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Plantar Fasciitis in 11 yr old high level gymnast

Discussion in 'General Issues and Discussion Forum' started by Debs, Feb 14, 2016.

  1. Debs

    Debs Welcome New Poster

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    I have a patient who is an 11 year old male gymnast training/competing at a national/international level. The Pt. is suffering with Plantar Fasciitis.
    I have issued supportive insoles and stretching exercises for the PF and posterior muscle group. Unfortunately the patient's mother informs that the patient is not very compliant with the exercises as he stretches at all gym sessions (but with toes pointed) and for approx 17 hours a week he is walking barefooted in the gym. The patient is growing quickly being tall for his age. His mother also informed he has an increasing tendency to walk on tiptoe's to help alleviate the discomfort felt, particularly first thing in the morning.
    His mother has asked if Laser therapy may be beneficial ?
    she is also concerned that he may suffer long term/permanent problems from this ongoing condition?
    I would be grateful if anyone could advice on the efficacy of Laser therapy in this cituation, any possible permanent/long term affects, and any other relevant treatment options to be considered.

  2. When I have a gymnast with plantar fasciitis, I teach them how to put a good Low-Dye strapping on their feet before their workouts. Works great, but you may need to spend a few office visits teaching them how to do it on their own correctly. Hope this helps.:drinks
  3. mgates01

    mgates01 Active Member

    Hi just out of curiosity would I be right in thinking that PF is relatively rare in younger patients. Anyone got any papers on its prevalence in the under 20 year olds. Thanks Michael
  4. Ben Lovett

    Ben Lovett Active Member

    Hi Debs,

    I'd be in agreement with Michael here, how certain are you of your diagnosis? Is the plantar fascia thickened on Ultra Sound Scan? Have you excluded Sever's Disease as a source of his heel pain?

  5. Craig Payne

    Craig Payne Moderator

    Yep; I would get an ultrasound done to confirm diagnosis, esp the extent of hypoechoic signal (if high, then thats bad) and thickness (if thick, then thats bad)

    Then go back to basics:
    1. Reduce the load in the damaged tissue: in this case: low dye strapping (as suggested above by Kevin); orthotics (make sure the orthotics have the right design features to actually reduce the load in the plantar fascia); negotiate with them (the them with the coach) to increase use of orthotics during gymnastics; eg use them during warm-ups; etc; reduce activity levels (I know he 'high level', but when you gotta do it, you gotta do it)
    2. Increase the ability of the tissues to take the load: in this case: progressive overload exercises with the plantar fascia under load; check nutritional status
    3. Facilitate the tissues healing (but really need to sort (1) and (2) first ... lots of things here: NSAID's; cortisone; shockwave; etc ... your question on laser therapy is, yes it does work (see this thread) ... but what you do not want to do is get into the trap of moving from one therapy to another (eg try this; it didn't work; so try this then; it didn't work; so try this ...etc) .... you need a plan that starts with sorting (1) and (2) first (after getting the diagnosis confirmed)
  6. JamesSainter

    JamesSainter Member

    Is low-dye strapping the same as K-tape or do they have different effects?

    I have been taught the fan method of strapping (see picture). Is this still the most effective way of doing this? does anyone have any better techniques?

  7. Philip Clayton

    Philip Clayton Active Member

    Are you sure its plantar fasciitis and not Sever's Disease which is more typically found in young people and especially girls of that age?
  8. Griff

    Griff Moderator

    This is the method I go for (fast forward to 4:11 if you don't care for the build up talk):

    Last edited by a moderator: Sep 22, 2016
  9. Is there any benefit in running the cross-straps from distal to proximal rather than proximal to distal, Ian?
    Last edited by a moderator: Sep 22, 2016
  10. Griff

    Griff Moderator

    None that I'm aware of: just habit on my part. You could argue proximal to distal has the advantage of being less like to 'ruck up' when socks are put on and with the action of putting a shoe on. I've not found it to be a deal breaker personally. You a proximal to distal guy?
  11. Again just the way I was taught was proximal to distal to prevent rucking up. Just wondered if I'd missed something.
  12. My cross straps go Distal to proximal FWIW,
    and I would never stick tape to the supine part of the foot, we would have failed at school so tradition

    last 13 years or so I have added an heel lock type of thing which has made the taping results much improved, with 5 cm start at the cuboid pulling the tape medially and a slight posterior angle, under the medial malleolus, around the back of the leg, finishing on the front tibia 1/3

    really helps pic included to make more sense

    the tape goes on last after the low dye is finished

    Attached Files:

  13. Debs

    Debs Welcome New Poster

    Thanks for all your replies.
    I had thought of severs as being the most likely cause due to his age, sex and sport, however the patient experiences no pain whilst walking or performing gymnastics. The pain is felt first thing in the morning and after periods of rest during the day. On one occasion he was fine when picked up from his gym session but after the 1/2 hour drive home was hardly able to stand when getting out of the car, after walking for a while the pain reduced.
    I will be seeing the patient again next week with a view to getting him to see his GP for an ultra sound, and showing him how to apply low-dye taping.
    I will update the thread when I know more, as i agree he is very young to be suffering with PF.
    I am still unsure why walking on tiptoe would alleviate his symptoms as from what I have read on both Severs and PF this should exacerbate the pain?
  14. Debs:

