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Plantar Fasciitis Discussions

Discussion in 'Biomechanics, Sports and Foot orthoses' started by admin, Dec 9, 2005.

  1. admin

    admin Administrator Staff Member

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    Plantar Fasciitis Discussions


    Is a calcaneal spur in the plantar fascia?
    Extracorporeal Shock Wave Therapy:
    Ultrasound therapy for plantar fasciitis
    Plantar fasciitis and dorsal pain
    Nutrition and plantar fasciitis
    Botulinum toxin and plantar fasciitis
    First-Step Pain
    Foot Orthoses Effective in Plantar Fasciitis Treatment
    Decompression drilling for heel pain
    Plantar fasciitis is associated with functional limitation in older people
    Growth Factors For Chronic Plantar Fasciitis?
    Wheatgrass cream no more effective than placebo for plantar fasciitis
    Plantar Fasciitis: Evidence-Based Review of Diagnosis and Therapy
    Plantar fasciitis treated with local steroid injection
    Orthoses vs plantar fasciitis
    Achilles loads and load in plantar fascia
    Functions and Dysfunctions of the Plantar Fascia
    Hamstring tightness and plantar fasciitis
    Low-Dye taping and iontophoresis for plantar fasciitis
    Heel cut-out in orthotic for plantar fasciitis
    Offload midfoot for plantar fasciitis?
    Plantar fasciitis in HIV positive people
    ActiPatch and plantar fasciitis
    Detecting plantar fasciitis on plain x-ray?
    Glucosamine In Treatment Of Plantar Fasciitis
    Plantar Fasciosis Neuropathy
    Plantar fasciitis vs FHL tendinitis
    Manual therapy for recalcitrant foot pain after fasciotomy
    Routine x-rays for heel pain of no value
    Clinical Trial on Low Dye Taping
    Persistent heel pain
    Effectiveness of Foot Orthoses to Treat Plantar Fasciitis
    Night splints for plantar fasciitis
    'Inflammatory' vs 'mechanical' plantar fasciitis
    Pathomechanics of plantar fasciitis
    Plantar Fasciitis Paradigms
    Injection therapy for heel pain
    Plantar fascia stretching exercise for plantar fasciitis
    Foot Orthoses Effective in Plantar Fasciitis Treatment
    Heel pain: Biomehanical and sensory differences
    Does anyone have a problem with this heel pain article?
    Counterstrain technique for plantar fasciitis
    Megavoltage irradiation for heel spurs
    A cure for plantar fasciitis? Dream on
    NSAID's and plantar fasciitis
    Work shoes and plantar fasciitis
    Obesity and pronated foot type may increase the risk of chronic plantar heel pain
    Plantar fascia thickness and pain
    Cryosurgery and plantar fasciitis
    Gastroc recession cured 93.6% of chronic plantar fasciitis
    Heel Spur vs. Plantar Fasciitis: Patient Education
    High heel shoes and plantar fasciitis
    Diagnosis for all heel pain "plantar fasciitis"?
    Plantar heel pain and Flexor Hallcis Longus dysfunction
    Unresponsive Heel Spur Syndrome/ Plantar Fasciitis
    Last edited: Jan 8, 2008
  2. njw podski

    njw podski Welcome New Poster

    Hi all,

    had an interesting conversation with a group of medicos a few days ago re: Plantar Fasciitis. The approach that several of them took was that the Plantar fascia is an area of vascular compromise, similar to the rotator cough in the shoulder. Therefore, plantar heel pain is viewed as an impaired healing process, micro tears don't heal because of poor vascularity. This line of thinking is familiar to me, and appears to be an approach taken with many enthesopathies.

    However, what I haven't come accross before is the use of nitrolingual spray, or the gel form of same, applied to the plantar heel to increase local blood flow and encourage healing of micro tears.

    Greatly interested in anybodies take on this.

  3. DrGillman

    DrGillman Member

    Take a look at Graston Technique: www.grastontechnique.com It is a means to non-surgically debride, stimulate tendons, and strip through fascia. It has been an excellent soft tissue method and has worked fairly well with plantar fascitis.

  4. Andrew van Essen

    Andrew van Essen Welcome New Poster

    Please see attached transcrit from the ABC Helath reportYesterday on Plantar Fasciitis


    Andrew van Essen

    13 November 2006
    Heel pain treatment
    Listen Now - 13112006 | Download Audio - 13112006

    Proximal plantar fasciitis is the most common cause of heel pain. Researchers in the U.S. suggest that a new plantar fascia-specific stretching exercise is proving quite effective to help treat and potentially cure plantar fasciitis.

    Show Transcript |
    Hide Transcript

    This transcript was typed from a recording of the program. The ABC cannot guarantee its complete accuracy because of the possibility of mishearing and occasional difficulty in identifying speakers.

    Norman Swan: Welcome to the program. This morning on the Health Report identifying people with whiplash injury who'll go on to have long term problems and it doesn't have much to do with compensation arguments; using stem cells to help children with brain injuries and a common problem which may be frequently misdiagnosed and ineffectively treated.

    It's heel pain and if you, or someone you know has had it, you'll be well aware that it can be very painful and the treatments can be too. One cause of heel pain is a condition called plantar fasciitis and an orthopaedic surgeon in the United States has found what he thinks is a simple, non-surgical treatment which works. It's a special stretch.

    Ben DiGiovanni is an Associate Professor of Orthopaedic Surgery at the University of Rochester School of Medicine in New York.

