Planter fascitis

[robertisaacs]

Did'nt know whether to put this on eductation or here.

There is a debate running on PF in Pod arena at the mo. It is, frankly, brilliant with some supurb posts by KK among others.

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

(kevin Kirby)

This is, in a nutshell, about the most sensible thing i have seen written about PF in ages.

Can i warmly recommend that if you want to update your knowledge on PF you get a wriggle on to www.podiatry-arena.com/podiatry-forum/showthread.php?t=1380

Regards
Robert

[ianl]

Hi all

On this theme I had an interesting chappy in today. Was only able to see him for a short while as he "dropped" in. So thought I'd pop this on the site for a bit of fun with the questions at the end. He has gone away to see if he wants to spend money with me. His policlinic pod has discharged him and suggested he "see a proper podiatrist". Sad to think they had such low self esteem.

If it is all a load of bo****ks happ to see it removed.
Cheers
Ian


Male - mid 70’s - CVA 12 years ago, very slight affect to right low limb then, but seemed to make good recovery.

Currently been under a Pod at a policlinic for over 4 months with diagnosed PF.

Symptoms are pain to the “ball of the foot” and to the knee when walking, that he classes as a P3-4. This can be an intermittent problem as some days it does not occur. Certainly occurs if he goes on a moderate walk and doing jobs around the house can “kick it off”

Pod intervention has been: stretching exercises, strengthening exercises, “Heath Robinson” type chair side device, finally, ultrasound on sole of foot and toes, though the Pod did advise it does not work for everyone. Apparently all ROM tests up to the hip were undertaken. In fairness he felt the Pod tried hard.

Brief observations:

STANCE - bilateral pes cavus with the right PF being palpably tighter than left in weight bearing and with pain being elicited when finger pressure applied to it in stance. Hyper-extension of knees, with the right knee extending further than the left. Small Bakers Cyst to right knee. Right toes exhibiting clawing synonymous with some Pes Cavus types but the left not.

SUPINE - Flexible forefoot bilateral and no obvious signs of stiffening or plantar flexing of first ray. Ankle dorsiflexion is plantar grade only, bilateral. Muscle patterning of movement is equal bilateral. Plantar and dorsiflexion muscle power is equal bilateral. Very tight TA’s

GAIT -
Left is not unusual and demonstrates a moderate amount of ankle dorsiflexion, small amount of MTJ in roll and minimal amount of pronation from vertical at the STJ. Knee and low leg appear to be reasonably stable on foot contact, foot flat and push off.

Right is unusual in that foot contact is flat, sudden and “jolts” the foot into a pronation (mostly MTJ) not exhibited in stance and pushes the knee into valgus with a small, sudden amount of internal rotation. It is clear that in gait there is no access to ankle dorsiflexion on the right. Knee does not appear adequately stable .

Palpation indicates medial band PF type pain


QUESTIONS -

1 In which structure would you consider the worst palpable pain can be elicited? (HINT soft tissue)
2 Why in all the above modalities offered was no hands on assessment of the soft tissue structures undertaken?
3 What simple intervention with this foot type might have brought some modicum of relief fairly quickly, certainly worth trying?
4 What would you consider to be the underlying possible cause behind lack of ankle dorsiflexion in gait (achievable non-weight bearing)?
5 Do you think intervention is appropriate, what type(s)?
6 Who else might you involve as part of a team approach?
7 Given age, tight TA’s and condition were stretches a good idea?

[robertisaacs]

Oooo, you tease! You know we love a challenge. This one smacks of "trick question" to me. Also i don't know what a "policlinic" is. However...

1 In which structure would you consider the worst palpable pain can be elicited? (HINT soft tissue)

Well you said the pain was ball of the foot so i would have to say there. Although the CVA, Pes cavus etc would seem to suggest that a neurological hypertonia of the flexor muscles might be involved so perhaps FHB / FDB.

2 Why in all the above modalities offered was no hands on assessment of the soft tissue structures undertaken?

Got me there. The podiatrist has no hands? The podiatrist could'nt undo the patients laces? The patient was in a charing cross 4 layer and the pod could'nt access the area?

