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Plantar Fascitis ideas?
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Plantar Fascitis ideas? - July 24, 2008 8:11:43 AM
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sthorso
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Hi everyone. I am new to this site but I have found it very helpful in getting ideas for some of my patients. I am a new grad and work in a very rural setting so sometime my interaction with other therapists is limited so I find this site helpful.
I recently have had an influx of plantar fascitis patient's. I have done the usual stretching of the gastroc/soleus as well as instructed in home icing. I have done some manual massage to the plantar fascia as well as some phonophoresis and iontophoresis (which I am not real sure is a big help). But I find this diagnosis so frustrating because they tend to not do well in my very limited clinical experience. I was wondering if anyone had any other tips or techniques for these patient's that they have seen work?? Anything would be helpful!
Thanks!
-Steph
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RE: Plantar Fascitis ideas? - July 24, 2008 8:27:27 AM
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PTupdate.com
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From: Pittsburgh, PA USA
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Steph,
I use the same above treatments as you, and also incorporate:
Intrinsic strengthening via towel crunches, with or without weights
Self PF soft tissue work, using a can or frozen bottle of H20
Resolution of any ROM, strength and/or biomechanical issues seen
Shoewear modification, usually the main culprit besides excessive weight
Taping, via the simple (yet modified by me) method published in JOSPT sometime in the past few years......some people LOVE this, and I have found that a simple elastic sling sold in foot catalogues provides the same subjective relief once the patient purchases
Ruling-out any neural issues via tension testing from the back/leg, and also ruling out (ala Shacklock) any instances of neurogenic inflammation.
Pulsed US at the focal insertion. Why? Because it worked for me, and with some try/not try scenarios, found the same with patients. We can all argue on the efficacy and science of that later and somewhere else.
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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RE: Plantar Fascitis ideas? - July 24, 2008 3:49:16 PM
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V Can
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I would do the same as John and I usually instruct the patient to strech their achilles [ with the towel ] and if possible do the step streches [ where you stand over the edge of the step with the ball of your feet and dip yourself down with knees extended ] and toe extn movts first thing in the morning. This seems to decrease the pain intensity they experience after nights sleep. Night splints can also be adviced but the splint itself seems to be more uncomfortable than anything so I am not for it. I do think US helps decreasing the inflammation.
Shoe wear modification plays a very important role too. Filp flops with poor soles is definitely a no, I suggest pts to wear sneakers that gives a little bit of arch support and soft thick sole shoes.
That's all I can think right now. More inputs welcome
< Message edited by V Can -- July 24, 2008 3:56:10 PM >
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RE: Plantar Fascitis ideas? - July 24, 2008 4:58:22 PM
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Tom Reeves DPT ATC
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you have to figure out why they got in the firtst place. assess rearfoot and forefoot structure, look at their shoes to see if the type of shoe matches the needs of their foot type, stretch the calves, tape the arch for a band-aid for now ( I am with Duffy, I have made a lot of friends with the arch tape) assess their balance.
It is usually one of these things. If they used to have cavus feet and are not quite as cavus, they will have PF. Taping might be all that is needed to get them over the acute inflammation and get them used to their new foot type.
Vcan, I am not a fan of "arch support", I prefer to post the forefoot and/or rearfoot and actually remove some of the height of the medial longitudinal arch (from the orthotic). the arch is not supposed to touch the ground, it needs to sag down then resupinate with control. If the arch is simply held up, the patients complain about arch pain in a new spot and they throw their nice new $300 per pair orthotics in the closet. Different people have different approaches to feet, soon they will realize that I am the all knowing authority on this issue. 
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RE: Plantar Fascitis ideas? - July 24, 2008 5:32:12 PM
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V Can
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Tom, I do agree with you. Arch support doesn't apply for all pts. I must have mentioned the word pes planus. I meant to imply that when assessing the pt we will have to check for hind foot pronation and if it exists then a milder version of arch support [ from that of sneakers , not customized orthotics ] would go hand in hand with our approach to treat PF to minimize pronation. Instead of letting the pts roam around with improper foot wear. Anyways your post helps to make things clear for the folks who read this thread. I appreciate ur input.:)
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RE: Plantar Fascitis ideas? - July 24, 2008 6:35:39 PM
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gundyPT
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Hey sthorso,
There is a case series in JOSPT from Nov. 2004 by Young et al that provides some good examples of clinical decision making for PF and manual therapy. Also, there is a clinical guidelines review article in JOSPT from Apr. 2008 by McPoil et al that sytematically analyzes current treatments. Hope they give you some ideas, good luck!
< Message edited by gundyPT -- July 24, 2008 6:41:20 PM >
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RE: Plantar Fascitis ideas? - July 24, 2008 9:46:01 PM
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bonez
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May I suggest that besides the above noted treatment make sure that it is not something else acting like plantars fascitis. Another item to rule out is chronic venous insufficiency which can refer pain in a similar pattern to PF.