    Ben DiGiovanni: The classic symptom is the first step in the morning pain, that's the key information when a patient stands in the morning and has severe heel pain, there's a high chance it's going to be plantar fasciitis.

    Norman Swan: So it's not in the middle of the foot, it's actually at the heel?

    Ben DiGiovanni: Exactly, right at the base of the heel pad on the bottom aspect, it's not that arch discomfort but it's that pain in the heel right at the base there.

    Norman Swan: And what's causing the pain?

    Ben DiGiovanni: The patient will not recall a significant injury, it's more they do something that's just a little bit more than they're used to doing. They may run hills instead of running on flat surfaces or they may do a lot of standing and walking at a Mall around holiday time because it's very, very common during the holiday season here in the States. What happens is they get a small tear, a micro tearing of the origin of that structure the planta fascia, which is a connective tissue that supports the arch. A small tear and have some discomfort but not terrible then they get off their feet and they sleep at night and the body tries to heel that in a contracted position. And then they take that first step in the morning and they cause further micro tearing and that's what the pain with the first step in the morning is.

    Norman Swan: And the plantar fascia if I remember my second year anatomy stretches from the heel right to the front of the foot?

    Ben DiGiovanni: That's correct and it inserts on all the toes so it originates at the heel bone, goes and inserts on all five toes so when you take that first step and you kind of lean forward on your toes that's stretching that structure.

    Norman Swan: And it's basically keeping your foot in place?

    Ben DiGiovanni: Exactly, supporting the arch.

    Norman Swan: And is there any relationship to the heel spur in terms of plantar fasciitis?

    Ben DiGiovanni: That's a great question and typically it gets called a heel spur syndrome, those kind of names and we used to think it was the heel spur that was causing the problem but we've learned actually that that structure, the plantar fascia in an MRI, it's really not directly associated with the heel spur. It's more superficial to that structure so it's really not the heel spur that's causing the problem, it's more that micro tearing of the plantar fascia.

    Norman Swan: Now people have told me who've had plantar fasciitis that it is incredibly painful and it's not just the first step in the morning, it can go throughout the day.

    Ben DiGiovanni: Right, and usually it's most commonly when they've been off their feet for a while, they've been in the car, have driven for a distance, or they've sat for lunch and they're going to take that first step. Usually it's after inactivity and then when they start to walk again they get the pain. Now when it becomes more of a chronic problem it's going on for months, typically they start to have pain when they're standing and at the end of the day it becomes worse so it's kind of a build up of symptoms that occurs.

    Norman Swan: And in the past thinking it's been a heel spur people have, I mean my eyes water just thinking about, have injected it with steroids to try and sort it out.

    Ben DiGiovanni: Right, steroids are one way of treating it but I've been away from steroids because there are two main problems with it. No. 1 is it can cause what's called fat pad atrophy, loss of the fat pad on the bottom of the foot, and you really need that. So I think that's a pretty significant disadvantage. And the other thing is it can weaken that structure and give you some temporary relief where you continue to walk through it, you kind of mask the symptoms. Sometimes it can lead to rupture of the plantar fascia.

    Norman Swan: So where did you get the idea for stretching being the solution?

    Ben DiGiovanni: Well you know it's one of those things that the Achilles tendon stretch has been a kind of tried and true way of approaching it and there's thought to be a connection between the Achilles tendon being tight and then having plantar fasciitis. And I think there is actually a connection but the problem is when I looked at things I kind of said well why are we stretching the Achilles tendon when the problem's the plantar fascia.

    Norman Swan: Just to explain here people would give you an Achilles tendon stretch like standing on a step with your heels going down or angling your foot against the wall hoping to stretch the whole foot structure.

    Ben DiGiovanni: Exactly right, so against the wall, or the heel hang right off the step is the classic and I found a lot of patients were having months and months of pain and it's not uncommon. I'm an orthopaedic surgeon as a foot and ankle specialist and it's one of the things that from the literature and my experience before I started doing this new stretch and you tell them well it's probably going to take nine or ten months for this to go away. And that's just way too long for something that's so painful so I wanted to get a better handle on it and I thought well, you know, let's target the plantar fascia better and based on knowing the anatomy and some other stretching protocols I'd done for different parts of the body I thought let's recreate this stretch to better target the plantar fascia by pulling up on the toes and pulling up on the ankle before you take that first step in the morning or prior to being active after inactivity.

    Norman Swan: So tell us you know, I'm your patient, tell me what to do with this stretch.

    Ben DiGiovanni: Well the key thing is before that first step in the morning or any time you've been less active and you you're going to stand up and have that sharp ouchy pain, what you want to do is, and the way I instruct them to do it is to cross their legs kind of like a guy does. So if it's your right foot you put that right foot and ankle over your left knee and then what you want to do is with your right hand, if it's your right foot, you pull up on your toes - you grab just the toes, not the ball of the foot, grab those toes and pull it up towards your shin and towards your knee. And what that does is that you've got the toes pointed up and that ankle pointed up and with the other hand you feel the structure in the bottom of your foot in your mid arch area and that's the plantar fascia. It'll feel like a firm nice tight guitar string, typically if you have a good stretch. That left hand, the opposite hand, kind of feel that area making sure it feels nice and firm like a guitar string. And what I actually ask patients to do then is to kind of let go of the foot and the ankle and then while the leg is crossed to feel for that structure, you can't feel it anymore. And then I have them again pull up on those toes, point it towards the shin and the knee, using the other hand to make sure it feels nice and firm like a guitar string and then you hold it there for a count of 10 and then you kind of let it go, let the foot relax, pull up on it again, hold it for a count of 10 and do that ten times before you take that first step in the morning, or any time you've been less active, and you're going to take that step and have that sharp ouchy pain, do the stretch again.

