Plantar Fasciitis Discussions

Hey all,
It has been great to read through the posts about this painful condition. I work with your scripts as an allied medical team member to the patients treatment plan. There are many conservative modalities that will help the patient in any given case. I have seen a combination of many such modalities used successfully. The main one is to provide support to the foot if the patient needs to get around.The support will help keep a pronated foot from torquing the plantar fascia and the PTT as well as keeping the arc the palntaqr fascia helps to keep in the windlast mechanism it is to accomplish. This can be in a combination of a good supportive shoe that is not worn out. A worn heel on a shoe will cause more invertion at heel strike. This will cause the moments of gait to be exagerated causing other pressures.
Orthotic support either OTC, custom functional or supportive accommodative device is in order. I have had great success with the birkobalance orthotic. These can be modified post fitting by heating up the cork on the prominent areas or gluing posts to the cork to change the pitch of the orthotic some what more.
I also talk to the patients about a night splint if needed and to see their doctor about that device. this will help to hold the foot in a positon to allow the plantar fascia to not be strained as much at weight bearing the first thing in the morning.
I have also seen patients who get this painful malady back again becaus ethey feel they are over the problem and don't need to be compliant to the support of the shoe and orthotic therapy. I have seen great success in cortozone shots given by doctors coupled with orthotic therapy and shoes that support midial and lateral displacement and torsion. It is a continual battle to find the one modality that works all of the time. The closest I have seen is the birkobalance with a good strong shoe. R.I.C.E.couldn't hurt. Mothers of three just laugh at me when I say rest is important.
It looks like a study needs to be done empiracally on the wife's tales and the sound scientific understanding that is out in the scholarly circles.This should cover the known OTC orthotics and the other modalities of stretching the achilles to have less pressure on the calcaneous so the plantar fascia will not be pulled on because of the tight Gastroc.
Rick Woodland
Cped0810

 

I'm a bit out of touch in my foot-care, but i was under the impression that Plantarfasciitis is inflammation of the plantar fascia - usually due to it being stretched around the calcaneus.... so if you reduce the tension in the plantar fascia, the pain will subside.
I recommend people to gradually stretch the plantar fascia before they get out of bed in a morning to sort of 'warms up' the plantar fascia so its not as easily damaged

Are Heel Raises / FFO's / Night Splints still the orthotic recommendation still?????

 

Its not an inflammation.

 

Craig:

There are studies that do show evidence of inflammation on biopsy http://www.bcm.edu/medpeds/articles_handouts/plantar_fasciitis.pdf,

edema in the bone of the plantar calcaneus http://radiology.rsnajnls.org/cgi/content/full/2341031653v1

and peri fascial edema. http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=12403

If it's "not an inflammation" of either the plantar fascia or the tissues that surround the plantar fascia, then what causes the pain of plantar fasciitis and the positive response of plantar fasciitis to oral anti-inflammatories and cortisone injections?

 

Hi Everyone

Reading these discussions with great interest.

I'm certainly not an expert on biomechanics or plantar fasciitis - however I still have dozens of patients with these types of symptoms walk in the door. Not being an expert doesn't mean I don't get to treat them apparently.

I think one thing that we seem to overlook with stretches is how all the different professions prescribe them. I don't know about anyone else but when I'm prescribing stretches for the gastroc, soleus and plantar fascia/aponeurosis (which I do for every case) I emphasise and emphasise again to the patient to stretch to comfort only - NO PAIN or DISCOMFORT. I explain it in terms that the plantar fascia has some micro tears and as a result the ligament tightens up like most people do across the shoulder blades when they feel stressed. It's not necessarily that the muscle/ligament/tendon is too short but rather it is stressed and needs to relearn how to relax rather than stretch. A lot of these patients have already been seeing other health practitioners and have been doing stretches for months with no noticeable improvement in muscle flexibility or "feeling" of muscle flexibility or symptoms.

I also initially prescribe ice/massage (ie frozen coke bottle) and ppt heel padding if the patient is on their feet on a hard surface all day.

Clinically (and please remember this is my own experience not a study of any type) I have found that the patients who "stretch" to discomfort or pain come back in four weeks with the same level of symptoms or worse (ie in my mind they tore those micro tears further) whereas about 90% of the patients who stretch to comfort report a significant improvement or complete resolution of symptoms. Those that have an improvement but not complete resolution always have another biomechanical issue at play (such as excessive pronation or 1st ray instability for example).

I've also found that patients have a much higher compliance rate with stretches when they know the treatment is not going to hurt.

Anyway this is just my experience - I'm not disagreeing with anybody else but I have a lot of patients who are initially sceptical because it almost feels like they are doing nothing (ie no pain no gain mentality) - few are sceptical when the pain goes away. I also follow up every patient with a phone call that doesn't turn up for their review - I don't like having unhappy, sore patients.

Do other people think we need to be more consistent with how we prescribe stretches to get maximum benefit?

