Re: Medial foot pain DDX

February 8, 2006

I would have her do the frozen bottle rolled under the foot every day for 10 minutes and take a break from heavy pounding for a week. I wonder if some tape would help? Ann Goldeen, Astoria

Medial foot pain DDX

32 YOF that presented with achy medial foot pain of a two week duration on the side of the calcaneus extending to the navicular into the arch. No similar previous episodes, no injuries/broken bones. She is pes cavus with restricted eversion. Nothing I do provokes the pain, except slight discomfort on end range dorsiflexion. Pain is typically worse an hour following exercise and in the morning.She has increased her workout regiment recently, so stress fracture was my first inclination, but there was no pain on palpation and the pain seems to be a little worse in the morning so that led me to plantar fasciitis, but there is no tenderness at the plantar fascia insertion or anywhere along the plantar surface of the foot.Previous knee pain with swelling and functional long leg on the affected leg. Tight ITB affected>non, tight psoas/quads on the non-affected leg.I decided not to shoot films due to the number of false negatives (thanks Rich Gillette... I think) and MRI isn't necessary at this point. She will decrease the high impact activities. I will focus on the LLI and the lack of eversion at the subtalar joint.Any other thoughts?

Dr. Bingham3531 Northeast 15th Ave, Suite EPortland, OR 97212Office: (503) 546-9987Fax: (503) 546-9988www.highlandchiropractic.net

February 8, 2006

,

It sounds like PF or medial calcaneal neuritis. I can go on for 6-12 hours on the subject. So I will spare you with a copy of a brief article Tom Hyde, DC, DACBSP and I wrote on this subject. Hopefully it is helpful. It is also possible she has a medial calcaneal fat pad retinaculitis.

Ted

Ted Forcum, DC, DACBSP, FICC, CSCSACA Sports Council, 2nd Vice PresidentBack In Motion Sports Injuries Clinic, LLC11385 SW Scholls Ferry RoadBeaverton, Oregon 97008

Abstract

Plantar fasciitis (PF) is a condition that will affect approximately 2 million people in the United States each year. This condition has also been referred to as “heel pain syndrome.” Differential diagnosis should include such entities as calcaneal fat pad atrophy, calcaneal stress fracture, tarsal tunnel syndrome, entrapment of the medial or lateral calcaneal nerve, first sacral radiculitis and Sever’s disease in 9-11 year olds. Plantar fasciitis can be unilateral or bilateral and is generally worse in the morning with the first few steps.

The condition is usually insidious but can be the result of sudden resistance of the dorsiflexor forces through the forefoot in the acute phase. Other suspected causes of PF will be discussed in this paper.

Treatment for PF has been extensive and varied. Some forms of treatment have included: injections; anti-inflammatory medications; Extracorporeal Shock Wave Therapy (ESWT); use of orthotics; taping, manipulation; night splinting; ice; stretching; correction of abnormal biomechanics; low level laser; ultrasound; electrical muscle stimulation; Low dye strapping; Active Release Technique (ART); Transverse Friction Massage (TFM); and Graston Technqiue (GT). GT begins with the application of a form of heat application followed by stretching, rehabilitation and ice of the area treated. In some cases, proprioception and plyometrics exercises may be recommended.

Most causes of PF recover with the use of conservative care within 6-9 months and approximately 90% recover without residual disability. GT offers a very effective conservative soft tissue approach to this common entity.

