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Plantar pain

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Ella Hurrell, Jun 10, 2008.

  1. Ella Hurrell

    Ella Hurrell Active Member

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    Dear all

    I saw a strange case this morning - 19 year old male who had pain bilaterally in the plantar central midfoot area. He had been standing, and bouncing :wacko:eek:n tiptoes at home for no particular reason and had a sudden onset of pain in both arches. He suddenly lowered to the floor and has now had pain that is gradually worsening for 3 months. He is not overweight, and is generally hypermobile. I could find no tightness in the calf muscles. He does not participate in any sports at present, but is keen to resume running.

    There was tenderness on palpation of the plantar fascia, although it feels intact, and pain on palpation of just about any area on the central plantar foot - not heels. Pain is worse at toe off during gait. Tib posterior seems to be functioning ok. He is very pronated and reports this has got worse since the pain began. There is no visible swelling. Active plantar and dorsiflexion against resistance causes pain.

    My questions are - is it that easy to tear/rupture one of the plantar structures? Is this likely to be the case, and is it likely that this occured in both feet simultaneously? I don't think it's the plantar fascia, but am wondering if it could be flexor digitorum brevis? Are there any specific diagnostic tests I can do clinically, or is it just MRI etc that will confirm?

    Any ideas gratefully received!:confused:

    Thanks in advance, Ella
  2. CraigT

    CraigT Well-Known Member

    Could be a partial tear of the plantar fascia (more like a strain)- it would still feel intact, and may or may not have some thickening. The mechanical change from the small elongation that would occur would then load other structures which in turn may cause symptoms elsewhere. In addition, if he is hypermobile, he probably has an unstable foot type which would cause constant tension to any damaged tissue and prevent it from healing.
    If the pain came without a specific incident, you would be concerned about something systemic as it is bilateral.
    At this stage I would probably tape the foot and see if that gives symptom relief. If it does not respond, then chase a more specific diagnosis.
  3. Shane Toohey

    Shane Toohey Active Member

    Hi Ella, You wrote:
    I think you are probably very close to the mark being suspicious of FDB.

    You often see this muscle looking quite prominent in painful mid foot conditions and very tender to palpate. Pain is also felt often in the anterior forefoot referred from this muscle. I dry needle it regularly for really quick resolution of the symptoms using acupuncture needles. I follow up with cold spray and stretching and thereafter have the punter use heat packs for a few days. The secret is to palpate thoroughly to find the absolute most tender points to needle. Rarely will there be more than two.
    If foot type warrants I will also often fit a simple insole such as an X-Line with wedging attached as required.
    I have had 90% reductions in pain within a few days that have been persisting for many years and have come to fully expect such a result.

  4. Ella Hurrell

    Ella Hurrell Active Member

    Dear Craig and Shane

    Thank you both for your replies.

    Craig - I think his "bouncing" activity while on tiptoes could be considered a specific injury. I'm not suspicious of anything more systemic at this stage, but will bear that in mind if he does not begin to improve. I'm not sure why he decided to bounce on his tiptoes however. There was no particular sport/activity involved?! Don't think I'll go there though - ask no questions......?!

    Shane - he does also have forefoot pain, which i did not mention in the original post, so that is very interesting! It certainly seems to confirm my theory. Unfortunately, I'm not trained in dry needling techniques, but I will take on board the other advice. Perhaps this is something I should look into a little more.

    I have already applied strapping (low dye type) and given him an x-line type device, and will see him again soon to check on the progress.

    Thanks again, Ella
    Last edited: Jun 12, 2008
  5. tarik amir

    tarik amir Active Member

    Plantar fascial strain/ tear could also present as pain in the forefoot. I think it maybe a bit difficult to differentiate if it is the plantar fascia or the FDB- as fibres from the plantar fascia insert onto its superior surface. Both stabilise the arch. I would normally do what Craig suggested above. The dry needling treatment sounds interesting, which we do in chronic cases of plantar fasciitis using a long acting local anaesthetic followed by massage and stretching.
  6. Shane Toohey

    Shane Toohey Active Member

    Hi Tarik, you wrote:

    I realize I possibly come from left field re the general understanding of plantar fascial strain/tear but it keeps me very busy doing what the others don't.
    So thanks for raising your point and I'll take it as an opportunity to explain myself a bit more.

