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Sunday, May 29, 2011

Plantar Fasciitis & Its' Healing Pains

When suffering from chronic foot pain such as plantar fasciitis, tibialis posterior tendonitis, a bunion, or general osteoarthritis in the foot, a different type of gait or walking pattern is adopted to avoid the pain  being caused.  Remember the word "chronic".  This typically means that a person has been suffering from plantar fasciitis for several weeks to several months or even years.  When a long or even a short period of time passes, the tendons and muscles in the leg become weak quickly if they're not used appropriately.  So, after you find help with resolving your foot pain, you need to prepare yourself for experiencing some moderate to marked soreness in your calf, achilles, and foot.  Pain deters us from normal movement.  If this abnormal movement and disuse of specific muscles continues over a long period of time, then muscle atrophy and weakness are imminent.  The articular cartilage in the affected joint will also become soft and subsequently be prone to temporary effusion and joint soreness.  Unused muscle atrophies quickly!  Introducing weight bearing activities through muscles and joints are are strongly subjected to marked soreness following the introduction of very mild resistance training.

And so, this is the case with plantar fasciitis and tibialis posterior tendonitis.  For those of you who are or have experienced pain from either diagnoses, I believe you would agree that the manner in which you walk or participate in sport and recreation is quite altered from your normal manner of weight bearing.  Let me ease your worries some with the following statement:

You Do Not need to panic about this!  This is a very common occurrence!  Remember, plantar fasciitis is about how you've not been using your feet over a long period of time.  When retraining your leg and foot muscles, tissue that has been dormant for a very long time will now begin to work. This is the reason for what seems to be very "unreasonable" soreness!

Here is a summary of a specific case:
A patient comes in to the clinic complaining of a long history of heel pain.  Over a course of several months, this patient prior to seeking professional help, used over the counter orthotics, heel pads, heel lifts, and even has tried multiple shoes to help alleviate their pain.  None of the self help methods alleviated the heel pain and this put quite a damper on what was a very active lifestyle.  So, this patient sought help from a physical therapist.  After a thorough evaluation was performed, it was deemed that this patient was suffering from chronic plantar fasciitis and was having acute pain symptoms.  The physical therapist exhausted all the usual conervative treatment methods such as ultrasound, iontophoresis, cross friction massage, ice, passive stretching, and revised orthotics.  The patients plantar fasciitis was not resolved.  The treatments were spread out over a course of several weeks.  During these weeks, the leg muscles had not attenuated any substantial forces.  In other words, the muscles were becoming weaker and quickly atrophying.  It was the therapists instructions to the patient to not aggravate the symptoms with physical activity.  In this situation, conservative treatment was a failure.
After the patient made a change in therapist, a thorough evaluation was performed regarding her symptoms, her history of treatment, history of physical activities, and even her postural habits.  The  patients prior daily lifestyle down to the smallest details were discussed.  Shoe type was discussed as well.  So, after all was taken into consideration, treatment was performed of which consisted of several mintues of deep soft tissue work on her achilles tendon, the tibialis posterior tendon and muscle belly, and any other adjacent tissues that presented with symptoms.  Through the soft tissue mobilization, the specific soft tissue structures of which were responsible the current symptoms were identified.  Through further evaluation, two of the muscles and tendons involved were not gliding independently of each other.  The prolonged inflammation and disuse created an environment in which fibrotic tissue or scar tissue had set in.  There was severe discomfort present with the soft tissue work.  This however was unavoidable.  Over time, the tissue became so de-conditioned that to the patient it felt like pressure was being applied on a very painful bruise when just light palpation pressure was being used.  During this same treatment session,  the patient was introduced to partial and full weight bearing exercises using air discs, a bosu ball, and other specific exercise modalities.  In all, the patient performed just 20 repetitions of assisted calf and foot exercises.  The patient was to come in the following day for a follow up but instead called and cancelled their appointment.  The patient reported being extremely sore in the calf muscles and achilles tendon area.  The patient was encouraged to continue performing the same exercises, contrast baths, and to passively stretch the calf muscles.  

Four days had passed before the patient returned to the clinic.  It was obvious that this patient was quite upset about having to go through this pain.  The patient thought for sure that there was severe damage done to their calf muscles, achilles tendon, and foot.  The patient was very upset about this.  After a discussion of the process and reassuring the patient that the process taking place and what she's experiencing is very often a normal response with regards the chronicity of her symptoms.  The patient after feeling reassured and confident again agreed to further treatment.  
After the second treatment of soft tissue work on the achilles, tibialis posterior muscle/tendon structure, and foot intrinsics, the bruised sensation resolved.  The patient walked out of the clinic pain free!  The patient was not entirely out of the woods yet though.  Strengthening and stretching would need to be continued though to make sure that her current symptoms and disuse atrophy would be permanently resolved.

