I have struggled over the years as to the importance of including toe flexor strengthening as part of a program for plantar fasciitis. Many researches agree that the potential causes of plantar fasciitis are just too numerous and multi-factorial. The evidence in the literature has not been conclusive and I have let many of my patient’s comments that “this is silly” when picking up marbles dictate my decision-making. I have slowly but surely, and I believe wrongly, eliminated this important exercise from my treatment approach. I have recently read several articles that have rekindled my enthusiasm for toe flexor strengthening. So why the change in heart??
I am always looking for ways to get our patients better…faster. I have written a book on plantar fasciitis called the Plantar Fasciitis Treatment Manual and it identifies ankle muscle weakness as a result of plantar fasciitis but not include the presence of toe flexor weakness. That is my oversight and I will correct that in the book. Yes, the literature does identify weakness of the ankle muscles and the toes flexor muscles with the plantar fasciits population, yet the research does NOT confirm any causative factor of this weakness on the development of plantar fasciitis.(1,3,4) It is the chicken or the egg conundrum. Unfortunately, there are theoretical assertions that the “flexor digitorum brevis muscle (the muscle directly underneath the plantar fascia) plays an important role in distributing pressure away from the plantar fascia” that are simply not supported by research. (2) Does this mean that we should not perform strengthening exercises? Let me provide some more evidence.
As we get older, we get weaker. We all lose muscle mass, we lose muscle fibers and, as a consequence, we see decreases in strength between the ages of 30 and 80 within a range of 20-40%.(5) Several articles have also shown that “older people” exhibit 24-40% less strength in the muscles of the foot and ankle(5,6,7,8). As a consequence of foot and ankle weakness, older adults are more susceptible to loss of balance, the development of foot and toe deformities and can be susceptible to overuse syndromes such as plantar fasciitis. (5,6,7,8) The biggest question that has not been answered when it comes to strengthening exercises for older adults is WHICH exercises are the most effective?
As a result, we have to rely on some common sense. If the muscles in our ankles and feet get weaker as we get older (proven!), then we should strengthen them to avoid plantar fasciitis. Right? Not necessarily. There is not a direct correlation between weakness and the development of plantar fasciitis but, then again, many people don’t believe that there is a direct correlation between human activity and climate change. My point is why should we wait to change our approach until it is conclusive – whether it be climate change or your plantar fasciitis?
I have treated a lot of foot pain over 22 years as a physical therapist. Because I make custom foot orthotics, I am exposed to foot ailments much more than other PT’s. Geoff and I treat a lot of these problems in the clinic every day. One of my patients even went so far as to nickname us the “foot whisperers” and another patient coined OrthoWell as the “doctors of knotology”. Can you feel the love? I have spent a lot of time researching the BEST strategies to treat foot pain. This has culminated in the release of my Ebook entitled “Physical Therapist Discovers the Truth about Plantar Fasciitis“ as well as my self-help DVD on the treatment of Foot Pain & Plantar Fasciitis. Both of these are now available and are on my HOMEPAGE.
The Ebook includes a complete review of the literature on the treatment of plantar fasciitis as well as a description of the the most effective treatment strategies. This book is not a re-tellling of on-line information about plantar fasciitis. It is the missing link! You can read more by clicking HERE.
The DVD is a collection of videos that will “take you by the hand” and teach you specific methods and exercises to resolve your foot pain. It is designed for those people suffering from foot pain who cannot come to see us or who have not responded to other practitioners. It is a great way for our SUCCESS STORY patients to help friends and family members who have foot pain but cannot come to see us directly. You can read more HERE. Watch the intro video below. Talk to you soon!!
Yes. We treat a lot of plantar fasciitis. There is a lot of foot pain out there. While performing a literature review of heel pain in 2005 (follow this link to READ MORE), I made reference to several articles about the prevalence of heel pain. One United States study estimated that one million patient visits each year are for the diagnosis and treatment of plantar heel pain. This disorder appears in the sedentary and geriatric population, it makes up one quarter of all foot injuries in runners, and is the reason for 8% of all injuries to people participating in sports. As many of you know, all that we do regarding foot orthotic fabrication and physical therapy is with good, evidence-based reason. I fabricate custom foot orthotics based on sound biomechanical principles and evidence-based research. Patients are always asking me “so how will foot orthotics help my plantar fasciitis?” Here is the answer! I have included both a clinical description as well as a more basic description in the video. This will allow you to refer your doctor and/or PT as well as a relative who may ask WHY or HOW we made your foot orthotics. I have included references for several articles that have had a profound influence on my treatment and fabrication philosophy regarding plantar fasciitis. I would like to share my insights with you.