    We all work from hypotheses and hopefully keep using them until we find an alternative that produces better results. For a few years I've worked on most arch pain as coming from the intrinsic musculature ie trigger points and treat accordingly if I find them. The location of the pain pattern usually lets you know which muscles to check. It's my understanding that the fascia is actually quite closely attached to a number of the intrinsics and it is when the intrinsics begin to fail and become triggered and often hypertrophy (obvious in abductor hallucis and FDB) that the fascia takes on an extra load and begins to thicken etc.
    Often enough when taking on the chronic 'fasciitis' that has had all the accepted treatment without significant result I have had remarkably quick and uneventful resolution with dry needling the intrinsics.
    I'll mention that I also often mobilise the foot joints and use temporay devices to replace existing devices or modify old devices all decided on a case by case basis.

  7. Stanley

    Stanley Well-Known Member


    I just want to expound on the condition you are seeing. You are treating a trigger point and you are manipulating. What happens is the FDB gets injured by a stretch injury (reverse strain-counterstrain) and the calcaneus subluxes posterior-laterally (a posterior calcaneus), or the calcaneus is posteriorly subluxed and this predisposes the patient to the stretch injury of the FDB.

    So the key here is treating 1. The trigger point of the FDB, and 2. Manipulating the posterior calcaneus.

    You do it by needling and mobilizing.
    I do it by reverse strain-counter strain, and downwards friction on the posterior talo-calcaneal ligament, which releases the talocalcaneal joint so the calcaneus is allowed to shift into position. :drinks


  8. Shane Toohey

    Shane Toohey Active Member

    Hi Stanley,

    We meet again.:drinks

    I'll just have to start with reverse strain-counter strain

    Rather than me simply guessing could you describe how you do that, please?

  9. Stanley

    Stanley Well-Known Member

    It is a 2 step process. Step one: rub the origins and insertions away from the center. Usually rubbing 10 times with medium pressure suffices. Step two: Put the muscle in a stretch position (dorsiflexing the toes for the FDB) and then approximate the muscle belly in the direction of the fibers, and hold this position for about 20 seconds. Then bring the toes back to the starting posistion without assistance from the patient.

    I hope that helps.


  10. Shane Toohey

    Shane Toohey Active Member

    Thanks Stanley,

    It sounds so simple. I'm sure I won't be alone and trying this out asap.

    So, next will you describe:

    again, rather than guessing.

  11. Stanley

    Stanley Well-Known Member

    All of my manual therapy techniques are about as simple.

    At the posterior lateral ( more posterior than lateral) talo calcaneal joint, palpate for the tender area. Friction means rubbing, so press in until you fell something solid. This way you are against the ligament, and rub downwards with 10 strokes.

    I am sure that you have seen the FDB/posterior calcaneus involved in some resistance cases of plantar fasciitis also.
    Just remember that if the treatment only works for a short time, then there is a reason for this problem, and you have to figure out why.


  12. Shane Toohey

    Shane Toohey Active Member

    Thanks again Stanley, as you said very simple and " a short time" being hours, weeks or months depending on the extent of other factors.:hammer:

    My short list of other factors involved in the persistence of "plantar fasciitis" includes chronic triggers in muscles such as abductor hallucis, FDB, QP, Peroneus tertius and soleus and extrinsic factors such as overly aggressive orthoses and poor footwear.

    Would you like to add to my list?

