Heel Pain – The scientific facts!!

Plantar heel pain is a very common and painful condition. One United States study estimates that one million patient visits each year are for the diagnosis and treatment of plantar heel pain. (1 in Radford, 07) This disorder appears in the sedentary and geriatric population (2-4 in Radford), it makes up one quarter of all foot injuries in runners (5 in Radford), and is the reason for 8% of all injuries to people participating in sports. (6-8 in Radford, 07) The exact nature of the disorder as well as the most appropriate treatment, however, remains unclear. (Martin 98, Radford 07, Wolgin 94, Crawford 02, Gill 97, Gill 96, Davis 94, Lynch 98) A study of 364 painful heels could find no causal relationship. (Lapidus in Wolgin 94) Few random, controlled studies document the efficacy of conservative care, (Barrett 11/06, Atkins in Barrett article, Radford 07, Crawford 02, Davis 94) ,yet success rates for conservative treatment of plantar heel pain vary from 46% to 100% in the literature. (Wolgin 94, Martin 98, Lynch 98,) It becomes clear from a review of the literature that the etiology of plantar heel pain is multi-factorial i.e. “multiple etiology heel pain syndrome”. There is not one specific cause, nor is there a panacea for conservative treatment. In 1972, Snook and Chrisman (36 in Wolgin) wrote “ it is reasonably certain that a condition which has so many different theories of etiology and treatment does not have valid proof of any one cause”. Are we any better off today?

The management of plantar heel pain begins with the correct differential diagnosis. (Gill 97, Shapiro 97, Meyer 02) Plantar fasciitis is the most common diagnosis for plantar heel pain. (1-Aldredge in Barrett 06) Clinical findings include medial heel pain which is often worse in the morning, worse after periods of rest, worse after prolonged weight bearing activity, and pain to palpation at the medial/plantar heel. (Perelman 95, 10-Scherer in Richie, Gill 97) Most researchers agree that the pain is caused by microtrauma to the origin of the plantar fascia at the medial tubercle of the calcaneus. (Perelman 95, Richie 05, 7-Grasel in Richie 05, 10-Scherer in Richie, 7-Schon in Gill 97). Subsequently, this microtrauma causes marked thickening and fibrosis at the origin of the plantar fascia. (Grasel in Richie, Schepsis, Martin 98) Many practitioners believe that the pain of plantar fasciitis is caused by inflammation. (Barrett, Khan’s work, Almekinder) However, researchers have shown through histological examination that there is an absence of inflammatory cells in chronic overuse tendinopathies. (Khan’s, Almekinder, Huijregts 99, Puddu 76) Animal studies conclusively demonstrate that, within 2-3 wks of insult to tendon tissue, inflammatory cells are not present. (Khan BMJ 02) Histologic findings from plantar fasciotomies have been presented to support the thesis that plantar fasciitis is a degenerative fasciosis without inflammation, not a fasciitis. (Lemont, Schepsis 91). In addition to the absence of inflammatory cells, tendinosis is characterized by a degeneration of tenocytes and collagen fibers with a subsequent increase in non-collagenous matrix. (Khan) The collagen tissue of tendons, for example, have only 13% of the oxygen uptake of muscle and require >100 days to synthesize collagen. (Khan, 94-95 in Khan) Thus, tissue repair in tendinosis may take 3 to 6 months. (Khan) With this increasing body of evidence suggesting fasciosis, not fasciitis, the practitioner needs to shift his/her treatment perspective.

As payers demand practitioners to maximize outcomes and minimize costs, the need for evidence-based interventions becomes clear. As stated above, however, there are few studies that have tested the efficacy of treatment protocols. (Khan, plus above) The first treatment goal for plantar fasciosis should be to protect the healing tissue. (Khan, Chandler 93, Cornwall 99, McPoil 95, Ross 02, Crosby 01)) How can damaged tissue heal if environmental stresses are not controlled? (McPoil 95) The second goal should be to restore the normal mechanical behavior of the tissue and to positively influence the structural reorientation of damaged collagen fibers. (Graston) Physical therapists have proposed that the treatment of plantar heel pain should be impairment based. (Young 04) A detailed examination would identify these impairments and an appropriate plan of care would utilize manual therapy, exercise, and modalitites. (Young 04) There is no standard physical therapy protocol for plantar fasciosis, however, upon review of the literature by this author, a framework of evidence is available to establish an appropriate protocol.