It has been my experience that positive results can be achieved much more quickly for cases of plantar fasciitis using the combination of softer materials to cushion the foot in combination with stiffer, denser materials to redistribute pressures on the foot. My direct molding techniques produce a total contact orthotic which reduces weight bearing pressure on both the heel and forefoot. These findings for total contact orthoses have been confirmed by both Mueller et al10,11 and Ki et al12. As you can see from my samples on the video, I utilize softer materials as a top layer with the addition of a heel pad on the bottom. I reinforce the arch in order to redistribute pressures up against the talonavicular joint (or midfoot). I utilize a forefoot valgus post (higher on the outside of the forefoot) with a slight reverse Morton extension (ledge under toes 2-5) in order to plantar flex the first ray (big toe lower than the other four toes) and unload both the fascia and 1st MTP joint (big toe joint) As I tell my patients, the foot orthotic is only as good as the shoe you put around it. Our best results with the over-pronating foot are achieved via the combination of motion control shoes and custom orthoses.
In regards to prefabricated orthotics such as ALine, it is one-shape-fits-all and only utilizes rearfoot posting “to help align the leg from foot to hip” per the website. The concept of rearfoot posting for biomechanical control is a much debated topic in the literature. Forefoot modifications are not an option. It is also a very rigid material against a painful heel. It has been my experience that prefabs such as ALine or Powerstep are a good option for the younger, athletic patient.
Don’t forget, our custom foot orthotics range in price from $120 to $165. I direct mold, fabricate, educate and issue in one hour! All adjustments included. Our WalkWell guarantee since 1997!!
Research findings continued……
Research done by Kogler1,2,3 et al has been instrumental in determining the appropriate type of rearfoot and/or forefoot posting for foot orthotics for plantar fasciitis. Kogler showed that rearfoot posting had little effect on plantar fascia strain, forefoot varus posting increased the stress, and forefoot valgus posting actually decreased the strain. Kogler concluded that foot orthotics which raised the talonavicular joint and prevented dorsiflexion of the first ray were most effective in reducing the strain on the central band of the plantar fascia. I recently made orthotics for a patient who said her doctor issued bilateral heel lifts “to take the stress off of the fascia”. Kogler actually showed no change in plantar fascia strain using heel lifts. However, heel lifts have been shown by Trepman et al4 in 2000 to decrease the compressive forces in the tarsal tunnel. Benno Nigg5, a researcher in Canada, has also published over 200 articles on biomechanics. He has stated that based on his results, custom foot orthotics, on average, control only 2-3 degrees of motion. This would be his kinematic results, however, he has done a lot of enlightening research on the kinetic effects of foot orthotics. A little bedtime reading for you!
Paul Scherer6,7,DPM has published several articles on the effects of custom orthotics on the 1st MTP joint. The concept of maintaining the first ray in a plantar flexed position unloads both the 1st MTP joint as well as the plantar fascia. Howard Dananberg8,DPM has also written several articles on this topic. Doug Richie9,DPM has been a great resource for the evidence behind the treatment of plantar fasciitis as well as posterior tibialis dysfunction. You may have heard of the Richie brace. Dr Richie states that the “most effective foot orthotic for plantar fasciitis is one that hugs against the navicular and flares away from (or plantar flexes) the first ray.”
1.Kogler, G. F.; Solomonidis, S. E.; and Paul, J. P.: Biomechanics of longitudinal arch support mechanisms in foot orthoses and their effect on plantar aponeurosis strain. Clin. Biomech., 11: 243-252, 1996.
2.Kogler GF, Veer FB, Solomonidis SE, et al. The influence of medial and lateral placement of wedges on loading the plantar aponeurosis, An in vitro study. J Bone and Joint Surg Am. 81:1403-1413, 1999
3.Kogler GF, Veer FB, Verhulst SJ, Solomonidis SE, Paul JP.
The effect of heel elevation on strain within the plantar aponeurosis: in vitro study.
Foot Ankle Int. 2001 May;22(5):433-9.
4.Trepman E, Kadel NJ: Effect of foot and ankle position on tarsal tunnel compartment pressure. Foot Ankle Int 20(11):721, 2000
5.Nigg, B. Biomechanics of Sport Shoes. 2011
6.Scherer PR, Sanders J, Eldredge, DE, et al. Effect of functional foot orthoses on first metatarsophalangeal joint dorsiflexion in stance and gait. J Am Podiatr Med Assoc 2006;96(6):474-481.