  13. Stanley

    Stanley Well-Known Member


    The answer to this question is a long one, as I don’t find the differential as simple, only the treatment.
    I don’t usually look for triggers in the muscle for the persistent plantar fasciitis, but maybe I should. I do look for the soleus trigger point in cases where the posterior of the plantar heel is involved. As you have mentioned to me in a private post, we have to evaluate the opposite wrist at the same time. In AK circles this is called ligament interlink, as the wrist and opposite ankle are doing the same thing in gait, and there is a neurologic connection. The most common area on the wrist is the lateral part, and just some distal rubbing handles this. Sometimes there are some weak wrist muscles that are destabilizing the wrist, and I have to track the cause of this down.
    I also treat the abductor hallucis. I have tried dry needling on this, but I gave up, as it didn’t work for me. It probably is the cook and not the recipe in this case. :confused:I do better with strain counter strain or reverse counter strain, depending on how the muscle tests for me (indirect muscle testing-which is not a common AK technique).
    Typically, for plantar fasciitis, I take the basic biomechanics of the foot, and extrapolate this to manual/neurologic therapy. In basic biomechanics, we deal with extrinsic factors (most notably leg length and equinus) and intrinsic factors (pronation-but in today’s times, we can separate it to midstance pronation and late stance pronation [FnHL]).
    First I treat the extrinsic factors. If we look at equinus and leg length, there are basically only a few possibilities (and causes). A low ASIS and no equinus (TMJ dysfunction), A low ASIS and equinus on the this low side (subluxed lateral cuneiform), A low ASIS and equinus on the opposite high side (a weak scalene and opposite quadratus lumborum), Equinus on both sides with or without a low ASIS on one side (mortise subluxation of the ankle), Mild equinus with or without a low ASIS on one side (Acupuncture meridian dysfunction). Each of the listed causes are just the last domino to fall, so the idea is to track the cause back as far as you can to the first domino and treat it. For instance, the reason for the subluxation of the lateral cuneiform is the muscle fibers in the fascia/ligaments are not functioning properly. These are under neurologic control, so subtle errors of the nervous system have to be treated. The treatments can end up being acupuncture (which I use to treat the emotional factors [one point technique] before I treat structurally [two point technique]), cranial sacral dysfunction, or fascial trains dysfunction-usually the superficial back arm line or the superficial front line.
    After the extrinsic factors are corrected, then I focus on the intrinsic factors. If you think about it, the extrinsic factors are taken care of in orthoses by heel lifts-one side or both. The intrinsic factors are taken care of by the traditional orthosis. When evaluating the foot with plantar fasciitis, the two main dysfunctions are the posterior calcaneus (which we discussed in the previous posts) and a “lateral talus”. If you look at your foot skeleton, you will see that the talus can slide in two different directions on the calcaneus-posterior laterally, and anterior laterally. The anterior lateral direction is the “lateral talus”. The lateral talus can be manipulated, but I prefer to rub the lateral talo calcaneal ligament distally in the same manner as I do the posterior talo calcaneal ligament for the posterior calcaneus. When you have a peroneal spasm in the patient with plantar fasciitis, this is usually the cause of it. Another factor to check is the cuboid. These are the patients that have a weak peroneal muscle (and no equinus or low ASIS, as these are already corrected). Palpate the cuboid-fifth metatarsal joint. If you palpate deep enough there will be a tender area. This is either the cuboid-fifth metatarsal ligament or the long plantar ligament. Rubbing in the standard manner distal laterally will resolve this. The weak peroneal will occur in patients that feel they are inverting their foot all the time and/or having pain on the dorsal lateral aspect of the foot, overlying the cuboid fourth or fifth metatarsal joints. Other areas that I inspect are the third metatarsal cuneiform joint, which requires distal rubbing of the plantar ligament of the joint, dropped metatarsal (which is nothing more than a strain counterstrain or reverse strain counter strain of the dorsal interossei. I also check for something called foot compression. This happens when the forefoot of the shoe is too narrow. The treatment is either manipulation of the fifth metatarsal, or reverse strain counterstrain of the flexor digiti minimi (make sure to dorsiflex and adduct the fifth toe).
    That is how I pursue persistent plantar fasciitis on a manual therapy basis. I didn’t mention ruling out systemic arthritis’s or looking for a partial tear of the plantar fascia with an MRI, and of course I have already made orthoses for these patients.