Key words: plantar fasciitis, conservative care; Graston Technique, biomechanics

Plantar Fasciitis and Heel Pain Syndrome

By Dr. Ted Forcum and Dr. Tom Hyde

Each year approximately 2 million Americans are afflicted by plantar fasciitis. One out of ten will struggle with plantar fasciitis over their lifetime.[ii] The plantar fascia, also known as the plantar aponeurosis, connects the calcaneal tubercle to the forefoot with five slips directed to each toe respectively (figure 1). The plantar fascia may become painful at the distal fibers (usually in the midfoot) or the proximal fibers near the insertion at the medial and lateral tubercle of the calcaneus. This condition is often referred to as "heel pain syndrome," and is differentiated from a variety of other syndromes, many of which occur concomitantly. The differential diagnosis should include calcaneal fat pad atrophy, calcaneal stress fracture, tarsal tunnel syndrome, entrapment of the medial or lateral calcaneal nerve, first sacral radiculopathy, and Sever's disease in 9 to 11 year-olds. Systemic arthritides may present with heel pain. Conditions such as rheumatoid arthritis, ankylosing spondylitis, Reiter's syndrome, and gout may be differentiated by what often appears radiologically as a large and fluffy calcaneal spur, as well as through further isolation via blood tests. Blood tests should consist of an erythrocyte sedimentation rate (ESR), rheumatoid factor, human leukocyte antigen B27 (HLA-B27), and uric acid.

Clinically, plantar fasciitis usually presents unilaterally, but it is common to have bilateral symptoms. Symptoms are generally worse in the morning with the first steps out of bed or with the first steps after prolonged sitting or non-weight-bearing. Symptoms are generally aggravated with activity and prolonged weight bearing. As a result of persistent pain, patients may present with secondary conditions related to antalgic position and gait, usually by weight bearing on the lateral border of the foot. Patients may acquire a strategy of reducing rearfoot and forefoot loading by increasing digital weight bearing.[iii] Often symptoms progress to the inability to bear weight. Generally symptoms develop insidiously. However, acute conditions may occur as a result of a sudden increase in activity or a sudden resistance of dorsiflexion forces through the forefoot, particularly in the overweight athlete. The plantar fascia helps assist in the propulsive toe-off phase of gait. It is critical in this stage due to the windlass effect, whereby metatarsophalangeal joint dorsiflexion elevates the medial longitudinal arch, locking the midfoot via tightening of the plantar fascia.[iv] This generates a more rigid foot for accentuated leverage during propulsion. Therefore, it is not surprising that athletes who participate in jumping sports and other sports requiring rapid acceleration may develop acute plantar fasciitis, whereas sports such as distance running may have a more insidious degenerative process. As such the condition is more properly described as a fasciosis in view of the lack of inflammatory cells.

Distal plantar fasciitis presents with tenderness in the midfoot region of the fascia. In these patients, dorsiflexion of the toes coupled with ankle dorsiflexion typically exacerbates symptoms. Symptoms are most notable during the propulsion phase of gait. However, proximal plantar fasciitis is frequently asymptomatic with dorsiflexion of the toes. Proximal plantar fasciitis accounts for 80% of plantar fasciitis. Palpation of the plantar fascia in the distal aspect of the forefoot and midfoot may be asymptomatic or present with minor symptoms. However, palpation of the origin of the plantar fascia at the calcaneal tubercle may result in exquisite pain. On palpation, the pain is usually knife-like, sharp, and often burning.

Plantar fasciitis may occur secondary to a pes cavus or pes planus. Over pronation is a common precipitating factor, as is overuse. Plantarflexion of more than 60 degrees during the propulsive phase of the running gait may predispose an athlete to plantar fasciitis by requiring further dorsiflexion of the first metatarsal phalangeal joint. In turn, the windlass effect is increased, creating greater stress within the plantar fascia.[v] The risk of plantar fasciitis significantly increases with restriction of ankle dorsiflexion.[vi] Improper footwear may be a major cause of plantar fasciitis, both proximal and distal. Such footwear may allow excessive pronation or under pronation as well as impaired shock absorption. Excessive pronation elongates the plantar fascia during the midstance phase. Such elongation may be controlled by low dye taping and functional biomechanical orthotics to control forefoot and rearfoot deviations as well as any other mechanical deviations causing pronation.