3 What simple intervention with this foot type might have brought some modicum of relief fairly quickly, certainly worth trying?

Pain on ball of foot excacerbated by WB... Something squidgy under the ball of the foot? Is the patient walking on laminate at home? Slippers?

4 What would you consider to be the underlying possible cause behind lack of ankle dorsiflexion in gait (achievable non-weight bearing)?

Got me confused here. YOu said that the ankle was moveable to plantergrade (90 degrees) in NWB exam.

5 Do you think intervention is appropriate, what type(s)?

Impossible to say without more information. I suspect SOMETHING would be appropriate assuming the patient is not dead, psychotic, or a quad amputee!

6 Who else might you involve as part of a team approach?

Again, more information needed

7 Given age, tight TA’s and condition were stretches a good idea?

Oooo contentious. I'm gonna say no, not as a first line treatment. If the Ankles can make 90 (and you don't say whether that is talo crural range or TC + ST range BTW) i'd say that unless he is a sprinter that is an acceptable range. If i was that concerned that the GSAT tightness was contributing, i'd stick a heel raise in!

I would also question the Dx of PF. The "ball of the foot" is pretty vague! PMA 1- 5? PMA 1? Proximal PMA? Is the pain elicited by proximal tensioning of the Planter structures(PF,FDB&FHB)? Is the pain better or worse during this test if the patient activly flexes the flexors against resistance from a dorsiflexed position.

Come on then. Put us out of our misery. Its going to be something really simple like "the patient has a b*****D great HD on his foot isn't it!

Robert

[ronm]

is the pain in both feet/knees or unilateral. if unilateral which limb effected? where is the pain situated in the knee?

any pain on first w/b in morning?

apologies if this is clear in the text

[ianl]

1 In which structure would you consider the worst palpable pain can be elicited? (HINT soft tissue)

Well you said the pain was ball of the foot so i would have to say there. Although the CVA, Pes cavus etc would seem to suggest that a neurological hypertonia of the flexor muscles might be involved so perhaps FHB / FDB.

Any of these might be possible. However, on palpation of the ball of the foot there was no pain elicited even with deep grade 3 pressure. Origin of the PF and along its medial band there was pain on grade 2 palpation (foot relaxed) but it was Abductor Hallucis that the greatest pain was felt, very sensitive, even to grade one pressure (relaxed), when stretched the slightest touch caused foot withdrawal.

Concerning the ball of the foot pain in gait I am suspicious that one contributor may be trigger points in FDB but am not ruling out other options, not least sudden sheer and compression forces from how his foot lands.

2 Why in all the above modalities offered was no hands on assessment of the soft tissue structures undertaken?

Got me there.  The podiatrist has no hands? The podiatrist could'nt undo the patients laces? The patient was in a charing cross 4 layer and the pod could'nt access the area?

Surprisingly, none of the above. Don’t know the answer myself, seems lots of things were done apart from getting the hands into the tissues. Guess this is what surprises me.

3 What simple intervention with this foot type might have brought some modicum of relief fairly quickly, certainly worth trying?

Pain on ball of foot excacerbated by WB... Something squidgy under the ball of the foot? Is the patient walking on laminate at home? Slippers?

Strangely enough the pt achieved some of this relief himself. He kept cutting the chair side device further back (it was uncomfortable) until he effectively ended up with the equivalent of a 3mm heel raise! Nothing squidgy needed.

4 What would you consider to be the underlying possible cause behind lack of ankle dorsiflexion in gait (achievable non-weight bearing)?


Got me confused here. YOu said that the ankle was moveable to plantergrade (90 degrees) in NWB exam.

Part of this ties in with the question of who else to involve. My suspicion is that there has been a very mild form of motor loss from the CVA that has grown in magnitude over the years to this point, evidencing itself now because of discomfort. It is only on WB and so I will be linking in with a physio to explore this and to see if, post my intervention, neurophysio work can achieve anything.