    Shane, you mentioned that you treat trigger points of several muscles. What are the symptoms for each individual trigger point, and what is a QP muscle?

    I hope I didn’t bore you too much. :morning:


  14. Shane Toohey

    Shane Toohey Active Member

    I'll have to go over your response with a fine tooth comb sometime in the next few days when traveling. Thanks Stanley for a comprehensive reply.

    At least I can answer your questions briefly.

    The referral patterns are simply straight from Travel and Simons.
    Soleus, as you mentioned for posterior and posterior plantar heel.
    Abductor Hallucis for medial and medial plantar heel.
    Quadratus Plantae for central plantar heel.
    Peroneus Tertius for lateral and lateral plantar heel.

    I recently had a patient who has had 10 years of persistent chronic heel pain and had orthoses/triggers/cortisone/ECSWT etc, etc.
    One dry needling of QP reduced her pain by 80% and a couple of other sessions have given her total resolution.

    At risk of losing some folk on this thread, I should mention that usually before dry needling I use a few acupuncture points to help the overall pattern and release.
    Using body pain maps I try and categorise patterns into dorsal, ventral, lateral or mixed zones and use lower and upper limb distal points to set up for release. The upper limb points are used on the opposite side and vary according to the zone.
    I'm talking about severe chronic pain here and not just a simple recent overuse injury.

    The key to dry needling QP, Abd Hall etc is to get to the exact most tender point.
    Generally everywhere hurts and it means really getting patients to participate in finding the points and needling into them exactly. In any muscle there may be 1,2, 3 or more points sometimes. The points are where you palpate them and not where the any book says they should be. I follow with spray and stretch and a home programme of heat and stretching if possible.

    For mobilisations, I also treat it as I find it rather than having worked out a pattern of which blocks go with which trigger, although that sounds a plausible extension of my approach. Releasing the the fibular head is usually a good start and I just check through the tarsal and mid tarsal joints after that and try and release anything I find blocked.

    I hope this explains a bit more and will get back with some more questions for you soon.

    Shane ;)
  15. Asher

    Asher Well-Known Member

    Hi Shane

    What about Flexor Hallucis Longus. Since learning about this one from Paul Conneely and yourself, I have used it several times to great effect. I just do a spray and stretch (no needling) three times and after that treatment, if it is the answer, it is significantly better. If not 100%, I repeat. If no improvement, its not FHL. It doesn't necessarily give a classic referral to the 1st MPJ and hallux, often just arch pain.

    Do you still use this? Would you say this is a trigger point or more a tendinosis?


  16. Shane Toohey

    Shane Toohey Active Member

    Yes Rebecca!

    It's easy to miss out good points when generalising.

    FHL is so often missed out in stretching programmes and folk nearly always feel such great freedom after it is treated. I still often dry needle it if I find triggers.
    This would happen once or twice a day I'd say, so very common.

    I'd say all of the above, tight with or without triggers. Tendinosis if you find it.

    Not a common cause of heel pain but often part of the complex involved in arch pain.

  17. Dantastic

    Dantastic Active Member


    Possibly a bit off topic, but why do you use heat and not ice?
  18. Shane Toohey

    Shane Toohey Active Member

    Dear Dantastic,

    You asked:
    My quick on the run response as follows:

    Very simply, I'm treating the problem as non-inflammatory, which is what the evidence is showing these days. Further, I am treating the problem as trigger points in the intrinsic musculature, which respond to heat after dry needling and in fact would seem to become more congested with ice and persist longer.

    This is the basic approach from Travell and Simons.


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