I also incorporate a modification to calf stretch either elevating the rear foot on one side to create a varus or valgus position which can hel further and also have patients try to stretch the arch by placing the toes up the wall and bringing the ball and arch to the floor. further stretch can be added to the region by having the patient gently rotate internally and externally around the tibia while in this position. For stubborn conditions a nite splint is often helpful.
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RE: Plantar Fascitis ideas? - July 24, 2008 10:16:00 PM
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TC PT
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Lots of good suggestions. I have used all the above and also use ASTYM in many cases (not trying to start anything). Also check great toe extension ROM/flexibility.
The night splint is a good idea in theory, but I've found this isn't very practical because most people hate trying to sleep with the appliance. Not to mention the expense of most of the splints I've seen given by orthopods. I've had decent luck using a Strassburg sock in cases where I think a night splint might help. Here's a link to the sock if you're not familiar with it : http://www.thesock.com/
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RE: Plantar Fascitis ideas? - July 25, 2008 1:27:25 PM
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buckeye
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Also consider adding strengthening for the decelerators to improve muscular control of pronation.
TomReeves - intersting concept about 'supporting' the arch. I never thought about it in those terms but it makes some sense. What do you mean by removing some of the height of the of the medial longitudinal arch from the orthotic? Do you shave down the material so the arch is not supported? What do you do with a flexible flat foot?
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RE: Plantar Fascitis ideas? - July 25, 2008 1:55:27 PM
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Tom Reeves DPT ATC
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Buckeye,
Yes, that is what I mean. With a flexible flat foot I still try to control the height of the arch by controlling the rearfoot and forefoot. Also, work on balance and intrinsic foot muscles for stabilization. Unfortunately, those with very weak intrinsics have trouble controlling the forces of simple ambulation. I often will tape them in addition to the orthotic while they gain strength and control over their midfoot. Sometimes you have to put some arch height in the orthotic but with a really planus foot the material has to be forgiving or else they won't wear it.
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RE: Plantar Fascitis ideas? - July 25, 2008 2:13:59 PM
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grifffdog
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Is the foot mechanically patent? If you cannot find subtalar neutral by (patient in supine) palpating the sinus tarsi and the divot on the other side made by the talus and navicular and find where these are symmetrical and the foot "hangs" there with passive dorsiflexion, then something is restricted. Measuring to find the subtalar neutral postion does not let you feel the lack of joint congruency, where the clinical eval does. Lots of controversy in the literatue on the STJN position, but this seems to work for me. I posted a reply to "toe crepitus" citing some sources for foot mobilization which may be helpful.
I have generalized from Mike Cibulka's hamstring article in "Physical Therapy" in 1985 (I am a geezer,57) looking at inominate restrictions and hamstring strains. Soft tissue is affected by the postional faults which underlie it. Pelvis and hamstring, joints in the foot and plantar fascia. As there are many ,and many unsucessful, treatments for plantar fasciitis, I switched my model from a soft tissue problem to a mechanical model which AFFECTS the soft tissue attached to it. See this quite often, if treated relaticely acutely, they do well, chronic problems still need all the other stuff one may do to stretch out and keep moving all the tissue, muscles and articulations that are tight, sore, weak , etc after a period of time.
If you get things in the foot moving normally, the patient and you will notice a rapid change in their problem. Give it a try.
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RE: Plantar Fascitis ideas? - July 25, 2008 8:24:43 PM
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TexasOrtho
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I lean toward Duffy's recommendations, but others are very reasonable as well. Neural tension is a sometimes underappreciated component of the presentation particularly in chronic cases IMHO. I think local subtalar biomechanics plays a role but I always ask myself - Why now? This person has had this foot their entire life without experiencing difficulty so why are they now experiencing pain?
If they are runners or very active we look closely into their training program. If they are overweight we try to discuss some ways to unload the joint with orthoses or even weight loss. You can imagine the effect just a 5-10 pound weight loss may have in reducing tourqe across the plantar aspect of the foot. I also look above and below the problem from forefoot mobility (particularly hallux extension) and really strengthen the crap out of the proximal LE all the way up to the hip.
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: Plantar Fascitis ideas? - July 25, 2008 8:27:06 PM
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PTupdate.com
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Rod, you loser....it's Friday night. What are you doing sitting and posting on this site for????????????????
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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RE: Plantar Fascitis ideas? - July 25, 2008 10:07:40 PM
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TexasOrtho
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Joined: December 22, 2007
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Checking to see if there are any other losers out there...
...yup.
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: Plantar Fascitis ideas? - July 26, 2008 6:11:47 AM
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SJBird55
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From: Michigan
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You know what makes it really fun for the rest of us who check in on those of you posting on a Friday night? Friday night posters need to reduce their inhibitions so that the Saturday morning readers have some laughs. This morning my expectations aren't being met.
