Tight hamstrings play an important role in plantar fasciitis, according to a study published in the June issue of Foot and Ankle Specialist.
“These findings show that while we always consider the tightness of the gastrocnemius/soleus complex and the subsequent restricted ankle motion from this equinus, we also need to consider the role of the hamstrings,” said Jonathan Labovitz, DPM, lead author and associate professor at Western University of Health Sciences, Pomona, CA.
The prospective cohort study included 105 participants (210 feet); 79 had plantar fasciitis, which researchers assessed with palpation, who measured popliteal angle with a tractograph and diagnosed hamstring tightness when the popliteal angle ≤160°.
Without controlling for covariates, body mass index (BMI), tightness in the hamstring, gastrocnemius/soleus, and gastrocnemius, and the presence of a calcaneal spur all had statistically significant associations with plantar fasciitis.
After controlling for covariates, participants (86 of 210 feet) with hamstring tightness were 8.7 times as likely to experience plantar fasciitis (p < .0001) as participants without hamstring tightness. Patients with a BMI >35 were 2.4 times as likely as those with a BMI <35 to have plantar fasciitis.
Researchers at Cappagh Orthopedic Hospital in Dublin, Ireland, first linked hamstring tightness with plantar fasciitis in a study published in the December 2005 issue of Foot & Ankle International. The Western University researchers now suggest that an increase in hamstring tightness may induce prolonged forefoot loading and, through the windlass mechanism, may be a factor that increases repetitive plantar fascia injury.
Triceps surae tightness was not included in the Western University covariate analysis, raising the possibility that hamstring tightness was not actually the cause of plantar fasciitis in patients wth tightness in both areas.
“People who have tight hamstrings are more than likely going to have a tight triceps surae,” said Michael T. Gross, PT, PhD, a professor in the Division of Physical Therapy at the University of North Carolina in Chapel Hill. “The investigators of this study admitted that 96% of subjects who had tight hamstrings also had tight triceps surae. Now there’s a cause and effect. If you can’t get dorsiflexion at your talo-crural joint, this often drives dorsiflexion at other joints and that is going to cause collapse of the longitudinal arch of the foot, loading the plantar fascia with increased tensile stress.”
In people with hamstring and triceps surae tightness and plantar fasciitis it’s not known whether the ankle equinus from a tight triceps surae causes hamstring tightness or vice versa, Labovitz said.
“There is no question that the tightness of the triceps surae will cause flattening of the arch and increase tensile stress on the plantar fascia,” Labovitz said. “The question becomes, are the hamstrings involved in this and, if so, to what effect?”
The timing of plantar fascia loading and hip kinematics during gait raise additional questions about possible hamstring involvement, Gross said.
“When loading is taking place at the plantar fascia, it’s mid to late stance. At mid to late stance, the hip is in extension and even hyperextension. Even though the knee is extended, extension/hyperextension at the hip will limit the amount of passive tension that could be developed in the hamstrings, so it is a mystery to me how tight hamstrings would cause trouble for the plantar fascia,“ he said.
Labovitz suggested, however, that a little hamstring tightness might go a long way in influencing the plantar fascia.
“The practical application is that since the hamstrings have been shown to be involved and possibly have more influence than equinus due to the longer lever arm, showing greater effect on the flattening of the foot and plantar fasciitis, less restriction is necessary to have the same effect as equinus,” he said.
The researchers suggest that treatment of plantar fasciitis should address hamstring tightness along with equinus and obesity. Night splints, orthoses, and gait retraining have been shown to be effective for managing plantar fasciitis pain but will not address hamstring flexibility, Labovitz noted.
“The hamstrings should be examined and treated,” Labovitz said. “Stretching is the best treatment for increasing flexibility.”
Showing posts with label stretching and heel pain. Show all posts
Showing posts with label stretching and heel pain. Show all posts
Tuesday, January 31, 2012
Wednesday, November 2, 2011
New frontiers in PTTD
Focus is on ultrasound, hip strength
Research presented in February at the Combined Sections Meeting of the American Physical Therapy Association highlighted underappreciated clinical characteristics of posterior tibial tendon disorder that could influence patient management.
