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Management of plantar heel pain: a best practice guide informed by a systematic review, expert clini

Discussion in 'Biomechanics, Sports and Foot orthoses' started by scotfoot, May 7, 2021.

  1. scotfoot

    scotfoot Well-Known Member


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    A helpful guide for the management of plantar heel pain has recently been published by D Morrisey et al .

    I have one concern about the paper and this has gone down very badly with some on social media, for example ,Ian Griffiths . That concern can be summed up by an exchange between Craig Payne and Mathew Cotchett in Episode 64 of Pod Chat Live (2019).

    When discussing the paper ,which was still being researched at that stage , Craig asked Mathew about strengthening in relation to rehabbing any deficits in the intrinsics caused by plantar heel pain ( PHP ) .
    Mathew responded with an answer about the effect strengthening has on the pain symptoms of plantar fasiitis ( PHP) and did not answer the question asked . IMO the paper also fails to make the distinction .

    It's a shame that some of the papers authors, such as Ian Griffiths and Christian Barton, don't think I should have any right to an opinion on the paper, but thankfully not all think as they do .
     
    Last edited: May 7, 2021
  2. scotfoot

    scotfoot Well-Known Member

    Moving on with the complex question of how to treat plantar fasciitis , I wonder if Susan Mayes has come up with part of the answer .
    Simply , full extension calf raises ,in minimal shoes, and on a hard surface . This likely maintains a properly functioning parabola effect allowing the foot to stiffen at push off without unduly taxing the PF .

    To understand the parabola effect here is a link to a thread that explains it .

    https://podiatryarena.com/index.php?threads/the-transverse-arch-of-the-foot-venkadesan-et-al.112183/
     
  3. scotfoot

    scotfoot Well-Known Member

    The Morrisey paper is an interesting read, and, though I was surprised to find that strengthening exercises for intrinsic muscle atrophy rehab are not among the paper's recommendations , I was happy to see that plantar fascia stretching is among the 3 do's for PHP treatment .

    Happy particularly because my company recently applied for a patent for a method of executing the plantar fascia stretch which does not require a degree of flexibility that many older people simply do not have ( The paper does not address this very real problem )

    The stretching method and related equipment are part of the poZamarg system (pat and pat pending ) which should be available before Christmas .

    Contrary to the stated beliefs of Mr Ian Griffiths , I welcome this new paper and we will be referring to it in the sales literature .

    Moving along ,one other problem I see with the paper is the use of orthotics .

    After 10 years of reading I am fully aware of the great value of orthotics when correctly prescribed, but recently more evidence has started to emerge that some orthotics can produce muscle weakness . I would have thought that with chronic plantar fasciitis ,which is often associated with weakened intrinsic foot muscles in the 1st place, if you are going to use a treatment that may weaken the feet further, complimentary foot exercises might be a good idea .

    link to D Morrisey et al Worth reading http://dx.doi.org/10.1136/bjsports-2019-101970

    Conclusion
    Best practice from a mixed-methods study synthesising systematic review with expert opinion and patient feedback suggests core treatment for people with PHP should include taping, stretching and individualised education. Patients who do not optimally improve may be offered shockwave therapy, followed by custom orthoses.
     
  4. scotfoot

    scotfoot Well-Known Member

    Ian , how do you do the left foot onto right knee and press back toes etc plantar fascia stretch if you are a 70 year old with hip pain ?


    As a co- author of the paper under discussion, what alternatives would you prescribe and are they as effective ?
     
    Last edited: May 9, 2021
  5. scotfoot

    scotfoot Well-Known Member

     
  6. scotfoot

    scotfoot Well-Known Member

    Why does plantar fascia stretching help with the symptoms /condition of PHP .

    I am starting to think that the PF stretch works with PHP ,not because of direct stretching the PF but by the mobilization of the forefoot, and the metatarsal parabola in particular ,which is a bi-product of the stretch .

    The parabola dictates , even with less than 4 met heads in contact with the ground ( more or less and counting the sesamoids as a continuance of the 1st met head ) , that when the heel lifts, the met heads move apart anteroposteriorly and together mediolaterally . This accentuates the transverse arch of the foot giving greater stiffness and reducing the load the PF is subjected to .

    So the PF stretch actually helps PHP because it is also a transverse ligament stretch . I think that Susan Mayes's work with heel raises teaches in this direction .

    Video explaining "parabola effect "



    Any thoughts ?
     