6 Will feed back when I see the chap for proper assessment.

7 Given age, tight TA’s and condition were stretches a good idea?


Oooo contentious. I'm gonna say no, not as a first line treatment. If the Ankles can make 90 (and you don't say whether that is talo crural range or TC + ST range BTW) i'd say that unless he is a sprinter that is an acceptable range. If i was that concerned that the GSAT tightness was contributing, i'd stick a heel raise in!

I would also question the Dx of PF. The "ball of the foot" is pretty vague! PMA 1- 5? PMA 1? Proximal PMA? Is the pain elicited by proximal tensioning of the Planter structures(PF,FDB&FHB)? Is the pain better or worse during this test if the patient activly flexes the flexors against resistance from a dorsiflexed position.

Tensioning certainly increased the discomfort converting it into severe pain. 90 deg was the limit with feet both in STJ neutral and out of STJ neutral.

I posted this in response to yours because the last 3 pts I had with diagnosed PF were not, to my mind, traditional PF problems but much more Abd Hal issues. Of course it can be difficult to separate the two, even pedantic to suggest it. As yet I have not looked at Trps in the calf etc.

The chap has now booked in to spend a lot of money with me to try and get it resolved. I made it clear that there is no promise of resolution but what I said to him made mechanical sense so he has gone for it.

Cheers
Ian

PS other ideas welcome
Thanks for having ago ron

[robertisaacs]

Thank you for putting this up ian, its very stimulating.

A few questions if you will induge me?

90 deg was the limit with feet both in STJ neutral and out of STJ neutral.

eh? Thats a bit weird. That would suggest that either A: he had little or no STJ movement available or B: that he had a GROSS frontal / tranverse planal dominance!

Part of this ties in with the question of who else to involve. My suspicion is that there has been a very mild form of motor loss from the CVA that has grown in magnitude over the years to this point, evidencing itself now because of discomfort. It is only on WB and so I will be linking in with a physio to explore this and to see if, post my intervention, neurophysio work can achieve anything.

Flexor contracture is certainly not uncommon in mild CVA cases in my experiance. Had you considered a neurological FFO?

Any of these might be possible. However, on palpation of the ball of the foot there was no pain elicited even with deep grade 3 pressure. Origin of the PF and along its medial band there was pain on grade 2 palpation (foot relaxed) but it was Abductor Hallucis that the greatest pain was felt, very sensitive, even to grade one pressure (relaxed), when stretched the slightest touch caused foot withdrawal.

Intruiging. Where was the pain actually perceived? Because it strikes me that if the initial pain the patient presented with was in the ball of the foot then the insertion of the ABD hal would seem the most likely culprit and since the medial branch of the flexor hal brev shares a tendon with the abd hall it would be damn hard to distinguish which of these was causing the pain!!

Where was the pain elicited?
What is your protocol for tensioning the abd hal?

I posted this in response to yours because the last 3 pts I had with diagnosed PF were not, to my mind, traditional PF problems but much more Abd Hal issues. Of course it can be difficult to separate the two, even pedantic to suggest it.

Not pedantic at all! Absolutly key. They are different diagnoses in different structures requireing different treatments.

Regards
Robert

[ianl]

Hi Robert
A few questions if you will induge me?

Quote:

90 deg was the limit with feet both in STJ neutral and out of STJ neutral.

eh? Thats a bit weird. That would suggest that either A: he had little or no STJ movement available or B: that he had a GROSS frontal / tranverse planal dominance!

STJ movement was minimal at least at that assessment, of course diurnal variation may make it different at the next assessment tomorow morning!

To be honest I rarely think in terms of dominance. Lazy of me perhaps but over the years have tended to view that what I find none weight bearing may have no link to what I find weight bearing, however what I treat none weight bearing may and frequently does affect the patient weigh bearing. So the none weight bearing treatment may have no bearing directly on what I might prescribe orthotic wise ( Boy would i be even more a pariah on pod arena with that!!). Equally, as I would be mobilising the joints on this guy dominance may alter as joint freedom increases and indeed muscle pattern action changes.