Tendon thickness as measured using high-frequency ultrasound may help determine which patients with Stage II PTTD are most likely to benefit from conservative interventions and which might be better candidates for surgery, according to research from Upstate Medical University in Syracuse, NY.
Ultrasound imaging identified 12 Stage II patients with abnormal tendon thickening, seven with tendon enlargement and five with tendon atrophy. Mean tendon cross sectional area was 39.7 mm2; those with tendon enlargement averaged 53.4 mm2 while those with atrophy averaged 24.6 mm2.
Tendon thickness was not visibly evident prior to imaging, nor were there apparent functional differences between subjects at presentation. However, the researchers did observe significant kinematic differences between the two groups. Patients with tendon enlargement demonstrated significantly greater range of motion for hindfoot inversion/eversion, forefoot plantar/dorsiflexion, and total excursion; forefoot abduction/adduction did not differ significantly between groups.
Although PTTD is typically thought to be associated with tendon enlargement as the result of degeneration, the Syracuse findings show that tendon atrophy also occurs. The kinematic differences related to relative tendon thickness could help explain inconsistencies in patient response to exercise interventions, and knowing the cross sectional area of an individual patient’s tendon could facilitate more effective patient management.
“Targeted exercises to move the foot may be possible in the tendon enlargement group, and conservative or alternative treatments may be indicated,” said Christopher Neville, PT, PhD, an assistant professor of physical therapy at Upstate Medical University, who presented the results at the Combined Sections Meeting. “The tendon atrophy group may be surgical candidates, or if they don’t have surgery, the goal of treatment may be to protect the secondary structures that maintain foot posture and stability.”
A second study from the University of Southern California suggests that practitioners may also want to consider proximal joint kinetics in their patients with PTTD.
After anecdotally noting increased frontal plane motion at the hip in patients being seen for PTTD, researchers compared hip and calf muscle performance in 17 female patients with Stage I PTTD and 17 healthy matched controls. Patients reported a history of symptoms lasting from six months to one year.
They found that the PTTD patients demonstrated significantly lower levels of strength and endurance across the board, with 33.8% less hip extensor torque, 38.5% less hip extensor endurance, 28.5% less hip abduction torque, 27% less hip abduction endurance, and 62.9% less calf muscle strength. Interestingly, these effects were seen in the uninvolved limb as well as the involved limb. The PTTD patients also covered significantly less distance on the six minute walk test (497 m vs 571 m) and reported as much as a 50% increase in pain following the test.
These two sets of findings may be related, said Lisa M. Noceti-DeWit, DPT, ATC, adjunct instructor of clinical physical therapy at USC, who presented her group’s findings at the Combined Sections Meeting. The researchers theorize that because the PTTD patients walk more slowly, their muscles—all the way up the lower extremity—are being underutilized and over time lose their strength and endurance capacity.
“Walking does not depend solely on the actions of the foot and ankle,” Noceti-DeWit said.
The researchers are unable to tell from this study whether the decreased walking velocity occurred as a result of the pain of PTTD or whether other mechanisms may have been involved. Nevertheless, the findings suggest that practitioners treating patients with PTTD should not limit their focus to the most distal aspects of the lower extremity.
By Jordana Bieze Foster
Research presented in February at the Combined Sections Meeting of the American Physical Therapy Association highlighted underappreciated clinical characteristics of posterior tibial tendon disorder that could influence patient management.
Tendon thickness as measured using high-frequency ultrasound may help determine which patients with Stage II PTTD are most likely to benefit from conservative interventions and which might be better candidates for surgery, according to research from Upstate Medical University in Syracuse, NY.
Ultrasound imaging identified 12 Stage II patients with abnormal tendon thickening, seven with tendon enlargement and five with tendon atrophy. Mean tendon cross sectional area was 39.7 mm2; those with tendon enlargement averaged 53.4 mm2 while those with atrophy averaged 24.6 mm2.
Tendon thickness was not visibly evident prior to imaging, nor were there apparent functional differences between subjects at presentation. However, the researchers did observe significant kinematic differences between the two groups. Patients with tendon enlargement demonstrated significantly greater range of motion for hindfoot inversion/eversion, forefoot plantar/dorsiflexion, and total excursion; forefoot abduction/adduction did not differ significantly between groups.
