories in conservative treatment for P/F and orthotics??
    3) (now this probably will get me in strife lol) what are the qualifications of the researchers ie are they orthopaedic surgeons and if so what are the bio mechanical qualifications held?
    Only reason I ask is two of my good friends are ortho surgeons and they admit to not knowing a huge amount of lower limb mechanics, I also recently had an ortho surgeon as a pt who also explained how throughout training unless one specialises in foot and ankle they don't really do a lot..
    Not trying to be rude just my valid questions about this paper.. Be interesting to hear others views on the paper!!

  5. Paul Bowles

    Paul Bowles Well-Known Member

    Didn't Dr Karl Landorf put this baby to bed already some years ago? Are the orthopods still trying to come to terms with it?

    Col you are correct about the in elastic properties - which is why I believe I see so many tears ending up in my office - "keep stretching it and you are going to start tearing it!"
  6. cpoc103

    cpoc103 Active Member

    Paul exactly the same in our practice!!

    I find it unbelievable how many clinicians still get pt's to roll a bottle or ball and massage and stretch the fascia!!

  7. Paul Bowles

    Paul Bowles Well-Known Member

    We haven't published this yet, not sure if we ever will because it was almost a completely coincidental finding - I presented the results in Hong Kong last year.

    We followed 14 patients as part of a prospective trial we were trying to set up. All 14 had presented with "heel pain" prior to seeking any treatment for it. We had them diagnostically US by one radiologist. All had thickened fascia's greater than 4mm and clinically presented with signs and symptoms of plantar fasciosis. No intrasubstance longitudinal tears were evident and no fibromas. All patients then sought treatment from independent practitioners of their own choosing.

    When we reviewed them at 6 weeks all of them still had pain and discomfort, most worse than original presentation. We ultra-sounded them again by the same radiologist and the results flawed us - nearly ALL had longitudinal intrasubstance tears!!!! We then reviewed what treatments they all had undergone.

    Some went to physio, some podiatry, some had othotics, some had corticosteroid injections, some went to sports physicians, some went to GP's.

    What was the single common thing they were ALL asked to do?

    You got it: STRETCH the plantar fascia!

    Makes me personally dubious about some of the data on stretching for heel pain - almost as dubious as the studies on glucosamine, but BMJ set me right on that I think!

    Made us seriously sit up and take note.....how "stretchable" is the plantar fascia fibers? I think the answer may actually be obvious!

    Also made us think - if you do not ultrasound your patients with clinical fasciosis PRIOR to managing them, how can you prove you didn't tear the fascia with your intervention? The amount of clinical data we have amounting on this is amazing. The amount of Pts I see in my office every week who have 3 pairs of orthotics from 3 different people for their heel pain and NONE have a diagnostic ultrasound. If I ultrasound them and find a tear can I blame the person who provided the treatment for it? Food for thought in this litigious world!
  8. Craig Payne

    Craig Payne Moderator

    How do you explain this?

    Digiovanni, B.F., Nawoczenski, D.A., Malay, D.P. et al. (2006) Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up. Journal of Bone and Joint Surgery American Volume 88(8), 1775-1781.
  9. cpoc103

    cpoc103 Active Member

    Craig the only thing I can come up with here is over the course of their treatment did they stretch the fascia beyond its elastic capabilities? And what if any were the consequences of this irreversible stretching of the fascia on the other medial longitudinal structures that aid in holding the foot in its propulsive phase of gait?

    Story we hear all so often, "pt attends the ED with bad sprain in ankle, ED doc says its only sprained no signs of #, however would have been better off breaking than spraining"
    Pt says whys that? Doc says because you have a grade 2 sprain in the ligaments around your ankle!!
    Pt says is that bad? And doc says ligaments are not very stretchy if they stretch past a certain point they unfortunately don't return to the original length, and thus can cause instability and ligamentous laxity!!

    Stretch the fascia and remove the load on it, but move the load to another structure during propulsive gait??

    This is what I'm thinking.