Iontophoresis and corticosteroid injections have been used to treat the proposed presence of inflammation at the origin of the plantar fascia. Iontophoresis is a process that uses bipolar electric fields to propel molecules of a drug such as dexamethasone across intact skin and into underlying tissue. (Anderson 03) The depth of drug penetration averages 8-12 mm with deeper penetration occurring through a slower process of passive diffusion. (Anderson 03, Li 95, Costello 95) Two articles have documented an improvement of plantar heel pain using iontophoresis with dexamethasone, yet long term relief was questionable. (Gudeman 97, Page 99) Steroids have been shown to inhibit the early stages as well as the later manifestations of the inflammatory process. (Fredberg 96) Corticosteroid injections for relief of plantar heel pain have had mixed results. (Martin 98, Wolgin 94, Crawford 02, Acevedo 98, Davis, Gill) However, ultrasound guided peritendinous injections of achilles and patella tendonitis have shown a significant reduction in the average diameter of the affected tendons (Fredberg 04) as well as a disappearance of neovascularization. (Koenig in response) Improper injection technique may be the reason for unfavorable results. (Wolgin 94)

Tissue protection can occur through rest, activity modification, taping techniques, and foot orthoses. Low-dye taping and various plantar strapping techniques have been shown to be effective in relieving plantar heel pain as well as altering foot kinematics and plantar pressures. (Lange 04, Hyland 06, Keenan 01, Holmes 02, Vicenzino 00) Although limited evidence exists (Gross 02, Kogler 99, Kogler 96, Scherer&Waters 07, Mundermann 03,Razeghi 00, Pfefer, Lynch), no conclusive evidence has been found to demonstrate the effectiveness of foot orthoses on plantar heel pain. ( Young 04, Lynch, Gill, Davis, Gross 02, Brown 95, Landorf in Pod Tod)

Manual therapy procedures used by medical practitioners can include soft tissue mobilization, massage, manual traction, joint mobilization, and joint manipulation. (DiFabio 92) Clinical interventions involving joint mobilizations and manipulations have been developed or refined by many authors. (Difabio 92, In DiFabio Maitland Periph/Spine, Grieve, Kaltenborn Periph/Spine, Cyriax, McKenzie) Although there is clear evidence to justify the use of manual therapy on spinal disorders, there is an absence of controlled trials in peripheral joints. (DiFabio 92) We can only speculate that a relationship exists between the identified joint impairment and the patient’s plantar heel pain. (Young) There is, however, a body of work that attempts to demonstrate the effect of mobilizations and/or manipulations of the talus and fibula on ankle dorsiflexion range of motion, yet with varied results. (Dananberg 00, Pellow 01, Denegar 02, Soavi 00, Nield 93, Dimou 04, Green 01)

Dorsiflexion range of motion restrictions have been identified as a significant impairment associated with plantar heel pain. (Young 04) One study reported a 5 degree or more dorsiflexion restriction in 78% of his patient population with unilateral plantar fasciitis. (Amis 88) Numerous studies have shown that heel cord stretching is one of the most effective treatments for resolving plantar heel pain. (Richie, Wolgin, Gill, Davis, Pfeffer) Plantar fascia-specific stretches have been shown to be even more effective than calf stretches in alleviating plantar heel pain (DiGiovanni 03,06) Due to the viscoelastic properties of muscle-tendon units, the duration of the stretch, active warm-up, and the concept of reciprocal inhibition can influence the outcome of stretching. ( Shrier 00, Taylor 90) Dorsiflexor and plantarflexor muscle weakness via isokinetic testing has also been identified as impairments in chronic plantar fasciitis. (Chandler 93, Kibler 91)