Radiographic findings are not a basis for a diagnosis of plantar fasciitis.[vii][7] Heel spurs may be present in 50% to 75% of individuals with heel pain. On the non-painful foot, these same spurs may be present 63% of the time. Heel spurs may be present 10% to 30% of the time in the asymptomatic population. Radiographs may be helpful in revealing a stress fracture at the heel spur. This view should be performed as a 45[deg] medial oblique view of the calcaneus.5 The presence of a spur by itself rarely correlates with the severity of symptoms or resistance to treatment. The plantar calcaneal spur is found deep to the fascia and is associated with traction and mechanical stress from the flexor digitorum brevis muscle of the first layer. However, when the spur is large, it can be associated with heel pain. This is more common in those conditions of systemic origin.

More than 60% of symptomatic patients will demonstrate an increased uptake with technetium-99 bone scans at the medial calcaneal tubercle.[viii] This is non-diagnostic for plantar fasciitis or a calcaneal stress fracture because it most often represents periosteal traction at the medial calcaneal tubercle. Many believe that in 95% of cases, radiographs or bone scans are unnecessary.

UItrasonography is useful in determining plantar fascia thickness. The average thickness of symptomatic plantar fascia is thickened at 5.35-5.61mm compared to 2.70-3.83mm in asymptomatic patients.[ix] [x] Histologic findings indicate myxoid degeneration with fragmentation and degeneration of the plantar fascia commensurate with a degenerative fasciosis without inflammation.[xi]

Conditions such as chronic Achilles tendonosis, calf strains, and tibialis posterior dysfunction may predispose the individuals to plantar fasciitis as a result of mechanical compensation.

The key to effective treatment of plantar fasciitis is aggressive conservative therapy and dedicated patient compliance. No one modality of treatment has been shown effective, thus multiple modes of therapy are required in this difficult condition.

Restoration of the full range of motion must concentrate not only on dorsiflexion of the ankle, but also on of dorsiflexion of the hallux at the metatarsal phalangeal joint. This combination is necessary to limit recurrence of the condition and/or compensatory conditions. Achilles tendon stretching with the foot medially rotated and supinated is particularly useful in the acute stages. This position reduces tension on the plantar fascia. Increasing dorsiflexion at the ankle will help compensate and reduce the necessity for elongation of the plantar fascia. During the acute stages, non-weight bearing stretching of the dorsiflexors and plantar fascia is advocated in combination with night splinting.[xii] Hyperextension of the metatarsal phalangeal joints while seated appears to isolate the plantar fascia.[xiii] Progressive posterior night splints have been shown to be particularly effective in reducing morning stiffness.[xiv] As the condition improves, semi-weight bearing and weight bearing stretching of the plantarflexors can gradually be introduced with the foot in a neutral position.

Trisurae and plantar fascia stretching may be enhanced by applying ice to the plantar fascia. These stretches should be performed several times per day. Icing the plantar fascia with the calf in the stretched position will further reduce any complaints of the ice causing tightening to the plantar fascia. Stretching can be incorporated with other modalities such as ultrasound.

The use of heel lifts during the acute phases decreases the angle of the rearfoot to the forefoot, shortening the distance between the plantar fascia origin and insertion. It is recommended that heel lifts only be used for a short period as they also require additional dorsiflexion of the first metatarsal phalangeal joint at toe-off.

Correction of abnormal biomechanics is essential, not only for recovery but also for prevention of recurrence. This correction may include the prescription of biomechanically controlled athletic footwear and/or the use of functional orthotics.

Manipulative treatment may be beneficial to restore normal joint mechanics to reduce tension across the plantar fascia. Frequently, the calcaneus will demonstrate a restriction of anterior glide, dorsiflexion, abduction, and inversion. Additionally, mobilization and manipulation of the first ray are essential to ensure complete range of motion and restoration of the windlass effect.