For any of you going through chronic or acute plantar fasciitis or tibialis posterior tendonitis, this is not an uncommon event!  These muscles have not been used properly over a long period time.  In this case, introduction to very light and mild resistance training caused severe delayed muscle soreness (also known as "DOMS").  During the recovery and healing process it is not uncommon for soft tissue work and manual procedures on the plantar surface of the foot, in the heel cord, and in the calf muscle to  be moderately or more than moderately painful at times.  Again, this is a normal healing process!  The body is so good at protecting itself that we don't even know it's happening!  So, those of you that have plateaued with conservative treatment, it may be that someone with good manual skills and soft tissue work is prudent.  Delayed muscle soreness just might order for the healing process to begin again and then finally be completed.

Our bodies are extremely tuff and durable.  In many instances our body needs an external stimulus specific to the diagnoses for it to respond in a manner in which healing will be activated.  Chronic "itis'" are stuck in the middle of a healing process.  Unless affected directly, this healing process or chronicity will not resolve.  Chances are, the inflammatory process will worsen.  The trick is to continue the appropriate amount of stimulus and treatment until the inflammatory process has stopped and healing is completed.

Happy Bipeding!!

Brad Senska, PT, DPT, BS, ASTYM.

Saturday, May 7, 2011

Five Finger Toe Shoes by Vibram: Part II

So, one of the reasons why I like the Vibram Five Finger Shoes so much is that they help solve a very frustrating problem with many people who are avid bipedalists (you know, people who spend a lot of time on their feet or using their feet while performing various acts of locomotion over various terrain all over the world).  However, many of these people don't quite know it yet.  Over the past two months, the theory and principles that I've applied in treating plantar fasciitis, involve the use of a minimalist shoe.  Vibram realized the need for a good minimalist shoe, and I was able to stop telling people to go out and find a pair of sandals that they can tolerate.  Sandals were the closest thing to minimal that was available and affordable. 

This shoe, and I've stated it before, lets all of the muscles in the leg and foot work the way they are intended to work.  The dilemma that running shoes with all of their cushion and support cause, is that we as avid bipedalists, take for granted how hard we can be on our bodies.  Running shoes allow us to land hard on our heels.  This allows a tremendous amount of force through our feet and legs.  The trade off is that running shoes allow us to not use muscles in our legs and feet the way they are intended for a faster run time.  Yes, when competing against yourself or others, we do need all the edge we can get.  However, over time, if we don't condition our feet and leg muscles the way they need to be while performing specific sports, the repetition of these activities allow nuances like plantar fasciitis to creep in.  When plantar fasciitis sets in, the first thing we do is run out and get a more supportive and more cushioned pair of shoes just so we can pound our heels harder into the ground.  When the new more supportive and cushioned shoes stop working, well, we go and buy a cushioned in-step for our cushioned shoes.  The trend here is that instead of properly conditioning the foot, leg, heel cord, etc, we continue to soften it and shorten it.  Without knowing, the usual prescription for treating plantar fasciitis is just making plantar fasciitis worse.

The Vibram minimalist shoe, when used in a proper manner over a course of time, does condition our feet the way they need to be.  They also allow the muscles attached to the achilles tendon or heel cord to elongate in a more functional and natural manner.  You know those big night splints that many people use at night to passively stretch out the plantar fascia and achilles tendon, well, why not quit propping your heel up in those fancy supported cushioned shoes during the day.  Spend a couple of hours out of the day wearing a minimalist shoe like the Vibram.  Several things will happen.  The leg muscles will begin to work again like they should.  You'll find yourself stepping or walking with purpose.  Your heel strike won't be nearly as forceful or severe.  And you'll find that you're toe off during walking or running will become more purposeful and powerful. 

One last thought here.  Let's say that after about 4 or 6 weeks of trading off wearing the minimalist shoe with your regular day shoes or running shoes, you notice that your plantar fascia, or arch of your foot, or your heel cord is no longer bothering you!  I believe that the carry over or transference of what you;ve accomplished in the minimalist shoe to your running shoe is going to improve your gait mechanics.  It will make you more efficient with running, and you'll most likely notice an improvement in your running times.

Using a minimalist shoe like the Vibram Five Finger Shoe is one of the main principles when I am treating and resolving plantar fasciitis.

Happy Bipeding!

Brad Senska, PT, DPT, BS, ASTYM.