Collagen production is probably the key cellular phenomenon that determines recovery from tendinosis. (Khan 00) Animal experiments have revealed that loading the tissue improves collagen alignment and stimulates cross-linkage formation, both of which improve tensile strength. (Khan 00, Villarta #34 in Khan 00) Interventions such as friction massage (DeLuccio, Loghmani 05, Davidson, Gehlsen 98, Chamberlain 82), ultrasound (Enwemeka 89, Ramirez 97, Young 89, Crawford/Snaith 96,Gum 97,Speed 01, DeDeyne 95,Dyson 68, Noble 06,Cunha 01,Draper 95,Doan 99Jackson 90,Ng 03,Harvey 75), and eccentric exercise (Stanish 85,Cannell 00,Ohberg 02,Alfredson 98, Khan 99,00,00 have been shown to stimulate collagen production and, thus, help to reverse the tendinosis cycle.

The purpose of this outcome study is to determine the effect of a standardized treatment protocol on a group of subjects that present with the diagnosis of plantar fasciosis or fasciitis. The subjects are required to have at least 3 of the 4 criteria listed above for the diagnosis of plantar fasciitis and to have a >4 week history of plantar heel pain. The specific goals of this outcome study are the following: 1) to evaluate how the subject population responds to the treatment protocol in terms of pain reduction and functional outcome measures, 2) to determine improvements in ankle dorsiflexion range of motion utilizing the protocol, 3) to assess changes of thickness at the origin of the plantar fascia via diagnostic ultrasound after utilizing the protocol, 4) to investigate the duration of time between start of treatment and maximal improvement in symptoms, 5) to investigate the time relationship between onset of symptoms and start of treatment to clinical outcome, 6) to investigate and document any reoccurrences of symptoms while performing a maintenance home program over a 6 month period, and 7) to assess patient compliance with the home program.

Patellar Tendinopathy – The role of Eccentrics.

Patellar tendinopathy can be a resistant and recurrent condition in running and jumping sports. An important part of your patient’s physical therapy program should include eccentric exercise. What are eccentrics? Eccentric contractions occur when the muscle-tendon unit LENGTHENS during exercise, producing so-called “negative work”. Squatting down is an example of a quad eccentric. Eccentric force production may exceed concentric (shortening contraction) and isometric (tensing without motion) forces 2-3 times. (Stanish et al) Eccentric training drills stimulate mechanoreceptors in tenocytes to produce collagen. (Khan et al) This effect helps to reverse the tendinopathy cycle.

The eccentric exercise commonly recommended for the patellar tendon is the squat. What kind of squat is best? A mechanism that may decrease the eccentric load on the quad is active or passive calf tension. This tension may limit the forward movement of the tibia over the ankle while performing a squat. This effect can be minimized, and load on the patellar tendon maximized, by performing a squat on a 25 degree decline. (Purdam et al) In a small group of patients with patellar tendinopathy, eccentric squats on a decline board produced good clinical results in terms of pain reduction and return to function. (Purdam et al) In the flat-footed squat group, the results were poor.

The eccentric training protocol for patellar tendinopathy should include 3 sets of 15 reps, 2 times per day, for up to 12 weeks.

“I started therapy at a rehab close to home but was not getting results after 12 visits. I then came to Chris and within 2 weeks (4 visits) the results have been substantial. What a difference!” — Kristin M.

The P.R.I.C.E. is right! Patient Handout.

As your therapist, one of my most important roles in your recovery is teaching you the fundamentals of proper healing. Healing of injured tissue is a physiological process that can be inhibited by many factors. Pain management strategies, activity modification, and proper exercise are three such factors that need to be examined.