    Norman Swan: And how many times during a day?

    Ben DiGiovanni: The study was three times a day. Most patients in clinical practice they will usually do it about 5 to 6 times a day.

    Norman Swan: So you did a randomised trial comparing Achilles tendon stretches to this plantar stretch, what did you find?

    Ben DiGiovanni: Well it was really some surprising and really encouraging information. We followed patients up initially at 8 weeks to see how they were doing and what you need to remember actually is we took the worst of the worst. So these patients had to have chronic heel pain of at least 9 months duration. What we wanted to do is avoid studying those people where we thought they were going to get better just with time. So these patients were the worst of the worst, had this chronic heel pain, they'd tried all kinds of other things, injections, inserts, night splints, all kinds of stuff. What we found is that at 8 weeks when you compared the plantar fascia stretch group with the Achilles tendon stretch group there was a dramatic improvement and it was significant statistically in favour of the plantar fascia group in terms of pain, resolution, decreased inactivity limitations, and satisfaction.

    And then that was a study that we published in 2003 in The Journal of Bone and Joint Surgery and then what we just published in August of 2006 in The Journal of Bone and Joint Surgery we presented the two year follow up on these patients,. And the results were very encouraging and it looks like they've maintained their improvement for the two years duration, the ones that improved and 90% had improved and were very satisfied. And what was really encouraging is we found about 75% of patients had no pain, no activity limitations and the best part is is after they were taught this stretching protocol is they really didn't need to see another physician or another physical therapist. And a vast majority of them had seen multiple people before starting this stretch.

    Norman Swan: I notice in your research in the paper you say there were no significant differences between the groups at 2 years. Does that mean the differences didn't change, in other words there was still a gap, or they merged because the group that had Achilles tendon stretches had got better of their own accord?

    Ben DiGiovanni: Well what we did is at the 8 weeks is that we did a cross over to the study. So basically the patients who had the Achilles tendon stretch we said ah, now we're going to teach you the trick, we're going to teach you the plantar fascia test.

    Norman Swan: Which is the only ethical thing to do.

    Ben DiGiovanni: Exactly, and so at that point we taught them the stretch and what was really interesting is you saw the disparity between the two groups go away and the Achilles tendon stretch group, once they were called the plantar fascia stretch group they behaved like the original plantar fascia stretch group.

    Norman Swan: Did you find out what happened if they stopped the stretch, because presumably not everybody stuck to the program?

    Ben DiGiovanni: The did it for 8 weeks when they were instructed to do it and then they did it as needed. So if they started to feel a little bit of discomfort they would do the stretch again and it wasn't a big deal cause they got a good handle on it right off the bat. And most of them did not have a recurrence of their symptoms but if they did they did the stretch and they quickly were improved again.

    Norman Swan: I mean the advantage in this is that you don't need any sort of long term physiotherapy, this is really quite cheap.

    Ben DiGiovanni: You know that's what's really, really encouraging.

    Norman Swan: You're doing all these colleagues of yours out of business.

    Ben DiGiovanni: Well I'm an orthopaedic surgeon, I love to operate and that's what I do but you know we do learn, I've got enough grey hair now, we learn there are certain things where surgery's not the answer. And when you look at plantar fasciitis it's really only about 50% of patients after surgery who have complete resolution of pain, complete resolution of activity limitations and are satisfied. So we've come up with something we think is superior to surgery and surgery really is not the answer unless you exhaust these other things.

    Norman Swan: Now in evidence-based medicine, they talk about a particular statistic called number needed to treat. In other words not everybody will benefit from a treatment even though the treatment is effective and when you're actually talking to patients about whether or not they're going to get benefit they say look 20 people have got to have this cholesterol lowering drug for one person's heart attack to be saved. Or 12 people have got to have their prostate out for one man's life to be saved from prostate cancer. Did you get any sense of how many people needed to have the plantar stretch for one to benefit?

    Ben DiGiovanni: Well you know with the randomised proto study we had 50 in each group and our statisticians thought that was a good number to evaluate for a statistical difference. What we did find is that if the stretch is going to be successful it was usually going to happen within the first 6 months and this is at the 2 year follow up. So you know the patients who did not improve, if they were not improving at 6 months it wasn't go to work.

    Norman Swan: And did you get a sense of what percentage it didn't have much affect on?

    Ben DiGiovanni: It was less than 10%.

    Norman Swan: You just mentioned earlier that you've done a fair bit of work on stretching in general. It's had a bit of a bad press stretching, it doesn't seem from randomised trial evidence to affect muscle soreness and people have questioned whether it affects injury rates and so on. What work have you done on stretching to suggest there might be benefits in other areas?

    Ben DiGiovanni: Well it's more my clinical sense. Let's say someone has a hamstring injury and they've pulled their hamstring. It's pretty much agreed upon that you need to stretch out your hamstring before you walk briskly or would run, otherwise you're going to have recurrent hamstring injuries.

    Norman Swan: But has that been tested?

    Ben DiGiovanni: I've seen information, not the best evidence based studies, but it certainly is something that most trainers and physical therapists in this country would agree upon. I often see it in myself too as I get older, if I don't stretch and prepare myself I have injury and have problems. So I personally really very much believe in stretching protocols even though I'm a surgeon and the physical therapist who were a big part of this study have also experienced the same thing.