  10. cpoc103

    cpoc103 Active Member

    Paul very interesting food for thought, pretty interesting stuff you found there??
  11. Paul Bowles

    Paul Bowles Well-Known Member

    The same way you explain self resolution of fasciosis or nearly any musculoskeletal disease over a prolonged time period. Was it really the stretching that helped those people? One has to ask the question......if it doesn't anatomically stretch how does stretching possibly help it? Does the data show that the plantar fascia actually stretches? How are they measuring that?
  12. lcp

    lcp Active Member

    I agree with what you guys are saying, but what if its the stretching of the plantar musculature that is helping some of these patients. Yeah, the fascia may be inflexible, but maybe the tight intrinsic musculature is having an influence on the pain levels also?? Just a thought.
  13. There is no doubt that the central component of the plantar aponeurosis (i.e. what clinicians commonly call the "plantar fascia") can be stretched. This was very clearly demonstrated by pioneering research by Wright and Rennels at the University of California Biomechanics Lab a half-century ago (Wright DG, Rennels DC: A study of the elastic properties of plantar fascia. JBJS, 46 (A):482-492, 1964).

    In fact, if a tension load is applied to any ligament or tendon, it will stretch. If the load is applied for a longer duration, the ligament or tendon will stretch more. This is one of the known viscoelastic characteristics of ligament and tendon called creep. Once the tension loading force is removed from the tendon or ligament, the ligament or tendon will tend to retract back to its original length, but this may take some time.

    The plantar fascia may be stretched by stretching the gastrocnemius and/or soleus muscles or by direct compression by rolling the plantar fascia on a cylindrical object. Again the stretch is temporary, but it doesn's take much elongation of the plantar fascia to achieve stress relaxation of the plantar fascia, another known viscoelastic property of ligaments and tendons.

    I don't see why some of you are so surprised that any of the viscoelastic structures of the body can be stretched enough to cause a difference in tensile stress in that structure. These are very basic viscoelastic characteristics of all ligaments and tendons that have been known about for decades!
  14. toomoon

    toomoon Well-Known Member

    here is one way Paul:

    Nonlinear finite element analysis of the plantar fascia due to the windlass mechanism
    Foot and Ankle International
    Volume 29, Issue 8, August 2008, Pages 845-851
    Cheng, H.-Y.K., Lin, C.-L. , Chou, S.-W., Wang, H.-W.

    Background: Tightening of plantar fascia by passively dorsiflexing the toes during walking has functional importance. The purpose of this research was to evaluate the influence of big toe dorsiflexion angles upon plantar fascia tension (the windlass effect) with a nonlinear finite element approach. Materials and Methods: A two-dimensional finite element model of the first ray was constructed for biomechanical analysis. In order to imitate the windlass effect and to evaluate the mechanical responses of the plantar fascia under various conditions, 12 model simulations - three dorsiflexion angles of the big toe (45 degrees, 30 degrees, and 15 degrees), two plantar fascia properties (linear, nonlinear), and two weightbearing conditions (with body weight, without body weight) - were designed and analyzed. Results: Our results demonstrated that nonlinear modeling of the plantar fascia provides a more sophisticated representation of experimental data than the linear one. Nonlinear plantar fascia setting also predicted a higher stress distribution along the fiber directions especially with larger toe dorsiflexion angles (45 degrees > 30 degrees > 15 degrees). The plantar fascia stress was found higher near the metatarsal insertion and faded as it moved toward the calcaneal insertion. Conclusion: Passively dorsiflexing the big toe imposes tension onto the plantar fascia. Windlass mechanism also occurs during stance phase of walking while the toes begin to dorsiflex. From a biomechanical standpoint, the plantar fascia tension may help propel the body upon its release at the point of push off. Clinical Relevance: A controlled stretch via dorsiflexing the big toe may have a positive effect on treating plantar fasciitis by providing proper guidance for collagen regeneration. The windlass mechanism is also active during the stance phase of walking when the toes begin to dorsiflex. Copyright © 2008 by the American Orthopaedic Foot & Ankle Society.

    I am not at all certain we can say for sure the plantar fascia is incapable of stretching..
  15. Paul Bowles

    Paul Bowles Well-Known Member

    Thanks Simon and Kevin.

    Lets consider the primary function of the plantar fascia for a few moments. Is it really desireable to have it stretch at all based on its primary function?
  16. phil

    phil Active Member

    Maybe stretching the plantar fasciia is like stretching for achielles pathology? Perhaps it is the effect of mechanotransduction, improving collagen restructuring?