PAIN MANAGEMENT

All new injuries or aggravation of old injuries need to be addressed with the acronym P.R.I.C.E. – Protect, Rest, Ice, Compress, Elevate. We will talk about the protection aspect in the next section on activity modification. After an acute injury, there is resulting tissue trauma and inflammation. Inflammation is part of the healing process as the body attempts to bathe the injured tissue with protein rich fluid as well as cells that cleanse and repair the injured tissue. Inflammatory cells can be present up to 21 days after an injury, but are the most prevalent during the acute inflammatory stage i.e. first 7-10 days. Uncontrolled inflammation is what delays healing and it is what we attempt to control with R.I.C.E. Ice should be applied for 10-15 minutes only in order to prevent frostbite. You can use soft, gel cold packs, bags of frozen peas or ice, or submerge the injured part into an ice water bath. You can ice every hour if you wish, but at a minimum of 2-3 times per day, for at least the first 7-10 days. Remember that the inflammatory process (in the controlled environment) can last 21 days. The adage “ice for the first 48 hours only” does not make physiological sense. Icing is not only anti-inflammatory, but it is also a great pain reliever. You should also consult with your physician regarding an anti-inflammatory medicine. Examples would be medicines such as Aleve 2x/day or 600-800mg of ibuprofen i.e. Advil or Motrin 3x/day for at least 7-10 days. Compression and elevation of the injury helps to prevent uncontrolled inflammation as well. Athletic taping, neoprene or Acewrap sleeves for ankles or knees, and back braces are examples of compression as well stabilization of an injury. Heating tissue can be relaxing and pain relieving, but it also causes the blood vessels to dilate, hence, increasing the flow of fluids to the area. If you wish, heating for 15-20 minutes can be added after the first 7-10 days as long it does not increase the swelling.

ACTIVITY MODIFICATION

Protecting the injury will prevent uncontrolled inflammation, thus encouraging proper healing. Pain is a warning sign. It is your body’s attempt to remind you that something is wrong. Pushing “through the pain” is NEVER a good idea. When a lower extremity joint is injured and walking becomes painful or limited, we advise and instruct patients in using crutches or canes. This is a temporary modification of activity in order to prevent reoccurrences of pain as the body is healing. Our patients use an assistive device as long as is needed, but most typically for the first 7-10 days. Proper posture and body mechanics are also very important in removing the stresses to an injured back or spinal condition. Remember that causing pain during activity is like taking a hammer and “banging” on the injured tissue. Take frequent breaks and pace your activity as to not provoke your pain. It is important to wean slowly back into walking or running. We will help to guide you in that process.

PROPER EXERCISE

Proper exercise can be initiated after the acute inflammatory stage. Movement of joints and tissues during exercise causes a mechanical “pumping”. This “pumping” can help to “push in the good and push out the bad”, prevent post-traumatic stiffness, and encourage a quicker return to function. Proper technique in these early stages would entail pain free, high rep, and low weight exercises. We will guide you in that process. Creating a global circulatory effect via pain free cardiovascular exercise is also beneficial to healing as it helps to cleanse and nourish the injured area.

I hope that helps!!

Chris Dukarski, PT

The Missing Link – SCAR TISSUE

 

Scar Tissue

All physical therapy is NOT created equal. As a physical therapist with 2 decades of hands-on care, I have tried many approaches in treating soft tissue dysfunction. Tissue stress can be identified objectively through a comprehensive biomechanical evaluation and well as subjectively through a thorough interview with the patient. Patient compliance and therapist experience is paramount in achieving maximum results in minimum time. I strongly feel that the “missing link” in achieving permanent, maximum results is inadequate treatment of soft tissue fibrosis i.e. scar tissue throughout the kinetic chain. Let me explain!

One of the most contentious debates that I have had with physicians as well as physical therapists is the inflammation versus fibrosis debate. Many health care practitioners feel that inflammation is the main source of pain in chronic conditions (greater than 3 weeks). This is evidenced through their long-term use of anti-inflammatory meds, cortisone shots, and the over-use of anti-inflammatory modalities in physical therapy such as iontophoresis and phonophoresis. My main adage as a physical therapist is “there better be a good reason for everything you do!” Evidence-based or research-based treatment is fundamental to our professional growth. I feel that using anti-inflammatory procedures is a very effective strategy in the short-term. It is true that we are our own worst enemies during our hectic lives. Intermittent, acute inflammation can certainly occur. However, what underlying dysfunction is present that predisposes us to this chronic, intermittent pain? What does the research tell us?