    Norman Swan: Associate Professor Ben DiGiovanni is at the University of Rochester School of Medicine in New York. And this is the Health Report here on ABC Radio National.


    DiGiovanni BF et al. Plantar Fascia-Specific Stretching Exercise Improves Outcomes in Patients with Chronic Plantar Fasciitis. The Journal of Bone and Joint Surgery, 2006;88(8):1775-1781

    DiGiovanni BF et al. Tissue-Specific Plantar Fascia Stretching Exercise Enhances Outcomes in Patients with Chronic Heel Pain. The Journal of Bone and Joint Surgery, 2003;85(7):1270-1277

    Dr Ben DiGiovanni
    Associate Professor of Orthopaedic Surgery
    University of Rochester
    School of Medicine
    Department of Orthopaedics
    601 Elmwood Avenue, Box 665
    Rochester, NY 14642

    Norman Swan

    Brigitte Seega
  5. musmed

    musmed Active Member

    Dear All

    I have read wit interest Dr Swann;s talk with Dr DiGionnovani.

    In one breath he says it is due to micro tears in the plantar fascia, and in the next he tells you to stretch it....?

    Where is the sense.Any explainers?

  6. Charlotte Darbyshire

    Charlotte Darbyshire Active Member

    Just a quick question is there any information held advocating steriod injection therapy as a first line treatment for plantar fascial heel pain syndrome. Or is it secondary to other conservative approaches such as stretching massage strapping orthotic provision
    NICE guidelines perhaps???
    as many replies would be grateful
    many thanks
    Charlotte :)
  7. musmed

    musmed Active Member

    Dear Charlotte

    Sorry for not replying sooner.

    Your question is a good one indeed.

    If you were a sports person and went to some clinics I know of, they would inject it and then tell you to jump up and down until it tore and then it does not hurt anymore. TRUE

    As no-one knows what is happening why stick steroid into it. For all I know just water will work just as well.

    The reason I say this is that the prolotherapy studies performed by Dr. Michael Yelland from the University of Queensland has followed up over 120 people with chronic low back pain for over 2 years.

    He found that those who had the magic glucose and L/A did a teeny weenie bit better than those who had L/A and water.

    It was a totally double blinded study to the extreme. I ahve spoken to him on several occassions about it all.

    It seems that no matter how you treat pain at 2 years: 20% are cured: 50% are 50% better and the rest no change.

    I have been collecting data on treatment of pain for many different conditions. These include treatrment for post heres zoster in the elderly, prolotherapy, recovery programmes used in rehab in the UK for chronic back patients, the use of radiofrequency to disc tears in the lumbar region.

    They all have the same outcomes.

    The question is. Does anything work and should we rely upon a 20% cure rate and 50% 50%better?

    I am currently conducting a large study on PF. All studies show they have the bull by the horns.

    Hopefully with 1 year follow up (finishes in MArch 2008) I will be able to tell you, but so far we have had 100% success rate (except for1 who does not listen) within 18 weeks. There has been one relapse so far.

    The thing I can tell you is that stretching is forbidden!




  8. Charlotte Darbyshire

    Charlotte Darbyshire Active Member

    Thanks for your reply
    Interesting reading. lots of literature seems to advocate stretching as a conservative treatment modality of choice.
    do you have references against this??? my msc dissertation is based around this therapy and would be great to know your thoughts
    thanks charlotte :)
  9. musmed

    musmed Active Member

    Dear Charlotte

    I know stretching is the mainstay of therapy. It seems that it is all one has to offer.

    When you read what's out there the overall cure rate is poor and it seems to take an eon at that.

    Just ask your patients about strtching. Almost all will tell you it hurts and makes matters worse and they stop doing it although they will tell you they are doing it.

    This is a question I am asking in my study. Interesting results I can assure you.

    As I posted somewhere else on this forum. If the problem is microtears, why stretch it.

    I ask you this. If you have a crack in the corner of your mouth (read microtear) do you get out and stretch it?

    Remember, periosteum has more nerve fibres than any other major structure.


  10. DawnPT

    DawnPT Member

    What works in therapy? I've seen a wide variety of patients with this problem (and even got some firsthand experience). It seems like they all respond different to treatment, which must mean that the cause of the plantar fascitis is not always the same.

    I actually never thought about it- if it was caused by micro-tears, why do we do major stretches? I have seen some people not tolerating that, so there may be an answer in itself.

    I've found the most effective stretches are just done with a tennis ball rolled under your foot. You can put as much pressure as you want through the ball, so it's done to pain tolerance. Plus you don't have to worry about the exact position of your calcaneus during the stretch.

    I have used kinesiotaping to help support the posterior tibialis tendon- that seems to help with pain relief while the tape is on. Taking it off is a different story. They make a special plantar fascitis "brace" that can assist with support. I like getting a good shoe orthotic (plastic base, foam on top, highly supportive arch) if there is overpronation.

    I've also used ultrasound and even phonophoresis....is this proven to help?

    And why does it take up to 6 months before you are "cured"?

    Does anyone know if Anodyne therapy would work if it was caused by vascular compromise? Are there any research studies based on that?

    Now I'm going to doubt what I've been taught, which is probably a good thing, but I seem to have more questions than when I started.
  11. musmed

    musmed Active Member

    Dear Dawn

    Maybe your name is the light in this issue.

    I like in general what you have written, but I await the 'heavies' to put you down.

    Then I will come to your rescue.