Cheers
RStone

 

I think we been around this trap many times, I just can't find the previous discussion:

 

Round and round the stump we goes.....where we stop....nobody knows....igs::drinks

 

Paul

You wrote

Paul

I'm not sure how long term stretching works and admit to being a little baffled at times when I think of the mechanics and physiology of it, but work it does.

Not just medics and therapists believe this but sportsmen and entertainers, yoga and pilates, martial arts and ordinary people who just naturaly stretch when their muscles are stiff and hurt. And they have been doing it for eons because it works.

People like contorsionists and matrial artists don't become more flexible than average by accident. They work on it for year and years. Some get so good at it that their joints are hypermobile (in the traditional sense) and suffer pathology due to this. I believe that a large part of it is that stretching allows more range of motion rather than manufacturing or forcing extra RoM. IE it allows the CNS to realise that the extra angular displacement will be ok and there will not be injury because of it in future. I also believe that joint mobilsation also physically allows greater RoM and that stretching after mobs allows the RoM to be preserved long term more effectively than stretching alone.

I do not understand why you say that

Muscle and joint are synergistic and one is useless and pointless without the other. Joints allow angular displacement and muscles control acceleration of angular displacement and to some extent control the range of angular displacement . The control implies protection but not solely protection.
Clearly muscles can become shortened eg spastic hypertonia and not allow wide RoM so the opposite should also be true.

It also seems clear that muscle stretching is never permanent and so stretching regimes must be kept up on a regular basis, but it apppears by my experience that the longer the regime is kept up the longer also it will take for the muscle to shorten when the stretching is stopped and restretching is easier than starting from scratch. This is my experience in over 40yrs of martial arts. I find it takes about 6 months of regular stretching for an average person to achieve a good high kick that can be taken to the head of a similar sized opponent. Over a number of years you can observe people gradually becoming more supple. Some more than others of course.

Just my thoughts and observations

Dave Smith

 

Hi all. Great thread to read.

In terms of heel pain which is commonly diagnosed as plantar fasciitis I too have been a little confused over the years due mainly to the contradicting views I have read in journal articles since leaving Uni as opposed to those views I was taught. I see from this thread I am not alone.

One aspect I have not seen in this thread is the possible contribution of nerve entrapement, mainly of the 1st branch of the lateral plantar nerve (otherwise known as the calcaneal nerve or sometimes the nerve innovating the abducti digiti minimi). Can such a nerve entrapement eventually be alleviated by stretching of the soft tissue structures around it? Could this be contributing to some people getting better results from the stretching than others? I also feel that this may be contributing to the pain relief felt when trigger points in the Abductor Hallucis & Quadratus Plantae are released. (I think Paul alluded to this in an earlier entry). Perhaps the dynamic stretching of the plantar fascia ie tennis ball, rolling pin etc actually contribte more to masaging the layers of muscles in the foot thus releasing some tension & freeing the entraped nerve.

Some food for thought is the Heel Pain Triad as described by Labib et al (Foot & Ankle International Vol 23, No. 3; march 2002). There are many other articles describing nerve components to heel pain also.

Personally I have found that in heel pain that is unresponsive to what I call traditional treatment (based on my original education not an indication of where I think the different therapies lie) such as orthotics, Gastroc/soleus stretching exercises, plantar fascila stretches, RICE, strapping etc a series of gentle mobilisation techniques (especially talar glide) seems to be very beneficial. Couple this with dry needling for trigger point release & continued orthotic therapy & most seem to resolve. (Daniel & Dawn I hope this is the sort of addition to the discussion you are looking for.)

Cheers
Ben:drinks

 

I have been reading this thread with interest for some time now and would like to add some of my own thoughts.

First I think we should be clear that there is an acute and chronic phase to the care of anyone suffering from PF; fasciitis vs fasciosis. The treatments are not the same so why on earth would the attending strecthes be?

Regardless of the methods different professions were taught in college to address the pain of PF, there is a common and overlapping thread that includes stretching.

Stretching can be further divided into active and passive, weight-bearing and non weight-bearing. There are also active, non-weight bearing stretches against gravity and resistance such as post-isometric relaxation, active release etc.

When a patient has an acute PF complaint and equinus due to a tight GSAT I do not believe that weight-bearing stretches benefit that patient. The increased load on these structures will in all likelihood exacerbate the complaint. Micro-tears and possible full thickness tears in tendons are a common result of permitting patients to bear the full load of weight-bearing in active stretching in acute conditions.

This is the phase of care where passive modalities such as RICE, night splints, ultrasound, electrical muscle stimulation, anti-noninflammatory medication or NSAID's etc. afford a great deal of relief. In this phase of care I find that among the most beneficial treatments is soft-tissue release and passive mobilization of the lower extremity in combination with the above.