    It might not be about increasing length at all.
  17. toomoon

    toomoon Well-Known Member

    yes, I do think there is a difficulty with the terminology and the concept of 'stretching", which, across the board is controversial, but let's not go there for the moment!
    I think what we are talking about here Paul is applying a physiologic load to the damaged fascial tissue to try to promote alignment of collagen fibres where possible. At a microscopic level, the changes are substantial. Biologically there will be higher collagen content but decreased collagen concentration Given that the healing tissue is probably now invested with type 3 collagen, vs the original type 1, the characteristics of this tissue will be quite different mechanically (Collagen alpha-1(III) chain is a fibrillar collagen that is found in extensible connective tissues such as skin, lung, and the vascular system, frequently in association with type I collagen. It is one of lifes little annoyances that damaged tendon, ligament and muscle tends to heal with a greater concentration of type 3 collagen!). Getting this collagen to 'line up" is going to be pretty important, and this may be where the Di Giovanni technique fits in. It is not "stretching" per se. Does that make any sense?
  18. toomoon

    toomoon Well-Known Member

    ps.. quick plug for www.bartoldbiomechanics.com.. if anyone is interested in the biomechanics and biology of connective tissue, there is an ongoing series in the members section. We have just finished Part 3 discussing collagen and will now apply that to tissue healing in Part 4..!!
  19. Paul Bowles

    Paul Bowles Well-Known Member

    Absolutely it does many thanks - very elegantly explained.

    So lets throw a curve ball into the equation here if fascia does (lets call it alter its function through re-arrangement because its definately NOT stretching) why does abnormal tension through the fascia in a sagital plane (I am assuming we all agree this is one of if not the cause of plantar fasciosis) cause inflammation and not elongation or re-arrangement?

    If the windlass fails and tension inreases why doesn't the fascia simply re-arrange fibres to adapt? Why does it get inflammed and require us to "manually" apply more tension through it to perform this most basic function?
  20. toomoon

    toomoon Well-Known Member

    It seems it is far more complicated than the old tension model Paul, and the idea of inflammation is also pretty controversial. Current thoughts are more that the condition.. let's call it plantar heel pain, is rarely inflammatory, and rarely due to failure in tension.
    The current thought is that there is a problem with the EDR (energy dissipation ration) of the plantar fat pad,,and that this somehow compromises the plantar fascia at the enthesis. trouble is.. it is chicken and egg in relation to what is probably the most important clinical clue.. fascial thickening on US. Did the thickening cause the change in EDR, or did the change in EDR cause the thickening. No-one knows. The more important question is the role of compression and shear in this injury c.f. the role of tension. And this of course links back to failure of the windlass mechanism in some form, with altered WB biomechanics.
    End of the day, I think "stretching " the plantar fascia as a treatment modality probably operates off a very simple platform, and that is to somehow influence collagen concentrations and alignments at the enthesis. Still leaves us with the problem of the whys and wherefores of the EDR though!!
  21. Paul Bowles

    Paul Bowles Well-Known Member

    Mate and thats why I like discussing stuff with you ! The problem is the more I throw ideas and theory around with you, the more questions we seem to raise. I don't know if I am fully on board with the EDR. How does that address corticosteroid improvement? and if EDR is the issue how does the the "reverse" order work when you stretch you get improvement and how does that effect the EDR? How does stretching effect intrasubstance tears? What causes the intrasubstance tears in the first place if its not inflammation, degeneration and tension/force?

    We have spent far too much time on this today and I do really thank you for your input. I'll be signing up to Bartold Biomechanics on my return from DFCOn 2013 (am dirty Bartold Biomechanics is not part of www.portaleducation.com though!)


    Maybe we should get together a panel of us to discuss this sort of stuff on a semi regular basis...throwing concepts and research around more regularly.
  22. toomoon

    toomoon Well-Known Member

  23. Paul:

    When you say the "plantar fascis is definitely not stretching", how do you propose that this viscoelastic tissue does not elongate even though research has consistently shown over the past 50 years that all ligaments and tendons will elongate once placed under tension loading forces? Is this a semantics problem since the plantar fascia definitely does stretch!
  24. Paul Bowles

    Paul Bowles Well-Known Member

    Yes I believe thats what I was pointing out to Simon. I think the term "stretch" is used very loosely....