Therapeutic modalities such as low level laser, ultrasound and electrical muscular stimulation may be effective in the reduction of pain and inflammation. Low dye strapping or taping of the foot is an essential part of successful treatment of plantar fasciitis. It is important not to apply the tape too tightly in the forefoot region as weight bearing will splay the forefoot. Compression resulting from taping may cause a secondary irritation to the interdigital nerves or blistering.

Soft tissue therapy(s) of the plantar fascia is a required element. The author recommends that the patient perform a brief self massage of the plantar fascia before getting out of bed in the morning, and before any weight bearing or stretching. This massage can be performed adequately with the use of a golf ball, rolling the ball from the midfoot to the proximal aspect of the metatarsal phalangeal joints longitudinal to the foot. After performing several sweeps, medial to lateral rolls should be performed along the course of the plantar fascia, followed once again by longitudinal rolls. This brief massage takes 20 to 60 seconds, and should be performed any time there is prolonged non-weight-bearing. Transverse friction massage, Graston Technique (GT) and myofascial release techniques can further enhance recovery.

Graston Technique (GT) utilizes molded stainless instruments for soft tissue mobilization. GT treatment for plantar fasciitis can be extremely effective in a short period of time and may actually offer relief within the first 3 treatments. Treatment with the GT instruments consists of utilizing several of the 6 patented stainless steel instruments over the plantar aspect of the foot,

Generally, one would initiate scanning the plantar fascia tissue with GT4 (figure 2). GT 2 can also be utilized and contours nicely to the conformation of the surface of the foot (figure 3) . Scanning involves searching for fibrotic changes in the fascia which will be felt through the instruments which act as a stethoscope to magnify these “lesions.” It is suspected that these lesions represent scar tissue within the fascia.

The instruments aid in breaking up existing scar tissue or adhesions located within the fascia and soft tissues. Use of the instruments stimulates fibroblast proliferation and the number of fibroblasts produced are related to the magnitude of the pressure applied. The greater the pressure, the larger number of fibroblasts produced. This increase of fibroblasts results in synthesis of collagen fibers. [xv]

Treatment of tendons following acute injuries heals like other structures going through 3 phases: inflammation, proliferation, and remodeling. During the inflammatory phase, blood platelets and fibrin begin to fill the wound followed by the migration of fibroblasts and phagocytes into the area. The proliferation stage results in an increase of fibroblasts which in turn synthesize collagen. The final stage, remodeling, leads to maturation and reduction in cellularity and realignment of collagen fibers.[xvi]

The use of GT 4 and GT 2 instruments allow for treatment of a large area. GT 4 is convex and contacts the treatment area with a more precise point of attack than does the concave GT 2. When more specific treatment is desired, the use of GT 3 and GT 6 are preferred (figure 4 and 5). GT 3 is convex but has a smaller treatment surface and may be used to treat the distal aspect of the calcaneus. If a more specific point of contact is desired, the use of GT 6 will accomplish this.

While managing plantar fasciitis with GT, the following areas should be assessed and treated if indicated: Plantar aspect of the foot, insertion of the fascia into the calcaneus, lateral band on the plantar surface, fascia surrounding the metatarsal heads, calcaneus, plantar flexors, Achilles tendon proximally to include the gastrocnemius heads all the way to it’s insertion above the popliteal fossa. In some cases, addressing the dorsum of the foot and treatment of the extensor tendons should also be considered.

Before treatment with GT, have the patient actively assume a position that increases the pain if possible. Have the patient hold that position and treat the area of pain if reachable with the instruments. If not possible, treat in he static position, then have the patient repeat the position of provocation of pain and readdress whether the condition has resolved or moved up or down the kinetic chain. This series of assessment and treatment should be continued until the patient is either markedly improved or the pain is gone. This may require from one to several treatment encounters.

Before the patient begins treatment, the tissue to be treated should be warmed. This can be accomplished by having them place the foot into hot water or a hot whirlpool, hydroculator packs, US or any other modality that produces heat. After application of the GT instruments, the patient should be instructed to stretch the involved tissues. Scanning for location of adhesions will take approximately 3-0 to 60 seconds. Each lesion treated will take approximately 60-90 seconds.