7.Scherer,P. Recent Advances in Orthotic Therapy. 2011
8.Dananberg HJ. Functional hallux limitus and its relationship to gait efficiency. J Am Podiatr Med Assoc. 1986; 76(11):648-52
9.Richie,D. Offloading the plantar fascia: What you should know. Podiatry Today, Vol 18. Issue 11, Nov 2005.
10.Mueller MJ, Hastings M, Commean PK, et al. Forefoot structural predictors of plantar pressures during walking in people with diabetes and peripheral neuropathy. J Biomech 2003;36(7):1009-1017.
11.Mueller MJ, Lott DJ, Hastings MK, et al. Efficacy and mechanism of orthotic devices to unload metatarsal heads in people with diabetes and a history of plantar ulcers. Phys Ther 2006;86(6):833-842.
12.Ki SW, Leung AK, Li AN. Comparison of plantar pressure distribution patterns between foot orthoses provided by the CAD-CAM and foam impression methods. Prosthet Orthot Int 2008;32(3):356-362.
I would like to highlight one of the unique treatment techniques that we offer at OrthoWell. As many of you know, we spend a lot of quality time during our biomechanical evaluation trying to “figure things out”. This is the reason that several of our referring physicians call us “THINKERS”. We pride ourselves in determining your functional diagnosis. This diagnosis is what we use to develop your plan of care and to educate you in how to alleviate your pain or dysfunction. Many of our patients have seen several physicians or therapists before hearing about us. For this reason, we offer specialized evaluation and treatment services that our patients may not have heard of and that may be appropriate to alleviate symptoms that have been unresponsive to prior interventions. One of these is Nerve Mobilization or NeuroMobilization. So what is it?
What is NeuroMobilization?
NeuroMobilization or Nerve Mobilization is a technique that we utilize to treat nerves that may be adhered, irritated, or compressed. Many patients that have been unresponsive to other physical therapy and present with a chronic history of referred symptoms like pain, numbness, or tingling into the arms or legs may respond to NeuroMobilization. Every patient that presents with referred symptoms or pain that has been unresponsive to localized treatment receives a complete neural tension evaluation. Neural tension testing is a way for your therapist to determine the extent of nerve involvement. By mobilizing a nerve, we can determine, in combination with manual traction and sensitizing maneuvers, whether your pain is originating from the spine or the periphery.
We can then perform NeuroMobilization techniques utilizing controlled neural tension maneuvers to mobilize the nerve up and down. David Butler,PT, has been at the forefront of these techniques for over 20 years. Although we still do not completely understand the exact mechanism, he proposes that NeuroMobilization (what David Butler calls Neurodynamics) can accelerate nerve healing and quiet down what he calls an “altered impulse generating system (AIGs)”. These AIGs may respond to the oscillations of NeuroMobilization by enhancing circulatory exchange or ion transfer in and around the nerve. You can read more about the techniques and science in David Butler’s book The Sensitive Nervous System.
Here is a video that highlights a sciatic nerve tension test and Neuromobilization.
I cannot count the number of times over the past 22 years that patients have told me “I USED to have an arch, but not anymore”. Is it true that you can actually lose your arch as you get older? The answer: YES. So what happens? Many doctors attribute a loss of your medial arch height to a condition labled posterior tibialis tendon dysfunction or PTTD. Your posterior tibialis muscle lies deep under your calf and it’s tendon inserts into your midfoot. It is responsible for turning your ankle inwards and “reinforcing your arch height.”
PTTD typically presents as a progressive increase in tendonitis pain which can lead to partial or complete rupture. The loss of PTT integrity has been hypothesized to produce a gradual change in the alignment of your foot. However, recent evidence shows that a partially torn or ruptured PTT is NOT the definitive reason for an adult acquired flatfoot. Let me show you. A study by Yeap et al followed 17 patients who underwent a surgical transfer of the PTT to a different part of the midfoot in order to control a drop foot. At a 5 year follow-up, none of the patients had a clinical flatfoot deformity. In other words, “losing” the PTT tendon by attaching it to a different part of the foot did NOT cause a flat foot. In light of this one study, there is sufficient evidence to rebuke the PTT as the sole reason for an adult acquired flatfoot.