Karim Khan,MD in “Time to abandon the “tendonitis” myth”, BMJ, 2002, 324(7338):626-7 reports that “animal studies conclusively demonstrate that, within 2-3 weeks of insult to tendon tissue, inflammatory cells are not present.”

Karim Khan,MD in “Histopathology of common tendinopathies”, SportsMed 1999;27(6):393-408 states that “We conclude that effective treatment of athletes with tendinopathies must target the most common underlying histopathology, TENDINOSIS, a non-inflammatory condition.”

Harvey Lemont,DPM in “Plantar fasciitis”, JAPMA 2003;93(3):234-237 states that, after analyzing tissue samples from 50 plantar fascia surgeries, “Histologic findings are presented to support the thesis that “plantar fasciitis” is a degenerative fasciosis WITHOUT inflammation, not a fasciitis.”

Although the literature states that inflammation is not present in chronic soft tissue lesions, many practitioners continue to get positive results with anti-inflammatory procedures. Why? Steroids have been shown to inhibit the early stages as well as the later manifestations of the inflammatory process. (Fredberg 96) Ultrasound guided peritendinous injections of achilles and patella tendonitis have shown a significant reduction in the average diameter of the affected tendons (Fredberg 04) as well as a disappearance of neovascularization. (Koenig 04) What this last statement means is that steroids have the ability to “shrink” pathological tissue. This “shrinking” has been associated with a decrease in pain, but it does not stimulate tissue regeneration and strengthening of the pathological tissue. As a result, the patient is susceptible to chronic reinjury. So how does the therapist stimulate tissue regeneration?

The first step in the process is to identify tissue texture abnormalities. Microscopically, healthy tissue is smooth, longitudinal, and symmetrical in presentation. Scar tissue i.e. fibrosis is laid down by our bodies in a very haphazard and erratic fashion. During palpation, both the clinician and the patient can detect areas of grittiness, nodules, and “knots”. A partial tear in the Achilles tendon is thicker, harder, and gritty compared to the healthy side. Fibrosis in the plantar fascia can be felt and heard as you stroke the edge of a coffee mug along the central band of the fascia. Once a lesion is detected, I utilize patented and proven techniques such as instrument assisted soft tissue mobilization(IASTM) and Active Release Technique to “break up” cross-links, adhesions, and/or restrictions in the tissue. Please read my links for Graston’s New IASTM and Active Release Technique for more information.

As a result of 2 decades of asking questions and critically appraising my successes and failures, I have become convinced that the “missing link” in the treatment of chronic pain is the release of scar tissue adhesions. In conjunction with IASTM and Active Release Technique, rehabilitation is accomplished through the functional integration of strengthening, stretching, joint mobilization, cardiovascular exercise, and compliance with a home exercise program. Correcting biomechanical deficiencies with foot orthotics is also a consideration. Most physical therapists do an adequate job of treating pain. Acute pain usually resolves with the most innocuous of therapy interventions. However, the only way to prevent reoccurrence of symptoms is to ensure that every aspect of the dysfunction is being treated in the most comprehensive manner. At OrthoWell/WalkWell, we do just that!

CLOSED CHAIN CREATIVITY

Closed chain exercises for the lower extremities should be an integral part of your rehabilitation program. They are important in terms of regaining dynamic stability and improving neuromuscular control. Co-contraction of the muscles on all sides of a joint occurs only thru closed chain or weight bearing activities. An effective program for a patient with an ACL tear of the knee should include exercises such as squats, lunges, and step-ups. A patient recovering from an ankle sprain should perform balance board activities. In terms of patello-femoral dysfunction or pain in the region of your kneecap, the literature describes a strong link between hip weakness (especially the hip abductors and external rotators) and P-F pain. Open chain exercises such as straight leg raises should be performed in every plane of motion. Closed chain exercises should incorporate multi-planar strengthening as well. The following exercises include hip abductor resistance during a functional squat exercise and hip adductor resistance during a lunge. Creativity is the key to devising a more functional and sport specific program.