Melham[xvii] et al state the use of Augmented Soft Tissue Mobilization (ASTM) theoretically works by allowing the clinician to more effectively introduce a specific and controlled amount of microtrauma into an area with excessive or poorly organized scar tissue. This treatment then creates and inflammatory process and stimulates connective tissue remodeling through resorbtion of excessive fibrosis, induces repair and regeneration of collagen secondary to fibroblast recruitment. GT is a form of ASTM.

Progressive resistance exercises should begin with isometric toe curls, whereby the patient holds the contraction for 10 seconds, repeated 6 to 10 times and performed 1 to 3 times per day. Initially, some muscular cramping may occur, at which point the active contraction should be stopped. Reintroduction to the exercise should be limited to cramping tolerance. As strength develops, progress to a single repetition contraction for 60 seconds without cramping. Concentric exercises should emphasize toe curl by gripping a towel or sock. Additional exercises should focus on controlling pathobiomechanics, such as strengthening exercises for the deep posterior compartment in those who over-pronate. Strengthening exercises of the calf muscle group must be performed over a progressively increasing range of motion.

Final stage rehabilitation exercises must include Proprioceptive exercises such as single leg stands with the eyes closed for 30 to 60 and seconds can be introduced with limited pain upon weight bearing (figure 6). Additionally, plyometric exercises will ensure optimal strength of the plantar fascia. Such exercises may consist of jumping rope or other hopping exercises in the final stages of rehabilitation.

Recovery from plantar fasciitis can be a slow process. A most recover in 6-9 months with conservative therapy. Approximately 90% will respond to conservative measure without residual disability.[xviii]

Should operative procedures be considered, care should be taken to confirm the original diagnosis. In addition, supporting diagnostic evidence (such as nerve conduction studies) should be gathered to rule out nerve entrapment, particularly of the first branch of the lateral plantar nerve and the medial plantar nerve. The previously mentioned laboratory tests should also be performed. Surgical treatment of spurs will rarely improve the pain caused by plantar fasciitis. When surgical release is performed less than 50% plantar fascia should be released to avoid secondary complications of lateral column symptoms.[xix]

Extracorporeal shock wave therapy (ESWT) was introduced with great promise. However, recent studies have reported less favorably results, and some report no effect.[xx] [xxi] Further complicating the prognosis, previous local steroid injection may have a negative effect on the results from ESWT.[xxii]

Plantar fascia rupture can arise secondary to trauma, or progressive degeneration. More frequently, local corticosteroid therapy results a 10% rupture rate. Interestingly, most patients will experience pain relief subsequent to rupture. However, the development of new compensatory problems usually soon follow, including longitudinal arch strain, lateral and dorsal midfoot strain, lateral plantar nerve dysfunction, stress fractures and hammer toe deformity.[xxiii]

Pfeffer G, Bacchetti P, Deland J, et.al: Comparision of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis. Foot Ankle Int 1999;20(4):214-221

[ii] Crawford F, Thomson C: Interventions for treating plantar heel pain, in The Cochrane Library. Chichester, UK, Wiley & Sons, 2004

[iii] Wearing SC, Smeathers JE, Urry SR. The effect of plantar fasciitis on vertical foot-ground reaction force.

Clin Orthop. 2003 Apr;(409):175-85.

[iv] Michaud TC, Fowler SM. Superficial peroneal nerve entrapment resulting from a congenital plantar flexed first ray. J Neuromusculoskeletal System 1995;3:27.

[v] Oloff LM. Musculoskeletal disorders of the lower extremities. Philadelphia: WB Saunders, 1994.

[vi] Riddle DL, Pulisic M, Pidcoe P, RE. Risk factors for Plantar fasciitis: a matched case-control study.

J Bone Joint Surg Am. 2003 May;85-A(5):872-7.