(Do you think Bel and Twirls are coping with the reference to dominance all the time?) ;D


Quote:

Part of this ties in with the question of who else to involve. My suspicion is that there has been a very mild form of motor loss from the CVA that has grown in magnitude over the years to this point, evidencing itself now because of discomfort. It is only on WB and so I will be linking in with a physio to explore this and to see if, post my intervention, neurophysio work can achieve anything.


Flexor contracture is certainly not uncommon in mild CVA cases in my experiance. Had you considered a neurological FFO?

Thanks for the input. Are you speaking AFO or a foot up or something different? At this point I am not wanting to lock his ankle in any plane so will likely go with an FFO posted 2 degrees FF unless, when I read his cast, I go counter to intuition. Once we have stability I would want to look at whether rehab of function is achievable. I'll look at this with the physio working on quads etc to regain muscle balance. Again it may be possible that patterned respnse could be encouraged when good feed back occurs (could be a long shot.)

(PS this kind of discussion works at getting me thinking laterally and gives a chance to get more focused planning Rx protocols more fully. Hope others get doing it as well.)


Quote:
Any of these might be possible. However, on palpation of the ball of the foot there was no pain elicited even with deep grade 3 pressure. Origin of the PF and along its medial band there was pain on grade 2 palpation (foot relaxed) but it was Abductor Hallucis that the greatest pain was felt, very sensitive, even to grade one pressure (relaxed), when stretched the slightest touch caused foot withdrawal.


Intruiging. Where was the pain actually perceived? Because it strikes me that if the initial pain the patient presented with was in the ball of the foot then the insertion of the ABD hal would seem the most likely culprit and since the medial branch of the flexor hal brev shares a tendon with the abd hall it would be d**n hard to distinguish which of these was causing the pain!!

Where was the pain elicited?
What is your protocol for tensioning the abd hal?

In this kind of scenario I recognise that it is difficult to isolate certain groups and that at times a gross guestimate is best achieved. With this chap I adopted a protocol of palpating at the above structures at various times while moving the foot towards a position that results as follows: maximally dorsiflexing the foot, maximally everting the STJ and then follow this with taking the MTJ through a maximal pronated position and then adding a maximal dorsiflexion of the toes. This would appear to be the position he is in when he gets pain in the ball of the foot. (maximal here means his maximal available rom).

Pain was always elicited in the areas mentioned above. As I said this was not a full assessment so I may be missing some things. Of course in gait this is very sudden and with a jolting action which I cannot mimic. He will be in shorts when I next see him so I can get a better look at whole limb function.

Hope this goes some way to answering the questions.

Rx is undetermined as yet but will likely include copious amounts of soft tissue mobilisations in various positions of stretch of the low limb. If you think I am fluffing some things let me know.

Cheers
Ian

[robertisaacs]

STJ movement was minimal at least at that assessment, of course diurnal variation may make it different at the next assessment tomorow morning!

To be honest I rarely think in terms of dominance. Lazy of me perhaps but over the years have tended to view that what I find none weight bearing may have no link to what I find weight bearing, however what I treat none weight bearing may and frequently does affect the patient weigh bearing. So the none weight bearing treatment may have no bearing directly on what I might prescribe orthotic wise ( Boy would i be even more a pariah on pod arena with that!!). Equally, as I would be mobilising the joints on this guy dominance may alter as joint freedom increases and indeed muscle pattern action changes.

(Do you think Bel and Twirls are coping with the reference to dominance all the time?)

Quick, bromide for our friends!!

ahem.
Dominance is an issue which probably deserves a thread all to its little lonesome.

Thanks for the input. Are you speaking AFO or a foot up or something different? At this point I am not wanting to lock his ankle in any plane so will likely go with an FFO posted 2 degrees FF unless, when I read his cast, I go counter to intuition. Once we have stability I would want to look at whether rehab of function is achievable. I'll look at this with the physio working on quads etc to regain muscle balance. Again it may be possible that patterned respnse could be encouraged when good feed back occurs (could be a long shot.)