Although PTTD is typically thought to be associated with tendon enlargement as the result of degeneration, the Syracuse findings show that tendon atrophy also occurs. The kinematic differences related to relative tendon thickness could help explain inconsistencies in patient response to exercise interventions, and knowing the cross sectional area of an individual patient’s tendon could facilitate more effective patient management.
“Targeted exercises to move the foot may be possible in the tendon enlargement group, and conservative or alternative treatments may be indicated,” said Christopher Neville, PT, PhD, an assistant professor of physical therapy at Upstate Medical University, who presented the results at the Combined Sections Meeting. “The tendon atrophy group may be surgical candidates, or if they don’t have surgery, the goal of treatment may be to protect the secondary structures that maintain foot posture and stability.”
A second study from the University of Southern California suggests that practitioners may also want to consider proximal joint kinetics in their patients with PTTD.
After anecdotally noting increased frontal plane motion at the hip in patients being seen for PTTD, researchers compared hip and calf muscle performance in 17 female patients with Stage I PTTD and 17 healthy matched controls. Patients reported a history of symptoms lasting from six months to one year.
They found that the PTTD patients demonstrated significantly lower levels of strength and endurance across the board, with 33.8% less hip extensor torque, 38.5% less hip extensor endurance, 28.5% less hip abduction torque, 27% less hip abduction endurance, and 62.9% less calf muscle strength. Interestingly, these effects were seen in the uninvolved limb as well as the involved limb. The PTTD patients also covered significantly less distance on the six minute walk test (497 m vs 571 m) and reported as much as a 50% increase in pain following the test.
These two sets of findings may be related, said Lisa M. Noceti-DeWit, DPT, ATC, adjunct instructor of clinical physical therapy at USC, who presented her group’s findings at the Combined Sections Meeting. The researchers theorize that because the PTTD patients walk more slowly, their muscles—all the way up the lower extremity—are being underutilized and over time lose their strength and endurance capacity.
“Walking does not depend solely on the actions of the foot and ankle,” Noceti-DeWit said.
The researchers are unable to tell from this study whether the decreased walking velocity occurred as a result of the pain of PTTD or whether other mechanisms may have been involved. Nevertheless, the findings suggest that practitioners treating patients with PTTD should not limit their focus to the most distal aspects of the lower extremity.
By Jordana Bieze Foster
Wednesday, June 22, 2011
Short-term study shows better results with PRP vs. cortisone for plantar fasciitis
COPENHAGEN — According to a presentation here, an injection of platelet-rich plasma resulted in better foot and ankle scores than cortisone in patients with severe chronic plantar fasciitis.
“I decided to apply the use of platelets and platelet-rich plasma (PRP) technology in this type of refractory case,” Raymond R. Monto, MD, said at the 12th EFORT Congress 2011. “How does it work? We are probably seeing modulation at least of angiogenesis of collagen turnover and some tissue healing.”
In his level 2 study, Monto block randomized 40 patients with chronic plantar fasciitis to receive either a 40 mg cortisone injection or a PRP injection at the site of injury. The injections were guided by ultrasound.
The mean American Orthopaedic Foot & Ankle Society (AOFAS) scores of in the cortisone group increased from 52 points pre-injection to 81 points at 3-months post-treatment. However, Monto found that the score dropped to 74 points after 6 months. The pre-injection AOFAS score of the PRP group increased from 37 points to 95 points at 3 months.
“I think the interesting finding here is that they maintained those high levels of results,” Monto said, adding that no patients were lost to follow-up or experienced complications.
“In this well-documented subset, PRP is significantly more effective than cortisone both in short- and long-term management for severe chronic plantar fasciitis,” he said.
Reference:
Monto RR. Platelet rich plasma is more effective than cortisone injection for chronic plantar fasciitis. Paper #652. Presented at the 12th EFORT Congress 2011. June 1-4. Copenhagen.
“I decided to apply the use of platelets and platelet-rich plasma (PRP) technology in this type of refractory case,” Raymond R. Monto, MD, said at the 12th EFORT Congress 2011. “How does it work? We are probably seeing modulation at least of angiogenesis of collagen turnover and some tissue healing.”
