Are Toe Crunches just as important as Stomach Crunches??

Intrinsic Marbles

 

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?

 

  1. http://www.ncbi.nlm.nih.gov/pubmed/12968860
  2. http://running.competitor.com/2014/06/photos/new-techniques-treating-plantar-fasciitis_96398
  3. http://www.jospt.org/doi/pdfplus/10.2519/jospt.2003.33.8.468
  4. http://www.ncbi.nlm.nih.gov/pubmed/1672577
  5. https://www.karger.com/Article/FullText/368357
  6. http://biomedgerontology.oxfordjournals.org/content/61/8/866.full
  7. http://www.jfootankleres.com/content/7/1/32
  8. http://www.jfootankleres.com/content/7/1/28

PLANTAR FASCIITIS….OUR OWN DVD!!

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.

 

3D ebook cover

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.

 

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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 HEREWatch the intro video below. Talk to you soon!!

 

 

 

Plantar Fasciitis & Foot Orthotics

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.

Nerve Mobilization Techniques

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.

NeuroMobilization Techniques

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.

 

Effect of Wedges on Plantar Fasciitis

ARTICLE REVIEWED

Kogler GF, Veer FB, Solomonidis SE, et al. The influence of medial and lateral placement of orthotic wedges on loading the plantar aponeurosis: An in vitro study. J Bone Joint Surg 81(A):1403-1413, 1999

METHOD

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.

RESULTS

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.

What kind of foot orthotic do you need??

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!!

Literature Review – Heel Pain

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.

IS IT PLANTAR FASCIITIS OR NERVE PAIN??

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.

Plantar Fasciitis and Foot Orthotics.

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 lateral aspect of the forefoot decreased the strain.
  • A wedge placed under the medial forefoot increased the strain.
  • Foot orthotics that raise the apex of the medial arch and prevent dorsiflexion (loading) of the first ray are the most effective in reducing plantar fascia strain.

The foot orthotic should be custom molded, fit snugly up against the navicular, and flare away from the lateral aspect of the foot.  The orthotic can include a post under the lateral 4 metatarsal heads.  We call this post a reverse Morton’s extension.  It will allow the first ray i.e. the first metatarsal and medial cuneiform to be plantar flexed 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.

DO FOOT ORTHOTICS CONTROL ALIGNMENT??

Foot orthotic devices (FOD’s) are widely used and prescribed for foot conditions ranging from diabetes to overuse injuries to plantar fasciitis.  A myriad of prefabricated and custom devices are now available.  The method by which the practitioner prescribes a device is determined more by his or her previous clinical experience than by conclusive scientific evidence.  The variability of FOD’s used in research as well as the prevalently small sample sizes (<20 subjects) makes it difficult to extrapolate useful clinical information.  There is, however, strong evidence that selected FOD’s prevent injury reoccurrence in runners and athletes in general.  FOD’s have also been shown to reduce impact loading by 10-20%.  What research does NOT prove is that foot orthoses control alignment like we think they do!!

The majority of foot orthotic research focuses on control of rearfoot motion in the frontal plane.  While there are numerous studies that demonstrate NO effect on rearfoot motion, most report that FOD’s result in control of some aspects of rear-foot motion such as peak eversion, eversion excursion, and/or eversion velocity.  The average amount of rear-foot motion control reported in the literature is on the order of 2-3 degrees.  That’s it!  The question is whether this 2-3 degrees is clinically significant—or can the observed control be explained in a different way?

WalkWell Foot Orthotics
Is   DIFFERENT   from   the   competition!!!

Each patient at WalkWell is evaluated by an orthopedic physical therapist with 19 years of experience treating disorders of the lower extremity and fabricating custom foot orthoses.  The evaluation includes a gait analysis and a complete biomechanical assessment.  Special materials of varying density and firmness are directly molded to the foot in order to create a completely CUSTOM orthotic WHILE YOU WAIT!!  The process is complete in ONE HOUR.

PROPER FIT IS GUARANTEED!!!

Each patient is thoroughly educated in proper footwear, stretching, and pain management strategies.  All follow-up adjustments are included.  Simply refer your patient to WalkWell Orthotics and we will do the rest!!