At OrthoWell/WalkWell, we use evidence-based and creative strategies to get our patients better- FASTER!   The following testimonial is from a recent “graduate”.

“I’ve had major ankle issues for over 15 years and have seen several PT’s and specialists but saw no progress until I came to WalkWell. After only 10 visits, I have made more progress than in the 15 years combined. The individual attention and rehab is without peer. And on the 8th day, God created WalkWell!” – Tom Lynch, Ipswich, MA

Shoulder Exercises: The Evidence

Everything we do at OrthoWell is evidence-based! Maximizing results in minimal time depends on the expertise of the clinician. As our knowledge of biomechanics and muscle function improves, more of an emphasis is placed on scientifically based rehabilitation protocols. This is particularly true regarding the shoulder and scapulothoracic complex. In the February 2009 volume of JOSPT, Mike Reinold, the Boston Red Sox team physical therapist, presented a thorough analysis of the shoulder and scapular stabilization exercise literature. One of the most effective exercises for each muscle will be presented.


Supraspinatus
*Full Can Exercise
*Enhances scapular position>
*Decreased deltoid compared to empty can
*Minimizes superior humeral translation

Infraspinatus/Teres Minor
*Side-lying ER
*Minimal capsular strain
*25% increased EMG using towel roll
*Highest EMG for infraspinatus

Subscapularis
*IR at 90 deg abd
*Position of shoulder stability
*Enhanced scapular postion
*Less pectoralis activity than 0 deg abd

Serratus Anterior
*Push-up with plus
*Easy position to resist protraction
*High EMG activity
*Also activates subscapularis

Lower Trapezius
*Prone full can at 135 deg abd
*Full can = horiz abd with ER(thumbs up)
*High EMG activity
*Also activates infraspinatus, teres minor, Mid traps, supraspinatus

Middle Trapezius
*Prone Full Can at 90 deg abd
*High EMG activity
*Also activates infraspinatus, teres minor, Mid traps, supraspinatus

Rhomboids
*Prone Row
*Below 90 deg abduction
*High EMG activity
*Good ratio of upper, mid, low traps

Combo Exercise
*Bilateral T-band ER
*25% increased EMG ER’s with towel roll
*Good ratio upper:lower traps per McCabe
*Emphasize scapula retraction and post tilting

In addition, it is clinically imperative to ensure proper technique during all therapeutic exercises especially as your patient is progressed to plyometrics, closed chain UE exercises, and sport- specific exercise training. Proper exercise TECHNIQUE and proper exercise CHOICE is required to effectively treat the muscular imbalances seen in most shoulder pathologies.

OrthoWell offers another exclusive service not available in any other physical therapy clinic – the fabrication of custom foot orthotics – ON SITE!

At WalkWell Orthotics, we fabricate custom foot orthotics based on YOUR individual need.  We use technologically proven materials, mold them directly to your foot, and, using our exclusive techniques, fabricate a completely custom pair of foot orthotics while you wait!  Walkwell’s same-day service guarantee for the past 20 years!

Our techniques are based on current orthotic research as well as WalkWell’s 20 years of experience.  In an hours time, we will perform a complete biomechanical assessment, fabricate your custom foot orthotics, and educate you in proper shoes, pain management strategies, and proper stretches.

Because we specialize in biomechanics, we realize that there are many factors that may contribute to your foot and/or lower extremity pain.  Foot orthotics may not be the ONLY answer.  At WalkWell Rehabilitation, we specialize in physical therapy of the foot and lower extremity.  We can help you to achieve COMPLETE relief!

You will need to bring a pair of work shoes, a pair of sneakers, a personal check or cash (no credit cards),  a copy of my directions (the Cummings Center is a big place!), and any questions you may have to your appointment.  Use my 24 hour self scheduler link on this website or call for your appointment TODAY.  See you soon!

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