    Hold tight

    Paul C.
    PS.is rolling a ball under one's foot stretching anything outside of ones imagination?
    pps.I am on your side
  12. christian00

    christian00 Welcome New Poster


    Looking forward to this.
  13. Craig Payne

    Craig Payne Moderator

    Stretching works, thats why its used:
    Plantar fascia stretching exercise for plantar fasciitis
  14. Ah, the images of Paul riding a white charger coming to the rescue of a lady in distress being attacked by the "heavies".........haven't I seen that in the movies somewhere before??:pigs:;):pigs:
  15. musmed

    musmed Active Member


    If stretching works why do patients tell me it has made them worse?. I get paid by them coming back. Pirvate practice and government run business are different things.
    Do you follow up those who do not come back?

    If stretching works,how?

    I get back to what I have said many a time, if it is microtears why stretch a tear?

    Could there a mis diagnosis?
    Could there be other factors present that I have written about. Yes if it is a FLH pain due to a short FLH muscle, yes stretching works because it has nothing to do with the PF.THis is a very common problem.

    The other major problem is a stuck cuboid. Maybe the stretching corrects the subluxation.

    Finally even Dr.Dananberg agree with me that most PF pain is coming from trigger pointsin the Abd. hallucis.

    So stretching again works, but the problem is it is not Plantar Fasciitis.

    As I have taught in many countires around the world, there is an endemic problem with podiatrists in general, they do not know their surface anatomy. Thus if you cannot palpate you cannot diagnose, but they do.


    Paul C
  16. musmed

    musmed Active Member


    Thanks for posting Romulus and Remus.
  17. Paul:

    Sorry, the pigs are the winged clones of Arnold Ziffel, my favorite actor from my younger days.
  18. Dawn, I assume that I may be one of the "heavies" that Paul (Musmed) described to you. Even though I am 5' 10" and about 168 lbs, I am certainly heavier than my college distance running days when I was the "70 kg man". I think your questions are excellent, and hopefully Paul won't need to ride in with his white charger to save you from me.;)

    "Plantar fasciitis" as we currently call it, is probably not just one diagnosis, but several diagnoses. Certainly, even though the pain in "plantar fasciitis" is generally in or directly adjacent to the central component of the plantar aponeurosis (the correct anatomical name for the "plantar fascia"), it may be caused by different forces. For example, "distal plantar fasciitis", where the pain is only within the longitudinal arch of the foot, is nearly always caused by increased magnitudes of plantar fascial tensile force. But in "proximal plantar fasciitis", where the pain is plantar to the medial calcaneal tubercle (the origin of the central component of the plantar aponeurosis), the pain may be caused both by an increased magnitude of compression force from the plantar heel hitting the ground too hard and/or an increased magnitude of tensile force within the plantar fascia.

    The problem is that when a patients presents to us with plantar heel pain and we tentatively make a diagnosis of proximal plantar fasciitis, we may not know if the injury was initially caused by compression forces on the plantar heel (e.g. walking barefoot on a tile or hardwood floor at home, plantar fat pad atrophy that decreases the natural cushioning force on the plantar calcaneus) or by a tensile force that is causing a traction injury to the plantar fascial origin site on the plantar calcaneus. This variable biomechanical etiology of what we call "plantar fasciitis" may directly influence our ability to get these patients all better and how these patients respond to various treatments.

    I have had very good clinical results in treating most cases of plantar fasciitis by having my patients do 3 minutes of gastrocnemius and soleus stretching exercises three times a day. I rarely have patients "not tolerating" the stretches, so maybe you are doing these stretches differently than I am. How do you have patients stretch, specifically??

    The theory behind the stretches is to try and lengthen the gastrocnemius-soleus-Achilles tendon (GSAT) complex so that the tensile forces within the plantar fascia are decreased during weightbearing activities. There are very good cadaver research studies that show that there is a direct correlation between Achilles tendon tensile force and plantar fascial tensile force. Therefore, if we can lower the tensile force in the GSAT and plantar fascia, and if we are trying to allow the plantar fascia to heal from a microtear while they are continuing to perform their daily activities, GSAT stretching makes good clinical sense to me. Even better, as Craig said, it works!

    Direct manual stretching of the plantar fascia (e.g. ball rolling or bottle rolling plantarly) does seem to work in some patients as do plantar fasciitis night splints, plantar strapping, over the counter and prescription foot orthoses, and therapeutic modalities such as ultrasound and phonophoresis. I have used extra-corporal shockwave therapy with mixed results and even had a patient that claimed that laser heat therapy helped her chronic plantar fasciitis.

    As far as I'm concerned, we are still in our infancy in understanding all the diagnoses that make up what we currently lump into a single diagnosis of "plantar fasciitis". However, most skilled podiatrists seem to get about 90% of these cases healed within 1-6 months with the above conservative treatment options, without surgical treatment.

    Hope this helps.
  19. musmed

    musmed Active Member


    Stretching appears to be in the mind here.

    If there is no ROM to the ankle joint you aint ever going to stretch the joint.

    You all have the bull by the tail.

    A muscles role is to protect the joint, nothing else. Simple. Why do they all act as eccentric loaders? Joint protection

    Thus if the joint no move muscles no move!

    Ask any athlete who stretches his calf and hammy muscles for 30-60 minutes a day and then the next morning they have shortened again.

    Simple they match the ROM of the joint.

    So mobilisation or manipulation (worth trying before putting down) changes the ROM and muscles lenghten immediately.

    Ankle ROM mobes/manip ccan increase hamstring lenght from the usual 40 (athlete) to an easy 80+ degrees. Done it 1000's of time.