    Is fascia as viscoelastic as we think? Does the anatomical function of the plantar fascia necessitate that it shouldn't "stretch" like other structures?

    Whats your opinion of the "force" or "tension" theory versus EDR thoery Kevin? I'd be interested to know.

    Also I would be interested to hear any anatomists views (Bob Kidd where are you!) on the structure and function of fascia generally.
  25. thekwie

    thekwie Active Member

    Hmmm, parhaps I've been operating on a crazy misconception for many years. My understanding was always to encourage gastroch/soleus stretching, thereby encouraging better functional ankle use, less pronation moment and therefore reduce functional loading on the plantarfascia?
  26. toomoon

    toomoon Well-Known Member

    That may not be in line with current thinking,. although personally I would still continue to stretch the gastroc compex, there is little evidence for it in the literature
  27. Paul:

    Let's define the word "stretch" (#3 below) as meaning an elongation of a structure.

    First of all, the classic scientific research from Wright and Rennels in 1964 clearly demonstrated that the plantar fascia stretched under tension load. I have attached the paper if you haven't read it yet (Wright DG, Rennels DC: A study of the elastic properties of plantar fascia. JBJS, 46 (A):482-492, 1964). Therefore, the plantar fascia does stretch or elongate under tension loads, as do all ligaments and tendons.

    Secondly, all the tissue of the body are viscoelastic structures. That includes muscle, skin, bone, ligament, fascia and tendon. Either tissues are viscoelastic or they are not. I don't know what "as viscoelastic as we think" means. Please explain how viscoelastic you think the plantar fascia is, Paul.

    Third, I have no clue what EDR theory is. Please explain.

    As far as what we do know, the plantar fascia transmits tension force from the plantar calcaneus to the proximal digits and has multiple functions which I have lectured on and written about for over a decade.

    Ten Biomechanical Functions of the Plantar Fascia

    The plantar fascia not only has elastic properties but also viscous properties and, as such, is viscoelastic in nature. The plantar fascia has been effectively modelled as being a viscoelastic structure using parallel spring and spring-dashpot combinations (Kim W, Voloshin AS: Role of plantar fascia in the load bearing capacity of the human foot. J Biomech, 28(9):1025-1033. 1995).


    So with this research evidence now presented, Paul, why do you still think that the plantar fascia doesn't stretch during gait and why don't you think the plantar fascia is "as viscoelastic as we think"?:confused:
  28. Paul Bowles

    Paul Bowles Well-Known Member

    Thanks very much Kevin for all that I shall go through them and get back to you - much appreciated.

    With regards to EDR I was referring to Simons previous post where he suggested fasciosis is not a tension/force related condition.

    Im not saying it doesn't elongate during gait, I am questioning how much elongation actually occurs and relating this back to the windlass mechanism. In consideration of that mechanism, is "stretch" actually advantagous to it? Is it elongation or is it as Simons article yesterday suggested "re-arrangement"?

    Again - I asked this yesterday if the tissue is viscoelastic at what point is this viscoelasticity negated by the abnormal force going through it? Simons answer was he didn't believe fasciosis was a solely related to that and gave the example of the EDR theory.
  29. toomoon