With chronic cases typically the patient can begin to add active weight-bearing stretches when indicated. Active strengthening of the muscle intrinsics and GSAT can be introduced comfortably and safely once the patient’s complaint is either resolving significantly, or their complaint is chronic but improving.

Refractory plantar fasciosis, where there is a thickening of the fascia is a condition that frequently does not respond to stretching and physiotherapy.

Differentiating between the phases of care is paramount to success in PF treatment as it is in any soft-tissue injury be it muscle, tendon or ligament or a combination of the above. All of these treatments in the appropriate phase support the successful outcome of any program where the patient’s biomechanical pathology is addressed with orthoses.

I believe that there exists a gap in the overlap between the professions that is as yet unfilled. I know of specialists who favor the old weight-bearing calf stretch for PF, even when the patient is in acute pain.

Also the Achilles tendon can be ‘stretched’ in some people and not in others. Muscles tend to be more complaint, although patients are not always so.

Any thoughts?

 

Hi all,

That's say when a patient fits all the typical signs and symptoms of plantar fasciosis (e.g. pain at insertion to medial calcaneal tubercle and along plantar fascia, first thing in the morning, etc) yet ultrasound scan showed absolute no abnormality with the plantar fascia (e.g. no thickening and no tearing).

Does this mean that this patient might not have plantar fasciosis?

Is ultrasound sensitive enough to pick up tiny damages to the plantar fascia?

cheers
Mike

 

Dear Mike

The radiology souls state that the PF at the level of the calcaneal tubercle that is thicker than 4.8mm has plantar fasciitis (or what ever it is).
In one study we did where the history of morning pain etc. was used, only 8 out of 114 had an ultrasound thinkness of greater than 4.8mm
One soul had 9.5 and 10mm thick PFascia but only the 9.5 worried her.
So like many things there are no gold standards.

The results on USonography depend on how skilled the operator is and how sensitive and what frequency the transducer being used is.
An 18Mhertz is a small unit used for looking at the pulleys of the fingers can see Pfascia thickness down to about .05mm in skilled operators. The problem is this transducer called the hockey stick (looks like one) costs $45000 so not everyone has one or use of one.

What you see is a increased thickness over the calcaneal tubercle, looks like a raised hillock at that point.
If there is a defect, it appears as a small black dot. One has to remember that u/sound works by transmitting a signal and getting one back. If there is a small tear, ie there is nothing there (or something with fluid there), so it appears as a black dot up to the size of the top of a biro pen.
All the tears I have seen using U/s and MRI are all on the medial side. Why? Worth having an anatomy think.
Another point, we used colour doppler on every case to see if there is increased blood flow (as used in Achilles Tendinopathy). Not one had any increased blood flow.
I have not seen a paper discussing this point.
Have a good one.
musmed

 

Hi there ,This isnt so much a clinical query more a 'where do I go from here'!.
My patient came requesting a new set of custom made orthoses(his old ones were like nothing I'd seen before and provided by a un-registered practitoner),so I duly examined casted and issued them with appropriate advice -but 6 months later and 3 refurbs later he still says they are uncomfortable.His symptoms are consistent with PF and I rec. all the evidence based stretches etc which I am sure he hasnt complied with.My question to you all is -Has this patient the 'right'to get his money back?and would this be MY easiest solution as I genuinely dont think no matter what I suggest will 'cure' him-(by the way he is a builder)

 

Hi Kevin,

This may have been done to death already, but the exact cause of the pain involved with chronic plantar fasciitis/fasciosis is something I'm still trying to understand better myself.

If the plantar fascia itself is not inflamed (but rather degenerative), then do we at least concede that there is localized surrounding soft tissue inflammation that clinically presents as hot, red, swollen and painful??

If yes, then would it be right to say that even though there is no inflammation of the fascia itself, the body mounts a localised "inflammatory response" in the surrounding soft-tissue structures in response to the repetitive micro-trauma and degenerative tissue damage occurring within the PF and it's attachment to the calcaneus??

Is it this localized "inflammatory response" that causes the heel pain that our patients experience, rather than the actual micro-tearing of the fascia?? Or both??

Am I on the right track here?

Thanks,
Berms

 

Proximal influences on plantar fasciitis?

Hi All -

I wanted to share an article wrote which may stimulate some thoughts on integrating pelvic influences on causes of plantar fasciitis. My background is Human Movement so it is difficult for me to look at the foot & ankle from an isolated perspective. Any patient with plantar fasciitis and decreased ankle joint ROM should be getting a pelvic mobility assessment - I often find MOST have overactive hip flexors and a anterior pelvic position which lengthens the posterior column (hamstrings and calves into plantar fascia).

Is Isolated Gastroc Stretching Adequate for Plantar Fasciits?

Emily

 

Dear Emily
Hi, just wondering how the lordotic spinal position irritates the plantar fascia? Also what does the Plantar fascia do?
Thanks
Paul Conneely
www.musmed.com.au