    You mention that there may be other causes of PF yet when you read what you wrote I did not see anything outside of the PF.

    Craig said it works even better...tut tut.

    We had a prime minister who told us we needed a banana republic and interest rates went to 17%.

    Can't wait, they now are at 9.05% this morning!
    Paul C
    PS my horse is happy to meet your pigs anywhere.
  20. DSP

    DSP Active Member

    Hi Paul,

    Paul, I don’t think Kevin implied that it was his goal to “stretch” the ankle joint. He was specifically referring to gastrocnemius-soleus-achilles tendon (GSAT) complex . Is there even such a thing as “stretching” the joint? I thought the whole idea of stretching was to stretch the muscle? Please correct if I am wrong.

    If there are micro-tears in the plantar fascia (PF), I can see why PF stretches are possibly detrimental, but why would GSAT stretches be a disadvantage? Wouldn’t these actually be beneficial (in some people)?

    Paul, could you please explain your technique/s as to how you mobilize and manipulate the ankle joint? I would find it very helpful as I have never applied these techniques before.


  21. musmed

    musmed Active Member


    AS to how to mobilise the joints of the foot and ankle it requires an attendance at a workshop. It is impossible to just read something I have typed in and apply it. I wish it was that simple.

    As regards to stretching. Just spend a minute thinking about what you wrote. It is impossible to only stretch a muscle without placing a joint or joints on stretch. If the joint does not have the ROM to allow the muscle to lengthen then how can a simple stretch work. If the joint has the ROM but the muscles does not, then there is something wrong with the muscle and you need to address the muscle.

    Finally, you cannot stretch the Achilles tendon. May I suggest you look at graphs of creep and tendon stress strain curves.

    Basically once you stretch a tendon more than 5 degree it loses it strength and the tendon will follow to failure.

    I doubt any of us can apply enough tension to stretch the Achilles tendon under normal stretching conditions.

    Hope this helps

    Paul C
  22. Paul:

    All materials can be stretched, even the relatively compliant Achilles tendon. When you look at a stress-strain curve of an Achilles tendon under tensile load that you mention above, what do you think that the strain side of the graph represents?
  23. Colleagues:

    Contrary to Paul's contention that the Achilles tendon can not be stretched, research has repeatedly shown that the Achilles tendon is an elastic structure, and as such is stretched repeatedly during exercise. The following study showed that the Achilles tendon contributed 38 Joules of energy back to the individual during one legged hopping by first stretching then recoiling during the hopping exercise. http://jeb.biologists.org/cgi/content/abstract/208/24/4715
  24. musmed

    musmed Active Member


    Lets be truthful here.

    Do you really think that by stretching the Achilles by 1-2% is going to make any difference to the overall change in the complexes length?

    Also, if the tendon is normal, I thought the graphs show that the creep you have put into the tendon should disappear. I thought that's what tendons do.

    Once you go to far and develop irreversible plastic deformity, you have non return to normal and pathology starts.

    Paul C
    PS this has nothing to do with achilles tendinitis and rupture.
  25. Paul:

    What is this statement implying?? Does your statement mean that what you say must be the truth, because you said it, and what I say, since I am disagreeing with you, must not be the truth? Please explain.
  26. DSP

    DSP Active Member


    It seems to me, that you think that just about everyone is prescribing GSAT complex stretches in pts with plantar faciitis. I don’t believe that to be true. I do not routinely prescribe GSAT complex stretches unless I suspect this muscle group to have some etiological involvement. If a tendon appears normal, then why prescribe stretches?


  27. musmed

    musmed Active Member


    I have been doing a 2.5 year follow up on about 120 patients who presented to the programme with a diagnosis of PF.

    One of the questions I asked on the initial question form was: Have you been told to stretch the gastroc/soleus. Over 115 were told yes.

    Another question was: 'did it hurt' Guess the answer
    Another question was ' did you stop' No banana for guessing the answer
    but a pearler was, when asked are you still stretching by their podiatrist, guess the answer, they all answered 'yes'

    One of the main stays of therapy is no stretching.

    Hope this throws a penny in the works.

  28. musmed

    musmed Active Member


    I am not saying what you aer saying is wrong but I am in reality about this.

    The paper is about one legged jumping. I see people all the time moving around on one leg saying I am recoiling with 18 joules.

    This is 4.3 calories of energy or 0.018Kilojoules. So close to nothing.

    This is what I am implying.

    Science is wonderful, but in the big picture, in this case of Achilles stored energy is basically irrelevant.


    For those who do not fully understand what is going on have a look at this website.

    It is a great teaching tool.

  29. DSP

    DSP Active Member


    Before you get all excited, out of the 115 pts, did you test how many pts had a tight GSAT complex? For the some of them (but of course not all) there must have been a valid reason for it.

    In all the pts I have prescribed GSAT complex stretches to (when appropriate), I have never once had a pt complain of soreness. I always make sure I ask too. For the 115 people that answered “yes” to “did it hurt” in your 2.5 year follow-up, obviously their technique was flawed. Consequently, this might have been a result of the practitioner misinforming the pt, or this could have been due to pts incorrectly executing the exercise.

    Paul, judging by what you wrote, “but a pearler was, when asked are you still stretching by their podiatrist, guess the answer, they all answered 'yes'”, I cant help but notice that you obviously have a feeling of contempt towards “podiatrists”. Paul, just so you know, there are just as many physiotherapists, GP's, osteopaths, chiropractor's etc out there who employ stretches for PF too (no disrespect to these professions either). Open your eyes, Paul, we aren’t the only profession on earth prescribing these stretches to pts.