Another study by Deland et al attempted to produce an adult acquired flatfoot in cadaver models by cutting the PTT. This produced only a minimal drop in height. It wasn’t until they severed the ligaments and plantar fascia on the underside of the arch that a complete arch collapse was achieved. Researchers Chu and Myerson confirmed the results of this study as well. So the evidence is here. A major contributing factor to the loss of arch height as we age is the loss of ligamentous integrity in the foot.
Did you know that women are 3 times more likely to be diagnosed with PTTD? It is most frequently found in women in their 50’s. Although a definitive hormonal link has not been established, PTTD appears to peak during the perimenopausal period. An interestingstudy performed at USCin 2011 found that women with PTTD compared with a control group had significantly decreased endurance and strength of hip muscles. Strengthening your hips may help to strengthen your arch. More evidence that everything is connected!
Can you raise your arch by strengthening the muscles in your feet? Did you know that there are 18 muscles in the arch of your foot? What does the research tell us? In my previous article on running technique, I mentioned an article by Robbins who showed radiographic changes in arch height after runners ditched their shoes and started walking and/or running barefoot. This should be a very slow process, but many coaches and therapists advise walking barefoot on grass or sand as a starting point. Two other studies by Fiolkowski et aland Headlee et alalso show that when muscles in the arch weaken, the arch falls.
So what, specifically, can you do about your fallen arches?
Number 1 : Custom Foot Orthotics. You need to control the pain and unload the injured structures first. We are attempting to control some of the mechanical imbalances by fabricating foot orthotics that “hug” your midfoot. We utilize both rearfoot and forefoot posting (angling of the orthotic) in combination with motion control shoes to control your excessive motion. For more severe cases, some research shows better control of the twisting or internal rotation of the leg using braces such as ankle-foot orthoses. The Richie Brace is one example.
Number 2: Exercise!! Yes, it is very important. The articles above prove it. In order to “raise” your arch height with exercise, you need to be very consistent and compliant with your program. I have mentioned HOW to exercise in a previous post. I want to emphasize that, if you have flat feet, your arches will fall every time you stand or take a step if you don’t train yourself to prevent it. This means using the appropriate intrinsic muscles in your arch in combination with active joint repositioning. If you can master this, you will be in a constant state of muscle retraining and joint stabilizing while bearing weight on your feet.
You could then add barefoot walking on grass or sand as an adjunct to your program. My next post will highlight the research on the muscle training effects of minimalist shoes such as the Nike Free. Stay Tuned! Now, check out my videos on foot intrinsic training and an effective hip strengthening exercise called Clams.
So what’s up with the claims made by these toning shoes??
I’m sure that you all have seen advertisements for the new rage in footwear…”toning” shoes. Several manufactures such as Shape-Ups by Skechers, MBT shoes, and EasyTones by Reebok have made unsubstantiated claims of increased gluteal activation and improved muscle tone as a result of wearing their products. A recent study sponsored by the American Council on Exercise compared 12 patients walking in “toning” shoes to 12 patients walking in traditional walking shoes. Researchers used electromyography (EMG) to evaluate muscle activity in several muscles of the lower extremity including the calf, quad, hamstrings, glutes, low back paraspinals, and the abdominals. The results indicated that none of the 3 studied brands of “toning” shoes exhibited a statistically significant increase in muscle activation. The researchers concluded that there is “simply no evidence” in their study to substantiate the “toning” claims made my the 3 shoe manufactures.
So why is that some patients feel better in “toning” shoes? These shoes are constructed with a rounded or rocker-bottom sole. This type of sole is designed to allow you to “roll” from one step to the next. It would thereby get you to transition more quickly from heel strike to toe-off and, as a result, decrease the amount of time that you are bearing weight on your midfoot. It would lessen the impact load on an arthritic or painful midfoot. It may also limit the amount of bend that is occurring in a painful or arthritic toe.
And: The heels of these shoes are very soft and may decrease the impact load on a painful heel.
And: Because of the raised apex of the rocker-sole, it feels to some of my patients that they are bearing more pressure against their arches thereby decreasing the weight bearing on the heel and the forefoot.
And, lastly: If you watch someone with “toning” shoes walking from behind, you will notice how their ankles tend to look a little unstable due to the softness of the heel and the rocker-bottom effect. This may predispose the patient with a chronic weak ankle to acute sprains. However, it may also have a positive impact on neurologic retraining ie proprioceptive retraining of the foot and ankle. Pre and post balance testing for “toning” shoe wearers would be an interesting thing to test.