[vii] Wall JR. Harkness MA, Crawford A. Ultrasound diagnosis of plantar fasciitis. Foot Ankle 1993;14:465-470.

[viii] Reid DC. Sports injury assessment and rehabilitation.

New York: Churchill Livingstone, 1992.

[ix] Vohra PK, Kincaid BR, Japour CJ, Sobel E. Ultrasonographic evaluation of plantar fascia bands. A retrospective study of 211 symptomatic feet. J Am Podiatr Med Assoc. 2002 Sep;92(8):444-9.

[x] Tsai WC, Chiu MF, Wang CL, Tang FT, Wong MK. Ultrasound evaluation of plantar fasciitis. Scand J Rheumatol. 2000;29(4):255-9.

[xi] Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc. 2003 May-Jun;93(3):234-7.

[xii] Barry LD, Barry AN, Chen Y. A retrospective study of standing gastrocnemius-soleus stretching versus night splinting in the treatment of plantar fasciitis.J Foot Ankle Surg. 2002 Jul-Aug;41(4):221-7.

[xiii] DiGiovanni BF, Nawoczenski DA, Lintal ME, et.al: Tissue specific plantar fasia stretching exercises enhances outcomes in patients with chronic heel pain: a prospective randomized study. J Bone Joint Surg Am 2003;85(7):1270-1277.

[xiv] J. Use of posterior night splints in the treatment of plantar fasciitis. Am Fam Physician 1995;52:891-898:901-902.

[xv] Gehlsen GM, Ganion LR, Helfst R. Fibroblast responses to variation in soft tissue mobilization pressure. Med & Sci in Sports & Exerc. 1999; 31(4) 531-535.

[xvi] son CJ, Ganion LR, Gehlsen GM, Verhoestra B, Roepke JE, Sevier TL. Rat tendon morphologic and functional changes resulting from soft tissue mobilization. Med & Sci in Sports & Exerc. 1997; 29(3) 313-319.

[xvii] Melham TJ, Sevier TL, Malnofski MJ, JK, Helfst RH, JR. Chronic ankle pain and fibrosis successfully treated with a new noninvasive augmented soft tissue mobilization technique (ASTM): a case report. Med & Sci in Sports & Exerc. 1998; 30(6) 801-804.

[xviii] PF Sererud E, Baxter DE: Painful heel syndrome: results of nonoperative treatment. Foot Ankle Int 1994; 15(10):531-535.

[xix] Brugh AM, Fallat LM, Savoy- RT. Lateral column symptomatology following plantar fascial release: a prospective study. J Foot Ankle Surg. 2002 Nov-Dec;41(6):365-71.

[xx] Speed CA, Nichols D, Wies J, Humphreys H, s C, Burnet S, Hazleman BL. Extracorporeal shock wave therapy for plantar fasciitis. A double blind randomised controlled trial. J Orthop Res. 2003 Sep;21(5):937-40.

[xxi] Haake M, Buch M, Schoellner C, Goebel F, Vogel M, Mueller I, Hausdorf J, Zamzow K, Schade-Brittinger C, Mueller HH. Extracorporeal shock wave therapy for plantar fasciitis: randomised controlled multicentre trial. BMJ. 2003 Jul 12;327(7406):75.

[xxii] Melegati G, Tornese D, Bandi M, Caserta A. The influence of local steroid injections, body weight and the length of symptoms in the treatment of painful subcalcaneal spurs with extracorporeal shock wave therapy. Clin Rehabil. 2002 Nov;16(7):789-94.

[xxiii] Acevedo JI, Beskin JL. Complications of plantar fascia rupture associated with corticosteroid injection. Foot Ankle Int. 1998 Feb;19(2):91-7.

FIGURES:

Figure 1. Plantar view of the foot with the spider web appearing plantar fascia.

Image by permission from 2001 Primal Pictures Ltd Interactive Foot and Ankle 2

Figure 2. GT4 scanning of the plantar fascia