    So if you don’t utilize stretches, I think from an educational standpoint, it would be very helpful to me and everyone following along in this thread, that you outline your treatment criteria and why? And please don’t tell me that I have to attend one of your workshops.

    Last edited: Feb 9, 2008
  30. musmed

    musmed Active Member


    All the patients (but one) had been to podiatrists for evaluation of their foot pain. 5 had been to 6 podiatrists over a period of several years. The longest time a patient had the condition was 13 years, the shortest was 3 weeks (this person had not seen a podiatrist).

    I have no bent towards any person or trade. I just feel that many treatments out there are used because some one said it works.

    Daniel if you want to learn re read your last sentence.

    You cannot beat a hands-on workshop for learning and understanding the process and reasoning behind it.


  31. DSP

    DSP Active Member


    This forum exists so that we can all learn from one another. That is what I would have hoped to achieve from our discussion. Judging by what I have read so far, it sounds like a contest for “who can outsmart the other”. What is preventing you from answering my question? I’m not asking you to explain your technique(s), that would be unfair. However, you should still be to explain what you do and justify why you do it. I am always keen to learn, especially if it is something I have never heard of or applied before. I'm sure what you do has tremendous value, but instead of facts all the time, a little more explaining would be helpful from time to time for all of us reading along, so that I/we can better understand your objectives. Unfortunately, Paul, as much as you continue to promote your workshops, in reality, not all of us have the opportunity to attend them, so as I said before, in future, more elaboration and justification would be appreciated.


    Last edited: Feb 9, 2008
  32. Paul:

    Let's be truthful here!

    The Achilles tendon does stretch and needs to stretch to optimize energy return in weightbearing activities (Lichtwark GA, Wilson AM. In vivo mechanical properties of the human Achilles tendon during one-legged hopping. J Exper Biol, 208:4715-4725, 2005; Ker RF, Bennett MB, Bibby SR, Kester RC, Alexander RMcN: The spring in the arch of the human foot. Nature, 325: 147-149, 1987).

    The amount of energy return into the lower extremity by Achilles tendon stretch and recoil has been estimated to be between 35 - 38 Joules, which is estimated to be not insignificant, as you say, but rather accounts for about 35% of the energy turnover with each footstrike during running (Ker RF, Bennett MB, Bibby SR, Kester RC, Alexander RMcN: The spring in the arch of the human foot. Nature, 325: 147-149, 1987).

    If you aren't familiar with the scientific literature regarding the significant influence that Achilles tendon stretching has on energy return during weightbearing activities, then just say so, rather than continually making authoratative claims, with no research to back up your claims.

    In addition, I don't remember you ever saying anything positive about podiatrists or about podiatric care, in all your comments here on Podiatry Arena, even though you use a podiatrist's comments as a testimonial about the "amazing" nature of your manipulative techniques on your website. It seems to me, from reading your comments over the years, that you think that podiatrists are always doing the wrong things for their patients, and you are one of the few who can do the right things for patients to make them better.

    If you want for us to be impressed by what you claim to be the "truth", then give us some good peer-reviewed scientific articles that support your claims, rather than continually directing us back to your website, where you obviously feel resides the only home of "truth" for foot-health practitioners on the internet.
  33. musmed

    musmed Active Member


    You must be joking

    38 joules.. where will it get you in reality

    Please explain

    Just because I do not have all the scientific data yet, does not mean I am incorrect.

    I spend about 4 hours a day reading from podiatry to tensegrity to cell mutation, cell biology, cellular morphology, genetic mutations etc.. But I certainly use criteria that can I use to see if the data is good.

    Unfortunately it is not in may cases.

    Lets back track a bit

    Every time you are challenged you bring things up that look good.

    But: I mentioned you never wrote out side of PF in the last few emails. Nothing said.

    I mentioned that muscles were for protecting the Joint thus if the joint had a reduced ROM then the muscle length was less.

    You continue to pick on nothings. Pick on what I have said or are they just too bit much for you to comment upon.

    Why do the muscles of the lateral cell group in embryological development eccentrically work in walking..

    They are there for a reason...

    Why in all the discussions we have ever had you have never mentioned a muscle in the foot. There are so many with so many functions.

    Hve you ever thought why does the lower limb and the foot have prime numbers of muscles present?

    So much to think about.

    I have spent years thinking about all of this, not some petty little thing about what your perceived ideas that what i have written that denigrates the profession.

    It is so easy to grab onto the negatives about anything, look at you presidential race..........................

    This is not what I am on about.

    Just stop changing the topic or grabbing onto something that may get you browny points.

    Podiatry and the world in general is bigger than both of us.


    PS on holidays out back in the wet. Best wet since the early 70's where I am going
    Looking at primitive frogs and fish.
  34. DawnPT

    DawnPT Member

    Wow, you guys rock. I am glad you all are helping me learn how to help treat this condition better in my little corner of the world. And you are making me question what I've been taught and actually turn the biomechanics and research on this issue.

    I have questions (of course)-

    1) For stretching the GSAT- does the calcaneus have to be in neutral for these stretches to be effective? This is why I have a hard time prescribing them because I don't think they are doing it properly.

    2) Ball rolling techniques on the bottom of the foot- does this help stretch the aponeurosis as much as it does increase the blood flow?

    3) Are we saying joint mobilizations to increase dorsiflexion will help or won't help?

