Effective Soft-Tissue Strategies for Plantar Fasciitis and Plantar Fasciosis. Douglas Nelson

Transcription

1 Effective Soft-Tissue Strategies for Plantar Fasciitis and Plantar Fasciosis Douglas Nelson

2 What is plantar fascitis? Notes on Plantar Fascitis Plantar fascitis is an inflammation of the plantar fascia of the foot. Studies estimate that there are about two million new cases of plantar fascitis a year in the US. It is second only to toenail problems as the leading cause for people to seek foot care. The fascia acts as a bowstring between the calcaneus and the ball of the foot. It acts as a shock absorber and allows us to adapt to uneven terrain. Under stress, the fascia becomes irritated and inflamed. Normally, the fascia is about 3-4 mm thick and 13mm wide. Under constant stress, it thickens. The medial band is the most injured aspect of the plantar fascia. What are the symptoms? The symptoms of plantar fascitis are pain and discomfort in the front and bottom of the heel with the first few steps in the morning or after any long period of inactivity. It is possible for the pain to be anywhere along the plantar fascia but the heel is the most common site. If the pain is sharp stabs with accompanying burning, it is possible that the plantar nerve is being entrapped by the abductor hallucis. Nerve pain often hurts worse at night, whereas plantar fascitis is worse in the morning. How long does the pain last? Several studies report that about 35-38% of patients have had the pain for more than one year. About sixty percent have had it over four to five months. About 90% of the patients with plantar fascitis are over thirty years old. What are the causes? A common cause is shortness of the Gastrocnemius. The shorter the Gastrocnemius, the more pressure put on the plantar fascia. Overweight. The more weight the body carries, the more pressure on the plantar fascia. Some studies show that 70% of the cases involve patients who are overweight. A five percent increase in weight will equal a five percent increase in pressure on the plantar fascia. Sudden change in activity. This is especially true if the person is not normally active. Common downfalls are pushing a stalled car, pushing a lawnmower, standing on a ladder with shoes that are too flexible, or starting a new activity like hiking. Poor footwear. (No arch support, no cushion, etc.) Too much time on one s feet, especially if the time is spent on hard surfaces

3 Plantar Fasciosis There is now ample evidence that many cases of plantar fasciitis may not be an itis after all. Traditional plantar fasciitis treatments often do not help. Consider this research article: The authors review histologic findings from 50 cases of heel spur surgery for chronic plantar fasciitis. Findings include myxoid degeneration with fragmentation and degeneration of the plantar fascia and bone marrow vascular ectasia. Histologic findings are presented to support the thesis that plantar fasciitis is a degenerative fasciosis without inflammation, not a fasciitis. These findings suggest that treatment regimens such as serial corticosteroid injections into the plantar fascia should be reevaluated in the absence of inflammation and in light of their potential to induce plantar fascial rupture. (J Am Podiatr Med Assoc 93(3): , 2003) Lemont, H., Ammirati, K. M., & Usen, N. (2003). Plantar fasciitis: a degenerative process (fasciosis) without inflammation. Journal of the American Podiatric Medical Association, 93(3), What this means is that the plantar fascia is essentially dying much like necrosis that happens in other areas of the body when the blood supply is reduced. What Could Cause the Loss of Blood Supply? One very likely possibility is tension in the Abductor Hallucis muscle. This muscle covers both the nerve and the blood supply to the calcaneal area. If the shoe the person commonly wears places the great toe in

4 What to do for Plantar Fasciosis First, treat the Abductor Hallucis very thoroughly. Second, the person should try to spend some time each day with the great toe in flexion. This will take the pressure off the muscle and should increase the blood supply to the plantar fascia. Second, encourage them to find shoes that do not have a cramped toe box, excessive toe spring, or much of a heel lift.

5 Assessment Ankle Dorsiflexion With the person prone, press the ankle into dorsiflexion. The foot should attain 90 with minimal resistance. Ideal ROM is 110 Ankle Dorsiflexion Soleus Isolation This is similar to the previous ROM, but with the knee bent the focus is the soleus. Ideal ROM is 110 Windlass Test Pronation With the client on the end of a surface (first metatarsal off the surface), extend the big toe. Positive test if pain in the plantar fascia. Palpation of the Artery Assess the artery by feeling the frequency and intensity in a neutral position and also with the foot in eversion.

6 Pronation Assess the medial arch in both nonweightbearing and weightbearing. Also assess single leg standing. Hamstring ROM The optimal Rom for the hamstrings is 170 Monitor resistance until you meet the second barrier. Bolívar, Y. A., Munuera, P. V., & Padillo, J. P. (2013). Relationship between tightness of the posterior muscles of the lower limb and plantar fasciitis. Foot & ankle international, 34(1),

7 Plantar aponeurosis Hands-On Technique Strand Differentiation Take each toe into extension while monitoring the stiffness in the corresponding strand of the plantar fascia. After establishing the most stiff areas, treat using a shallow angle Frictional pressure in the direction of the stretch At first, slower Then, at a quicker speed Frictional pressure in a direction opposite the stretch

8 Plantar aponeurosis Hands-On Technique Step #1. Plantar Aponeurosis Have the patient lie on their side. Put their foot on your leg as you sit next to the table. Using minimal lubricant, glide across the plantar aponeurosis, thinking of a more MFR approach to the release. Do not make the pressure penetrating, keep it at a superficial and fascial level. Moving transverse will help you stay superficial. Make sure the whole underside of the foot gets warmed up. After individuating the strands of the plantar aponeurosis, proceed with the following. Movements can be: Compressive as though you could lift the plantar fascia off the deeper layers. Broadening pulling apart as in transverse lengthening Juxtaposition- thumbs move toward each other but they are aligned one slightly above the other Pin and stretch- glide toward the heel while stretching the plantar fascia by pushing the ball of the foot and toes into dorsiflexion. Each of these movements may be done with the foot in neutral, dorsiflexed, or plantarflexed. Pay special (but careful) attention to the medial calcaneal attachment.