    Walking tiptoe will generally decrease the pain from distal plantar fasciitis, as will walking in shoes with higher heel height differentials.
  15. mgates01

    mgates01 Active Member

    I'm always wary of attributing the term Plantar Fasciitis to patients of this age. I certainly agree these symptoms are consistent with PF type condition.
    I tend to associate PF with older patients / over weight patients / or patients who have taken up activity after a relatively sedentary lifestyle. I realise I might be totally wrong in these generalistions.
    I would tend to tell patients of this age that it is most likely a plantar facial strain.
    I realise its probably semantics and I suppose that is why I asked if there was any evidence out there on the prevalence of PF say in the under 18s.
  16. efuller

    efuller MVP

    Interesting video. It is interesting to see more regional variations in how the low-dye strap is applied.

    When I was taught the strapping technique, there was an emphasis on plantar flexing the first ray during the application of the tape along the medial arch. I didn't see that in the video. Well, if everyone's method works, then maybe plantar flexion of the first ray isn't so important. Another potential study?

    Last edited by a moderator: Sep 22, 2016
  17. Griff

    Griff Moderator

    Hey Eric

    Personally I don't directly plantarflex the 1st Ray but the two first anchor straps slightly achieve this as long as they are adhered plantar to the 1st MTPJ and not medial to it (see attached screenshot from the video).

    You're right though - I'm not even sure what's important when this tape is applied anymore. In one of the multidisciplinary teams I work in there isn't a single person who does it the same as another. All report similar 'success' rates.

    Attached Files:

  18. Ina

    Ina Active Member

    There are some data from a prospective evaluation of 1000 consecutive clinic visits to an urban general pediatric clinic in Madrid, Spain, mentioned in:

    Chiropractic management of pediatric plantar fasciitis: a case report

    presenting the case of a 10-year-old football player with bilateral plantar fasciitis who improved with a multimodal conservative approach using chiropractic treatment

    From introduction:
    "Although plantar fasciitis occurs most commonly in the adult population, a study of 1000 consecutive pediatric musculoskeletal cases presented this condition as having a prevalence of 8.2%. 1"

    1. Inocencio J. Musculoskeletal pain in primary pediatric care: analysis of 1000 consecutive general pediatric clinic visits. Pediatrics. 1998:102.
  19. As mentioned earlier, if over-the-counter orthoses fail, then I will put a low-Dye strapping on the patient and have them try to keep it on a few days, if possible, to see how it helps relieve the pain. The parents and/or coach can be taught how to tape and then it is best to put the tape on before the workout, and then take it off a few hours later to minimize tape irritation to the skin.

    The reason why low-Dye strapping is so effective for plantar fasciitis is that low-Dye strapping shields the plantar fascia from excessive tension stress by sharing with the plantar fascia and plantar ligaments their tension forces that help prevent the medial longitudinal arch (MLA) from collapsing. With the low-Dye strapping sharing the tension load and helping to prevent the MLA from collapsing, the tension stress then on the plantar fascia and plantar ligaments will become less.

    In addition, since the plantar strapping is a larger distance away from the horizontal reference axes of the midtarsal and midfoot joints than the plantar fascia,and especially the plantar ligaments, the low-Dye can generate a relatively large external forefoot plantarflexion moment by pulling on the skin of the plantar foot with relatively little tension force. Certainly, for the motivated athlete, daily low-Dye strapping is an excellent way to treat this painful condition and still allow the athlete to train and compete with plantar fasciitis or any of the other varieties of pathologies caused by excessive external forefoot dorsiflexion moments commonly seen in the sports podiatrist's office.

    This illustration (http://images.slideplayer.com/12/3439413/slides/slide_19.jpg) fairly well describes how I apply the tape for low-Dye strapping. I prefer cloth adhesive tape, not K-tape (too stretchy and expensive) and I apply the tape while the patient is supine, not prone, so they can watch me apply it. All podiatrists should become very good at this technique since it has been around for over three-quarters of a century and can be "life-saving" for many athletes (Dye RW: A strapping. J National Assoc Chiropodists and Pedic Items, 29(11):11, 1939).
  20. PostMortem

    PostMortem Active Member

    Hi Debs, I am curious as to the history of the symptoms. How long has he been a gymnast, when did symptoms start, what was the onset pattern, had there been any change in training? Just a few questions that may help to inform diagnosis and diff diagnosis.

    What is happening with muscle function in the leg? Are there trigger points (focal areas of muscle spasm) in FDL, Tib Post, Soleus? Is there any knee, hip or lower back pain? What is happening on the other leg? What's his FPI score? Does he have a 'relative' soft tissue ankle equinus on the painful side?

    There are a lot more structures that cause heel pain than just the Plantar Fascia and duration of injury is likely to increase the number of muscles/tendons/ligaments that develop pathology/dysfunction. They will need treatment too.

    If there are triggers points, a course of acupuncture/dry needling may help as part of the treatment plan.
  21. Peter

    Peter Well-Known Member

    I scan all paediatric pts with heel pain; I have only ever seen plantar fasciosis in one child; he was aged 15 and very obese.
    Last edited: Feb 22, 2016

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