    4) "Ankle ROM mobs/manip can increase hamstring length from the usual 40 (athlete) to an easy 80+ degrees." (Paul)
    How are you measuring the HS length to increase 120 degrees? 90/90 test?

    5) Do podiatrists learn joint mobilizations while pursuing their degree?

    6) What about Anodyne therapy? Will the infrared light treatments help the problem since they increase circulation? Is it worth a shot? (insurances here don't cover Anodyne anyway, so where I work provides it free of charge for those with diabetes anyway)

    In regards to the study on stretching recommendations, my personal experience has been that stretches didn't hurt in a bad way, more like the "good" kind of hurt. I even added in the cross friction massage with the tennis ball on the origin of the fascia.

    On a side note, I definitely had the "compressive proximal PF". I developed it when I was pregnant and had bad heartburn the last trimester- I would sleep in the recliner with my heel of my foot resting on the edge of the footrest. I didn't realize the compressive forces would cause this condition. Thus began my almost 6 month journey to a pain free foot condition. Who would have thought?
  35. The subtalar joint does not need to be in neutral to get an effective GSAT stretch, but it certainly would help. To eliminate some of the arch flattening tendency with GSAT stretching exercises, I will instruct my patients to point their back foot (i.e. the leg they are stretching) straight ahead during the stretch. My office handout for stretching is located in this thread .

    2. Ball rolling probably locally stretches/massages the plantar fascia.
    3. Joint mobilizations may or may not help dorsiflexion, the jury is still out on this one.
    5. I didn't learn any of these, but some podiatrists, such as Drs. Howard Dananberg and Bruce Williams, routinely use mobilizations quite effectively in their practices.
    6. I don't know enough about "Anodyne therapy" to either recommend it or recommend against it.
  36. musmed

    musmed Active Member

    Dear Kevin

    Methinks the jury you mention is the one that gave the verdict in the OJ Simpson case.

    Back from the bush.

    Paul C
  37. What a great thread!

    That is probably the most sensible thing i seen written about PF for a long time!!

    As Kevin points out there can be several precipitant factors involved in PF. I also suspect a good deal of what is diagnosed as PF is in fact no such thing.

    If there is a treatment which some podiatrists seem to be using to good effect and some are not there would seem to be two possibilities. Either one group is mistaken as to the effectiveness of the technique, or the two groups are in fact using a DIFFERENT technique (or the same technique on different patients.)

    The Evidence supplied by CP would seem to indicate that, at least in some circumstances, stretches can be benificial...

    That would seem to suggest that either we are talking about different types of stretches OR that the perception that they are ineffective is flawed.

    Please remember, musmed, that if you are basing your observations on people who come to you AFTER seeing another professional and being prescribed stretches your subject group is grossly skewed. That would be like saying 100% of skis cause broken legs because all the people who attend the fracture clinic with ski's have broken legs. Its a gunslinger fallacy. People who get better don't seek further opinion.

    On a very slightly divergant note has anyone tried stretching using the strassburg sock

    Seems to be some kind of night splint. There was apparently a small study done with it in JFAS but for the life of me i can't track it down.

  38. DawnPT

    DawnPT Member

    A Retrospective Study of Standing Gastrocnemius-soleus Stretching Versus Night Splinting In The Treatment Of Plantar Fasciitis.

    Plantar fasciitis is the most common cause of heel pain, yet the conservative treatment of plantar fasciitis is not standardized. This open retrospective study compared the effects of standing gastrocnemius-soleus stretching to a prefabricated night splint. One hundred and sixty patients with unilateral or bilateral plantar fasciitis were evaluated and treated according to the standard regimen in addition to either night splints or stretching. Seventy-one patients performed standing stretching of the gastrocnemius-soleus complex. Eighty-nine patients utilized the prefabricated night splint without standing stretching. The night splint treatment group had a significantly shorter recovery time (p<.001), fewer follow-up visits to recovery (p<.001), and fewer total additional interventions (p=.034) compared to the stretching group. Absolute body weight, body mass index, and age did not have a statistically significant effect on the time to recovery or additional interventions needed. The duration of pain prior to our treatment was a predictive factor and was associated with increased time to recovery and increased number of treatment interventions. It was concluded that early treatment in a standardized four tiered treatment approach including the night splint without standing stretching of the gastrocnemius soleus complex, speeds time to recovery. (The Journal of Foot & Ankle Surgery 41(4):221-227, 2002)

    It was on their website...
  39. musmed

    musmed Active Member

    Dear Robert

    The numbers are not skewed. It shows that many are told to stretch and those I saw came from word of mouth and one article in a sydney magazine.

    This article generated more queries to the magazine than any of the other articles over 10 years it had published. That includes all forms of cancer etc.

    Interesting eh?

    Paul C
  40. Fascinating. But still statistically suspect.

    And the rothbart / glazer threads are probably the ones which generated the most "queries" on this forum. That is not necessarily to say that the theories are accurate!

    I contend that your sample group WAS skewed. You said
    Your sample was 120 patients. All of them had previously seen another professional. All of them (by virtue of the fact that they presented to the program) were unresolved. If 115 of them had beest prescribed stretches that shows only that stretches don't ALWAYS work.

    If i saw 1000 patients with PF and treated them all with orthotics a proportion of them will (sadly) for whatever reason, not reslove. If 20 of those turn up at your door and constitute a sample group then you would draw the conclusion that orthotics do not work on PF.

    Please show me the flaw in this logic cos i'm struggling to see how a sample based on those who have not resolved on "standard" treatments can be considered representative of the whole.


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