Neuro ffo, Can't find a picture anywhere for this one but its used quite a bit in paeds. Its an ffo with a pre met bump a little sharper and higher than one might use for mortons neuroma, a depression in the PM area and a slight shelf under 2-4 digits. Some companies also produce it with a ridge in the navicular area. The idea is that it resuces intrinsic muscle tone and whilst i've seen no evidence i have used them with hypertonic CP cases with good results. Its more an orthotist mod than a podiatrist one, (their catalogues are a bit different!)

Where are you looking for stability? You said his STJ range was minimal.

In this kind of scenario I recognise that it is difficult to isolate certain groups and that at times a gross guestimate is best achieved. With this chap I adopted a protocol of palpating at the above structures at various times while moving the foot towards a position that results as follows: maximally dorsiflexing the foot, maximally everting the STJ and then follow this with taking the MTJ through a maximal pronated position and then adding a maximal dorsiflexion of the toes. This would appear to be the position he is in when he gets pain in the ball of the foot. (maximal here means his maximal available rom).

Pain was always elicited in the areas mentioned above. As I said this was not a full assessment so I may be missing some things. Of course in gait this is very sudden and with a jolting action which I cannot mimic. He will be in shorts when I next see him so I can get a better look at whole limb function.

Hope this goes some way to answering the questions.

Rx is undetermined as yet but will likely include copious amounts of soft tissue mobilisations in various positions of stretch of the low limb. If you think I am fluffing some things let me know.

I'll leave the Soft tissue mobilisations to you as this is obviously an area in which you know more than me .

Sounds like there are a few options for DX here including ABd hal / digi brev medial slip tendon inflamation & Sesamoiditis / deviated / fractured sesamoid or even inflamation of the flexor hallucis longus where it runs between the sesamoids.

Orthotic wise, i would think that further assessment might inform your prescription. A lot will depend on what is causing the pain and in which structures.

If the reason for the pain is a tensile injury to the tendon (which just happens to be in the WB area) then i would suggest an intrinsic posted casted device with a heel raise might be the path to joy in order to shorten the FHB / Abd hal.

If the reason for pain is a sesamoidy type problem (which is entirely plausable considering the "medial snap" on gait) then a casted ffo in lunarsoft with a 1st met raise with a 1st pma cutout OR a Simple with a 6mm tadpole medial heel, a valgus pad = to the height of the arch when the rf is in neutral and the ff is inverted and a ff varus extention of around 6 mm in something like poron or soft diabet might work better.

this kind of discussion works at getting me thinking laterally and gives a chance to get more focused planning Rx protocols more fully. Hope others get doing it as well

Great thread! It does get the grey cells working. I hope others are getting as much from it as me!

Regards
Robert

[ianl]

Hi Robert

Thanks for the feedback.

Chap came into today so, as the cavus foot type compounded the issue for him, thought I'd try a different tack on the dorsiflexion issue especially as it was apparently linked to CVA years ago. Interestingly he was able to progress, active none weight bearing, a little past plantar grade position. (diurnal variation on joints,muscle,ligs?? or more familiar with the process??).

Application of a posterio\anterior talocrural draw bought him a little more still. However, WB he failed to exhibit this in gait. So then got him to hold onto a chair and to try and dorsiflex the said ankle WB but not whilst moving. He managed!. Began to think then of possibility of learned gait

Consequently spent a chunk of the time re-educating his gait style. By the end he was just managing to get ankle dorsflexion occuring in swing, improving ground clearance and enabling a faltering heel strike. Bilateral 6mm heel raises boosted his confidence in this and further reduced the jolting action of the affected side. Part of his Rx protol will now include improving proprioceptive awareness and gait re-education. He has gone off with instructions on how to practice and simulate dorsiflexion in swing phase

From a comp med perception I may well try an emotional trauma reduction technique to see if we can break any established psychological pattern involvement.

I have casted the chap now and he is coming in next week for more work regards the soft tissue issues, peripheral joint mobs etc.

I am sure there are others reading this who may well have some input to offer, so, please go ahead. Not least people may want to genuinely critique my approach.

Cheers
Ian