But anyways, “Different strokes for different folks”…just don’t be fooled by the claims.
The aim of this study was to quantify the strain in the plantar aponeurosis with different combinations of wedges. A single wedge or combination of wedges was placed under cadaveric models (varus and valgus wedges under the forefoot and/or rearfoot). A load was then applied to the cadaver limb in a walking apparatus, and a strain gauge in the plantar fascia measured the effect.
A wedge under the lateral aspect of the forefoot (valgus wedge) decreased strain in the plantar aponeurosis. A wedge under the medial aspect of the forefoot significantly increased the strain in the plantar aponeurosis. There was no significant change when a wedge was placed under either the medial or lateral aspect of the hindfoot.
SIGNIFICANCE OF THE ARTICLE
Since wedges are incorporated into the orthotic treatment for plantar fasciitis, it is important to know how they contribute to changes in strain on the plantar aponeurosis. The findings of this study revealed that “the placement of a wedge under the lateral aspect of the forefoot appears to be a promising orthotic control mechanism for shielding the plantar aponeurosis from strain”.
The results of this study indicate that a forefoot valgus wedge pronates the midtarsal joint reducing the stretch of the plantar fascia. The midtarsal joint likely contributes to the pathology leading to plantar fasciitis as a result of supination of the midtarsal joint stretching the plantar fascia. This is contrary to the common thought that subtalar joint pronation is the primary contributor to plantar fasciitis. Based on this study, we recommend adding a forefoot valgus wedge to the orthotic when treating plantar fasciitis to pronate the midtarsal joint. If you choose prefabricated orthoses as part of your initial conservative treatment of plantar fasciitis, select one that incorporates a forefoot valgus correction or wedge.
Have you been asked this question? Let me help you with the foot condition that you probably diagnose most often – plantar fasciitis!!
The purpose of foot orthotics with a diagnosis of plantar fasciitis is to decrease the strain on the plantar fascia. Kogler, in his articles in Clinical Biomechanics, has provided evidence highlighting the effect of several variables on plantar fascia strain. Let me give you a summary:
Heel lifts do NOT decrease the strain on the plantar fascia
A wedge placed under the outside of the forefoot decreased the strain.
A wedge placed under the inside of the forefoot increased the strain.
Foot orthotics that raise the apex of the arch and prevent excessive loading of the first ray (the inside part of foot) are the most effective in reducing plantar fascia strain.
The foot orthotic should be custom molded, fit snugly up against the navicular bone, and flare away from the outside aspect of the foot. The orthotic can include a post under the outside 4 metatarsal heads. We call this post a reverse Morton’s extension. It will allow the first ray to be in a downward position relative to the other metatarsals. As a result, we decrease the strain on the plantar fascia.
At WalkWell, biomechanical analysis is our specialty. We can fabricate custom foot orthotics as well as provide comprehensive and evidence based physical therapy. We hope to hear from you soon!!
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.
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.
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 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.
What happens when your patient returns and his/her heel pain has not improved? Do you assume that physical therapy didn’t work? What you CAN conclude is that your patient may not have received the RIGHT physical therapy.
Heel pain is multi-factorial. What needs to be determined in physical therapy is whether the origin of the pain is local, referred, or both. As our patients become heavier, more de-conditioned, and more susceptible to concurrent orthopedic dysfunction, the chance of referred symptoms from discogenic involvement and/or peripheral nerve entrapment is greater. If our patients at OrthoWell/WalkWell are not significantly improving after 4 visits of localized soft tissue treatment, then referring sources of pain need to be considered. If nerve involvement is suspected, then it is easier to perform manual differentiation testing after the nerve has been sensitized. Our patients are instructed to return to PT when they are most symptomatic. Neural tension testing of the sciatic nerve may elicit heel pain or a “doorbell” sign may be elicited along the course of the sciatic or tibial nerve. See below.
Our patients may be susceptible to the “double-crush” phenomenon due to concurrent areas of nerve entrapment. Centrally mediated entrapment may arise from a history of disc herniation or multiple lumbar disc sprains. Common peripheral entrapment sites are the lateral plantar nerve at the medial heel, the tibial nerve under the flexor retinaculum in the tarsal tunnel or as it courses through the tendinous arch of the soleus, and the sciatic nerve at the distal split of the hamstrings, between the biceps femoris and adductor magnus, or under the piriformis muscle. Active Release Techniques, as performed at OrthoWell/WalkWell Rehab, are very effective in resolving these entrapments.