    toomoon Well-Known Member

  30. toomoon

    toomoon Well-Known Member

    The plantar fat pad is thought to play an important role in protecting the deeper structures of the foot by dissipating impulsive loads associated with locomotor activities such as walking. In symptomatic cases of enthesopathy, thicker fascial
    entheses are associated with reduced energy dissipation of the plantar fat pad, providing a link between local mechanical factors and enthesopathy.
    The energy dissipation ratio is a measure of the energy
    lost by viscous friction within the tissue and is believed to
    play an important role in damping high-frequency vibration. Reduced energy dissipation of the plantar tissues during dynamic activities such as walking, therefore, has the potential to increase the vibrational loading experienced
    by deeper foot structures and so lead to adaptational thickening of the stress-dissipating fibrocartilaginous enthesis. In support of such a concept, small-amplitude, high-frequency vibrations have been shown to induce an
    anabolic adaptive response in both cortical and trabecular bone. Although the nature of the vibration associated with reduced energy dissipation of the heel fat pad is unknown, the findings are consistent with the ‘‘enthesis organ’’ concept, in which the classical view of the enthesis has been expanded to include a complex of adjacent tissues that jointly serve to dissipate stress. Based on Wearing 2010 a 12% decrease in the energy dissipation ratio of the plantar fat pad is associated with each 1-mm increase in the sagittal thickness of the enthesis in heel pain. While the latter has been advocated as a sonographic criterion for thediagnosis of enthesopathy, similar changes in the energy dissipation ratio of the plantar tissues have been found to occur with senescence.
    Although the relationship between the structural components and the mechanical properties of soft tissue is complex, the finding that the heel fat pad has a reduced energy dissipation ratio in plantar heel pain suggests it behaves in a more elastic manner. The elastic mechanical responses of collagen, as well as the energy dissipation arising from proteoglycan-collagen and proteoglycan/proteoglycan interactions, are known to be influenced by the quantity and size of proteoglycans, the degree to which they form stable aggregates, and the integrity of the surrounding collagen network. Thus, the reduction in the energy dissipation ratio of the heel fat pad in plantar heel pain may arise from a lower content, changes in quality or aggregation state of proteoglycan, and/or a relative increase in collagen organization and cross-linking.
  31. I couldn't read the paper, Simon. All the pages are black.:confused:
  32. toomoon

    toomoon Well-Known Member

    Ha.. i think Scotty is in the CIA so that does not surprise me.. sending to your private email
  33. Paul Bowles

    Paul Bowles Well-Known Member

    It opens for me in adobe acrobat.....thanks simon. Scotts been on this workpath for a while I - more light reading for me!!!! Cheers
  34. I was able to download the paper off the Clinical Biomechanics website. It looks very interesting on first skim.

    However, plantar heel pain and plantar fascia viscoelasticity,tension force may not be directly related to each other. My belief is that plantar heel pain, in most individuals, is a combination of trauma caused by the compression stresses from ground reaction force acting on the medial calcaneal tubercle and the tension stresses from the plantar fascia acting at its origain on the medial calcaneal tubercle. In other words, with just compression stress, the heel may not hurt and with just tension stress, the heel may not hurt either. (The compression stress is related to the energy dissipation ratio in the study by Wearing et al.)

    Plantar heel pain, in most cases, requires the compression loading from ground reaction force and the pull of the plantar fascia to start. What factor increases both of these mechanically damaging forces on the plantar heel in all individuals....? Obesity!

    As long as there is obesity and gravity...my practice will do very well.....:cool::eek:
  35. toomoon

    toomoon Well-Known Member

    and.. in a world first.. I would completely agree with you. Although the evidence is that a pronated or "low arched foot" does not cause plantar heel pain.
    It does however exacerbate it once established. What do you have to say to that Doctor?
  36. Paul:

    We must separate out two factors when speaking of "stretching" the plantar fascia:

    1) temporary elongation of the plantar fascia which will recover back to a shorter length over time due to its viscoelastic properties;

    2) plastic deformation of the plantar fascia into a longer length (i.e. a permanent lengthening of the plantar fascia) due to a plantar fascial tear or sliding of plantar fascia fibers on each other.

    As long as the deformation is elastic, the plantar fascia will shorten back to its original length over time after it has been lengthened temporarily by increased tension forces. However, if the deformation is plastic, the plantar fascia will not shorten back to its original length over time after it has been lengthened due to a pathological structural change in the arrangement of the collagen fibers within the plantar fascia itself.
  37. I still haven't picked myself up off the floor ever since you said you agree with me!:eek:
  38. Paul Bowles

    Paul Bowles Well-Known Member

    Thanks Kevin - yes further discussion of properties and definition is exactly what I was getting at with Simon. Its not a black and white area unfortunately. Good discussion gents.... I would still like Bob or Bernies opinion on fascial structure with regards to anatomical function.

    Also where does tissue tensility fit into all of this (if it even does?) - do people have different tensile tissue strengths within structures? i.e. considering force and abnormal load upon the fascia (not EDR theory) what measure of force would be required to "stress" my plantar fascia as opposed to the next persons?
  39. Paul Bowles

    Paul Bowles Well-Known Member

    He agrees with you but on the last page refuted my comment in the exact same context :) How rude!!!! ;)
  40. toomoon

    toomoon Well-Known Member

    I get that a lot Paul..:wacko:

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