  7. scotfoot

    scotfoot Well-Known Member

    Possible mode action of orthotics in helping with PHP syndrome .

    The "metatarsal parabola effect " as described above and elsewhere, is most apparent when the forefoot is on a hard surface .

    On a softer surface, like the inner of a highly cushioned shoe, the met heads will not move apart to as great an extent as they would on a hard surface, with the head of the 2nd met in particular, simply being pressed down into the yielding shoe insole .

    The foot may not become as stiff as it should in a cushioned shoe with a soft insole, thus putting greater stress on the PF .

    However, what if you put an prescribed insole or orthotic into the shoe which ,although flexible, is also hard . Even if this orthotic sits on a soft midsole, provided the orthotic extends far enough to be under the met heads , these will stay on the same transverse plane during gait and met head 2 will not be pressed down into the shoe .

    This may allow the parabola effect to function, stiffening the foot, and reducing stress in arch spanning soft tissues .

    IMO that the "metatarsal parabola effect " exists and acts to stiffen the foot is simply physics/mechanics .
     
  8. scotfoot

    scotfoot Well-Known Member

    Correction ; in post above "transverse plane" should read "horizontal plane " .

    Also, the concavity of the inner on which a forefoot rests likely negatively impacts the parabola effect . Minimal shoes do not have this inbuilt problem and neither do the shoes from OESH .
     
  9. scotfoot

    scotfoot Well-Known Member

    Here is a quote from Morrissey et al 2021 -

    " There was moderate evidence of large effect that plantar fascia stretching is superior to radial ESWT for first step pain in the short term (SMD: 1.21, 95% CI 0.78 to 1.63)39 and of medium effect in the medium term (SMD: 0.64, 95% CI 0.24 to 1.04) but not in the long term (SMD: −0.04, 95% CI −0.43 to 0.35). The sample was mainly people presenting with acute PHP, and this finding complements expert reasoning well, with there being clear guidance to continue stretching targeting the plantar fascia and related structures in a variety of ways throughout rehabilitation:"


    Question ; Is the plantar fascia stretched more when a person is in single leg stance , with the heel raised off the ground, or when the toes are dorsiflexed by manual pressure as is demonstrated in post #4 .

    I would say it is the first of the two conditions ,the single leg stance with raised heel, that subjects the fascia to most stress /strain/stretch, and probably by a very large margin .

    So why does the stretch in post #4 work ? Is it the PF that is being effectively stretch here or the intrinsic foot muscles ?
     
  10. scotfoot

    scotfoot Well-Known Member

    Below is a diagram from Welte et al 2018 . In the paper it is taken from, the researchers showed that the foot undergoes greater deformation under load if you start with the toes supported in a dorsiflexed position .

    It would seem therefore, that an effective way of stretching the PF might be along these lines ,so perhaps single leg stance with the toes held in a dorsiflexed position by a judicially placed towel ( Rathleff ) .( Note ;I am not saying anyone should do this stretch ,I am merely speculating )

    Key to this proposed stretch are (1 ) a starting position where the plantar ligaments are under less load allowing targeting of the PF and (2)the fact that loading moves the distal and proximal points of attachment of the PF apart .

    With the seated PF stretch ,where one foot is lifted onto the opposing leg and the toes are dorsiflexed with palm of the hand ,the foot shortens via the windlass and I very much doubt that the PF is stretched to anything like the same degree as it would be with a single leg bodyweight stretch, as described above .

    The seated PF stretch probably doesn't stretch the PF much at all, but it does help with PHP . Could it be about the intrinsic muscles ?

    [​IMG] "The purpose of this investigation was to understand the interaction between the windlass and arch-spring mechanisms, by engaging the windlass through MTPJ dorsiflexion, and investigating the effects on arch energetics during a dynamic compression. We hypothesized that MTPJ dorsiflexion would pre-tension the plantar fascia and stiffen the arch. However, in contrast to our hypothesis, the engagement of the windlass mechanism reduced the stiffness of the arch and increased energy absorption and dissipation. "
     
  11. scotfoot

    scotfoot Well-Known Member

    PHP may cause IFM weakness esp in chronic cases .

    Why would the treating physician not asses IFM function and address any deficits found to avoid later problems such as balance issues or impaired toe off ?

    Surely, with PHP, a case by case assessment is justified rather than a one size fits all prescriptive model .
     
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