Chronic Plantar fascitis

[Jay]

I have a patient with chronic bilat fascitis who is on her feet all day. this pt. has notable forefoot varus and overpronates. I have tried daily ionto w/ dexameth for 1wk with little if any progress. I am currently using cross-friction massage followed by cryomassage/US and stretching. Her HEP includes stretching before she takes any steps in the a.m. and concurrently throughout the day in addition to PRE's for hip LROTs and some core strengthening.
relief is intermittant but symptoms will arise to extreme levels during the day at work. she has been seen a total of 13 visits.
I am seeking any ideas or treatment(s) that have been very successful to remedy this condition. your feedback is greatly appreciated. thanks

[jma]

Hello,
This person may need orthotics. If there is a difference between the arch in non-weightbearing and wear bearing, then orthotics may be needed.

You may also want to try neural mobs. I think you can use SLR with foot in either IR or ER with manual PF/DF of ankle (I forgot specifically which ones) to see if that has an effect on the nerves, which may be entrapped and cause PF pain.

Has this person tried night splints. This may help as well. Hope this helps

JMA

[FallsPT]

You may also consider strengthing the anterior tibial compartment as this helps support the arch. I agree that orthotics will also be a great help in controlling comfort levels.

[somasimple]

Hi,

Avoid strengthning an prefers neural mobilization. Pull gently the toes up, 10/15 reps without hurting the patient. Then gently, too, do a flexion of ankle with no pain.

The pain will reduce in few days.
Then, restore a good posture without splints but with muscular activity over the whole limb.

[ali]

Disagree with part of last comment -- I have heard very good things about night splints.

Also, the most effective stretches reported in Advance recently have been to stretch at the toes (phalanges) as opposed to the arch of the foot.

I agree with JMA about orthotics, especially as the foot conformation in weightbearing may be very different than non-weightbearing. Do you have the opportunity to videotape your patient's gait? Watching that in slow motion can be very, very educational. And, as always, the type of shoes she wears to work as well as type of surface walked on also contribute to the problem (as you've probably already checked).

[somasimple]

Sorry Ali,

There is no stretch in neural mobilization.
And I have heard, too, very bad thing about splints.

The better way is, in my view, helping the patient to restore his normal functioning?

[Spencer]

Greetings all,
Please forgive me in advance for the lengthy post

The meaning of "Equinus" in relation to the foot is, any restriction which limits dorsiflexion at the ankle joint. When the posterior lower leg muscles are tight, the leg cannot pass over the ankle during the stance phase of gait.

There are several ways that the body compensates for this. One way is to ABduct the foot, which creates an increased demand for pronation. Another way is compensated dorsiflexion at a joint distal to the ankle joint which operates in the same plane of motion. Sagital. Being that the STJ primarily operates in the frontal plane, the next joint which is ready to compensate in the sagital plane is the MTJ, right above the arch.

I agree with the orthotic therapy, especially if the patient has gotten good results with arch taping or OTC insoles. However, if you put a corrective device underneath a joint that will chronically collapse over it because of an external force, the pt will not tolerate this device very well, especially if it's a hard device. Even if the pt does tolerate it, it's not treating the cause of the problem. Equinus contracture/pronation is a vicious cycle. The foot is pronated, the achilles tendon has a "Bowstring effect," and becomes tighter, and so on. Plantar Fasciitis is just one of the symptoms.

My advice, see if you can medially support your pt's foot with tape or wedges, and/or scaphoid support. This might give you an indication if orthotics, whether custom or OTC, will help. I have found night splints work very well. It is best to wedge the pt's foot medially within the splint to invert the STJ to insure no dorsiflexion of the distal joints. Not doing this is the main reason that DF night splints don't work. When you pronate the STJ even slightly, you increase the ROM of the distal joints of the foot, stretching the foot, not the calves. I would be interested in hearing your experience with night splints and I wonder if your troubles with them could have been related to this.

You should think about the limited amount of time your pts are actually stretching with you or on their own, VS. the amount of time they are not stretching at all. Sleeping for 8 hours with your feet in plantar flexion works wonders in tightening the calf muscles. This is why heel pain is usually worse first step in the morning.

Also, her shoes are very important. Check wear patterns to insure lateral heel strike. Make sure this pt is not overpowering the shoe medially. Rear counter of shoe should be strong and vertical. A inner heel lift of 1/8" Bilaterally couldn't hurt either.
Watching this pt walk could be quite helpful. Usually more so with pts who have unilateral symptoms, however.

About the Forefoot varus. If this forefoot/rearfoot relationship is structural, the forefoot needs a medial wedge to support it in that position and effectively "bring the ground up to meet the foot." If the foot doesn't get that, a structural forefoot varus in contact with the ground will create a marked rearfoot valgus during the stance phase of gait. If the forefoot varus is only a functional position, then a rearfoot medial wedge is recommended.

In my practice in NYC, I make orthotics and do inner and outer shoe modifications for pts of doctors and PT practitioners like yourselves. I also make wedges and cookies for arches and heels, and all types of on-the-spot diagnostic tools. I would be happy to make some for any of you. I very much enjoy this forum and I scan it for foot topics. This is the first one I have seen in almost a year.

Please feel free to contact me at OrthoSolutionsNY@aol.com

Regards,

Spencer B. Weisbond, C.Ped.

[LauraMPT]

Here's an abstract from the Journal of Bone and Joint Surgery for an RCT performed at my alma mater.
http://www.ejbjs.org/cgi/content/abstract/85/7/1270

There's also a summary article from Advance that describes the non-weight bearing and morning stretches a little better.
http://physical-therapy.advanceweb.com/ ... 6/2004&FP=\

The full text version fully describes the standing morning stretch better.
I've used this in the clinic and although the people with chronic heel pain were not completely relieved of all symptoms, those diligent with the morning stretches reported a significant improvement in pain with the first steps in the morning. I apologize for not being able to get the full text...maybe someone else can post it?

[Graham]

This post is a little late and hope that this patient is still not suffering from (B) plantar fasciitis, but I have used all the above procedures as far as ionto, phono and mobs with good success. But, I have also used a neuroprobe both with pulsed and D/C currents which has worked really well. May try it. Good luck

[Manda101]

ever try kinesio taping as a gentle arch support? or to relax the feet? I have had a few patients with mild cases of PF and have had good results as well.

[Graham]

Yes, a teardrop taping technique works well and pts feel they are taking active roll in rehab. I still have pts use it even after sx's have diminished.

[ptmikey]

An important treatment technique that has not been mentioned so far is MFR of the lower leg. If you think along the lines of anatomy trains you'll want to work from the low back down the backside of the leg to the toes. But I find it necessary to also do the deep and superficial front lines of the LE for balance. Using a dowel or small ball to roll the arch across longitudinally in a sitting or standing position can also be useful. I really don't find the typical stretches patients try to do beneficial other than maintaining what we gain in the clinic. Good luck!

[durga]

Thats exactly what I need