The Clinical Coach: The Missing Link in Plantar Fasciitis.

Another ahhh-mazing Friday is upon us . Any plans for this weekend?

Before you get to them, you’ll want to save this issue as this is one of the most common complaints you’ll see or hear about in practice.

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If you or someone you know is interested in obtaining your Certified Dry Needling Practitioner certification but would like to save money in travel and lodging, stay tuned as we re-open the course.

I’ll be frank. I do not enjoy treating plantar fasciitis pain as much as I enjoy treating shoulder pain.

There’s a couple of reasons:

• Patients are stubborn when it comes to rehab.

• Majority of doctors have misdiagnosed PF

• It takes close to 12 weeks to see results and close to 24 weeks to fully resolve in severe cases.

But I still do it, because I owe it to my patients to provide them with solutions

What is… plantar fasciitis?

Plantar fasciitis is the inflammation of the plantar fascia.

If you recall this is the tissue in the foot used during walking and foot movement.

Plantar fasciitis can be caused by a number of factors, including type of shoes, foot structure, overuse and types of walking surfaces.

The main symptom of plantar fasciitis is heel pain.

And your patients will tell you about their heel pain.

Most Common Treatment

Most patients that have plantar fasciitis have already been to PT.

They have already been show how to stretch the foot, and how to strengthen the calf.

They most likely were given a band, strap or even a stretch boot that they are supposed to sleep with to reduce the pain.

Yet, they still have “the pain.”

Why?

Well there are a couple of reasons.

• The type of shoe they wear (dumb fashion)

• The way they walk (often related to the shoe)

• The job they perform (often related to both of the above)

In my opinion, when it comes to PF, you can’t neglect your patients static and dynamic gait.

• How they stand?

• How long they stand?

• What shoes are they wearing?

• How they walk?

• How they walk with those shoes?

• What is their foot doing in those shoes?

• You can also assess their gait barefoot — you should probably do both.

Assessing the foot for PF

As any good clinician your assessment should include the testing of:

• Gastrocnemius/Soleous

• Anterior/Posterior Tibialis

• Extensor Hallucis

• Flexor Hallucis

• Plantar Fascia

• Walking gait

• Windlass mechanism

What are we looking at here?

From the muscle assessment, we are looking for good muscle strength, non-painful movements of the ankle, and non-painful muscles during dorsiflexion. Preferably we’d like to maintain the pain at the level of the plantar fascia.

If the pain changes location, then we may not be looking at a plantar fasciitis diagnosis.

In our walking gait, we are looking for foot mechanics. I’m not nearly as concerned with the knee or hip just yet. While they may be involved, correcting a few key mechanisms at the foot will most likely change the kinetic chain upwards, affecting the knee and hip.

What specifically are we looking in foot mechanics? We are looking at foot flare. Is your patient walking with their toes pointing forward? Or are these pointing outward? Is the painful foot even more flared out than the non-painful foot? In 95% of the cases, this is quite noticeable.

Why? Because your patient is avoiding the strain placed on the plantar fascia by avoiding the Windlass Mechanism.

By avoiding the Windlass Mechanism this tissue looses its extensibility [to an extent], becomes highly sensitive to pressure (think body weight) and begins to change the mechanics of the foot.

Now let’s add the types of shoes most patients are wearing. Narrow, pointed shoes.

To think that I was obsessed with this type of shoes back in my early twenties.

This type of shoe (if you follow foot mechanics) compresses the joints, reduces joint motion at the toes, and begins to change the mechanics of the whole foot.

Add this type of compression to the windlass mechanism, and you get a patient who wants to flare their foot outward to avoid toe extension, windlass mechanism and dorsiflexion.

What happens next? Tissues become sensitive to stretch and pressure.

The missing link

Addressing the windlass mechanism is pretty cut and dry.

Get your patient to load the toe into extension.

But, if you’ve already tried this with your patients, you already know this is quite uncomfortable. The chances of them doing it at home is slim because it hurts.

Every so often you’ll get a patient who’ll do any treatment even if it’s painful to get the relief later on.

But… no need to make their rehab uncomfortable.

How to load the windlass mechanism and progress it?

Have them walk backwards.

That’s right. They’ll have to trust that they won’t be tripped by you or a family member.

What happens when you walk backward? Go on try it and tell me.

That‘s right. You find your step by reaching back with your TOE! Your big toe specially.

Then what?

Correct. Now we are eccentrically loading the windlass mechanism of the foot.

Now, I recommend you start your patient with small steps, and have them walk 15-25 ft in your office. Make sure the are loading the foot from toe to heel before they take the next step.

You’ll want them to do this as often as possible at home. If they can get 500-1000 steps broken down throughout the day, the better. I usually start my patients with 1000 steps (it’s come down to 5 minutes every hour-ish) a day.

Anything else?

You know it!

Rehab is part of the process, but it may not be all of it for your patient.

Pain Management

Dependent on the chronicity and your patients I would only recommend two modalities you already are familiar with: IASTM, and IMES Dry Needling.

If you have access to a Class IV laser, a shockwave, or the new softwave these also have great clinical application in pain reduction. Keep in mind that each tool has different settings and therefore standardizing a dose or setting might not be easy.

Clinical Pearls

Tissue remodeling, tissue capacity, and tissue adaptations only occur through adequate stressors. In those cases your best progressions are based on volume, load, intensity and frequency of the stimulus. Start conservative and build.

Every patient is unique.

Make sure you take the time to understand them.

Until our next issue!

In health and strength,

P.S. If you have questions or comments, feel free to respond to this email. I reply to all emails personally.

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