AND... there are a few of you NOT checking your PM boxes.... tsk, tsk.
< Message edited by SJBird55 -- July 26, 2008 6:18:29 AM >
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RE: Plantar Fascitis ideas? - July 26, 2008 1:31:41 PM
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PTupdate.com
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Joined: October 8, 2001
From: Pittsburgh, PA USA
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I quit checking my PM box......Rod and Reeves keep spammin me with nude pictures of themselves
Glad Rod busted me back for also being online on a Friday night.....figured he'd get that. And SJ, my Friday night posts depend on the volume of booze I have imbibed. Last night was quiet....home from work, trim the hedges, play with kids, have a scotch, and post.
One item not mentioned above is an article in JOSPT noting that those who passively extend their toes and stretch the fascia in the morning when rising, do much better than those who don't. One extra tip.
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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RE: Plantar Fascitis ideas? - July 26, 2008 5:35:41 PM
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Kaden
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Is there anything like a clinical prediction rule for those who would benefit from orthotic intervention like we see in the lumbar spine manip CPR.
I am with Rod and often wonder why a foot type all of a sudden gave someone a problem. I am not saying orthotics aren't at times necessary but they are expensive and compliance with wearing is often poor, so if I can avoid them I try to do so.
Now it is different if a patient has taken up jogging recently and really never done so before. Now this could be a case that they finally found an activity their foot type could not handle. But, if someone has been jogging recreationally for 10 years without problems and then comes in with PF, I have a hard time blaming it on the foot type.
I am very little experience with orthotics, so I am not trying to discredit there us, just would like to hear from thos with more experience how you decide to go that route, and how you decide this is actually the cause of the condition.
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RE: Plantar Fascitis ideas? - July 26, 2008 9:29:19 PM
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Sebastian Asselbergs
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Kaden, feel free to criticize or question orthotics. After all, there is pathetically little actual usable data on those things! Most of us who have used/are using/will use these devices, do so based on good anatomical, arthrokinematical (nice eh?), physiological and neurological knowledge, "common sense", and some clinical experience (or a nice weekend workshop). As you can see, not a hell of a lot of good study.....
That is why the $500 charges are so out of line....
Nowadays I will try some temporary materials: calcaneal posts, MTpads, forefoot posts etc. together with a patient-bought simple insole - create the necessary changes and let them try this for a couple of weeks. IF it makes a big diff, then they can go and get permanent ones for the big $$ (not from me) .....or pay me a visit and about $20 for another four months of orthotics...and a lesson on how to do it themselves. Cheap.
< Message edited by Sebastian Asselbergs -- July 26, 2008 9:34:18 PM >
_____________________________
Mundi vult decipi
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RE: Plantar Fascitis ideas? - July 27, 2008 8:46:13 AM
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PTupdate.com
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From: Pittsburgh, PA USA
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I tend to be in the same line of thought as Bas. When I first started working, I was with a group of foot guru's using Root et al as their bible(s). Orthotic molding was done NWB, and posting was quite often used. Once I moved away from them, I switched to molding in WB and relied less on posting. Both my Mom and I have horribly flat feet, and a nice forefoot varus. Posting was done for this, and we both ended up with hallux limitus and MTP issues. As I saw so many other patients having issues with their system of orthotisis management, I tended to move the other way. Custom molding in the NWB position, where I was not posting and not trying to "perfectly correct" the foot ended up with many happy people and no returns on the product.....except to make a spare pair.
Insurance changes and DME contracts have reduced my opportunities for the custom stuff, but that's fine with me. I had/have a nice orthitic lab at the clinic, complete with grinder, oven, materials, glues and fancy stuff, and don't even need to use it much any more.......I let the OT use it as her hand therapy room, and put the grinder/oven on a cart and stuck in the back corner of the men's locker room!
I have found that even simple correction, such as a good pair of shoes, often eliminates the need for anything at all. Most women that have this condition are wearing flats, Keds, or EasySpirits. Get them into a decent, yet inexpensive pair of New Balance 600-series shoes, and it's usually all they need. Even I don't put anything into my NB shoes, only into my work/dress shoes, which are typically control-poor and arch-poor.
And, if the NB shoes are not enough, the inexpensive Accomodator and BFO products help manage 95% of these patients. Those who like these pre-fab inserts can either return every 6 months for a new pair, or are at least comfortable knowing that something custom molded will actually work. Nothing pisses off a patient than someone rushing them into $250 custom orthitics and not seeing any benefit.
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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RE: Plantar Fascitis ideas? - July 27, 2008 9:32:08 AM
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blast7
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As a runner, PT, and someone with flat feet I found the recommendations of shoe from this site very helpful along with my local running shop. http://www.aapsm.org/crishoe.html
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