9 Foot- Layer One Hands-On Technique Step #1. Flexor Digitorum Brevis Using minimal lubricant, glide up the Flexor Digitorum Brevis from the calcaneal attachment to the toes. The pressure should be a bit deeper than the plantar aponeurosis. Abductor Flexor Abductor Step #2. Abductor Hallucis Compress the Abductor Hallucis with a pincer grip as shown in the two pictures. Either use fingers or your thumbs pointing towards each other. Gliding up the Abductor is also possible, but not a great idea if you suspect neural entrapment. Step # 3. Abductor Digiti Minimi A. Muscle test to locate (push on the muscle to see movement in the little toe) B. Compress the muscle belly C. Glide the whole lateral surface of the foot from the little toes to the calcaneus.

10 Foot- Layer Two Hands-On Technique Step #1. Quadratus Plantae A much deeper glide from the long tendon of the Flexor Digitorum Longus to the calcaneus. This is very important in the event the person has heel spur pain. Step #2. Lumbrical Muscles Glide in each of the valleys of the metatarsals. (not shown)

11 Foot- Third Layer Hands-On Technique Step #1. Adductor Hallucis This muscle has two heads that essentially form the number seven. Treat both heads with deep cross fiber motions. Figure A shows treatment of the oblique head and Figure B shows treatment of the transverse head. This is important for restriction of extension of the great toe and also for a feeling of arthritis in the great toe. A B

12 Self-Care High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up. The aim of this study was to investigate the effectiveness of shoe inserts and plantar fascia-specific stretching vs shoe inserts and high-load strength training in patients with plantar fasciitis. Forty-eight patients with ultrasonography-verified plantar fasciitis were randomized to shoe inserts and daily plantar-specific stretching (the stretch group) or shoe inserts and high-load progressive strength training (the strength group) performed every second day. High-load strength training consisted of unilateral heel raises with a towel inserted under the toes. Primary outcome was the foot function index (FFI) at 3 months. Additional follow-ups were performed at 1, 6, and 12 months. At the primary endpoint, at 3 months, the strength group had a FFI that was 29 points lower [95% confidence interval (CI): 6-52, P = 0.016] compared with the stretch group. At 1, 6, and 12 months, there were no differences between groups (P > 0.34). At 12 months, the FFI was 22 points (95% CI: 9-36) in the strength group and 16 points (95% CI: 0-32) in the stretch group. There were no differences in any of the secondary outcomes. A simple progressive exercise protocol, performed every second day, resulted in superior self -reported outcome after 3 months compared with plantar-specific stretching. High-load strength training may aid in a quicker reduction in pain and improvements in function. Rathleff, M. S., Mølgaard, C. M., Fredberg, U., Kaalund, S., Andersen, K. B., Jensen, T. T.,... & Olesen, J. L. (2014). High load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12 month follow up. Scandinavian journal of medicine & science in sports. Have the client: 1. Stand barefoot on a box or stair with a rolled up towel under the toes 2. Raise the heel with a count of three seconds, hold at the top for two seconds, and lower eccentrically for three seconds. 3. Repeat this for 12 times 4. Do this every day

13 Self-Care Background: Approximately 10% of patients with plantar fasciitis have development of persistent and often disabling symptoms. A poor response to treatment may be due, in part, to inappropriate and nonspecific stretching techniques. We hypothesized that patients with chronic plantar fasciitis who are managed with the structure-specific plantar fascia-stretching program for eight weeks have a better functional outcome than do patients managed with a standard Achilles tendon-stretching protocol. Methods: One hundred and one patients who had chronic proximal plantar fasciitis for a duration of at least ten months were randomized into one of two treatment groups. The mean age was forty-six years. All patients received prefabricated soft insoles and a three-week course of celecoxib, and they also viewed an educational video on plantar fasciitis. The patients received instructions for either a plantar fascia tissue-stretching program (Group A) or an Achilles tendon-stretching program (Group B). All patients completed the pain subscale of the Foot Function Index and a subject-relevant outcome survey that incorporated generic and condition-specific outcome measures related to pain, function, and satisfaction with treatment outcome. The patients were reevaluated after eight weeks. Results: Eighty-two patients returned for follow-up evaluation. With the exception of the duration of symptoms (p < 0.01), covariates for baseline measures revealed no significant differences between the groups. The pain subscale scores of the Foot Function Index showed significantly better results for the patients managed with the plantar fascia-stretching program with respect to item 1 (worst pain; p = 0.02) and item 2 (first steps in the morning; p = 0.006). Analysis of the response rates to the outcome measures also revealed significant differences with respect to pain, activity limitations, and patient satisfaction, with greater improvement seen in the group managed with the plantar fasciastretching program. Conclusions: A program of non-weight-bearing stretching exercises specific to the plantar fascia is superior to the standard program of weight-bearing Achilles tendon-stretching exercises for the treatment of symptoms of proximal plantar fasciitis. These findings provide an alternative option to the present standard of care in the nonoperative treatment of patients with chronic, disabling plantar heel pain. Level of Evidence: Therapeutic study, Level I-1a (randomized controlled trial [significant difference]). See Instructions to Authors for a complete description of levels of evidence. Digiovanni, B. F., Nawoczenski, D. A., Lintal, M. E., Moore, E. A., Murray, J. C., Wilding, G. E., & Baumhauer, J. F. (2003). Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain: a prospective, randomized study. JBJS, 85(7),