In his level 2 study, Monto block randomized 40 patients with chronic plantar fasciitis to receive either a 40 mg cortisone injection or a PRP injection at the site of injury. The injections were guided by ultrasound.
The mean American Orthopaedic Foot & Ankle Society (AOFAS) scores of in the cortisone group increased from 52 points pre-injection to 81 points at 3-months post-treatment. However, Monto found that the score dropped to 74 points after 6 months. The pre-injection AOFAS score of the PRP group increased from 37 points to 95 points at 3 months.
“I think the interesting finding here is that they maintained those high levels of results,” Monto said, adding that no patients were lost to follow-up or experienced complications.
“In this well-documented subset, PRP is significantly more effective than cortisone both in short- and long-term management for severe chronic plantar fasciitis,” he said.
Reference:
Monto RR. Platelet rich plasma is more effective than cortisone injection for chronic plantar fasciitis. Paper #652. Presented at the 12th EFORT Congress 2011. June 1-4. Copenhagen.
Wednesday, February 23, 2011
Current Insights On Conservative Care For Heel Pain
A Two-Pronged Approach to Treatment
To develop an effective treatment plan, one should consider using what I refer to as a “two pronged” treatment approach for the patient. This approach considers treating the symptoms and treating the cause. Treating the symptoms of pain and inflammation would include any combination of: nonsteroidal anti-inflammatory drugs (NSAIDs); cortisone injection; physical therapy; or cryotherapy. Treating the cause would include any combination of: taping; orthotics; shoe recommendations or modifications; night splints; cross training; and/or modification or restriction of activity.
Too often, a treatment plan will address only one of these areas. For example, the patient receives an injection, which does nothing to address the cause of the heel pain.
I have found taping to be a valuable tool in treating heel pain but it appears to be a lost art. Taping can be therapeutic as well as diagnostic in determining if a patient could benefit from functional orthotics. I like to say, “Orthotics are only as good as the shoes that you put them in.” If shoes are worn out or not recommended for your patient, orthotics will not be as effective in controlling the foot.
The biomechanical exam and gait evaluation are critical to addressing the underlying cause. You need to determine what diagnostic studies are needed to confirm your diagnosis, especially if it does not appear to be your classic plantar fasciitis injury.
Is Stretching Beneficial For Patients With Heel Pain?
To stretch or not to stretch — that is the question. All too often we will recommend stretching to patients for treating heel pain in the acute phase of the injury. Unfortunately, stretching often starts before the area has healed sufficiently. Stretching should not begin until the rehabilitation phase of the injury, after the healing phase has occurred. If stretching starts too early, it creates a vicious cycle and can prolong the healing of the injury.
There is also quite a bit of controversy over the value of stretching so the jury is still out. However, I tend to be a believer in the benefit of stretching both in recovering from an injury as well as helping to prevent injuries. When addressing stretching, one should specifically focus on stretching the calf muscles as well as the plantar fascia for both sides. It should be a gradual approach with slow, long, static stretching that builds up gradually over time as the patient can tolerate. One should avoid rapid, violent stretching (ballistic). I will usually recommend a pre-activity stretch after a brief warm-up and a post-activity stretch after cooling down.
How Cross Training Can Keep Heel Pain Patients Active
Cross training is a very important aspect of the treatment plan. It is important that patients are able to keep up their level of fitness while recovering from heel pain. Ideally, you can have them use pool therapy, bike or elliptical training to stay in shape and avoid stressing their foot.
Limiting or restricting activity is often difficult, especially for the athlete. One should address the intensity and frequency of activity, especially when it comes to those participating in youth sports. Fortunately, children are often involved in varied activities anyway so cross training is helpful in the treatment plan for youth injuries. Cross training is an essential part of the treatment plan for dealing with high school, college and professional athletes.
It is important to realize that exercise prescription is a major part of dealing with the treatment of heel pain. Prescribing exercise and tailoring it to a specific patient is a talent you should develop. Proper exercise prescription can greatly assist in motivating patients to be actively involved in the treatment and help ensure that their fitness level does not drop off significantly. Improper exercise can prolong the recovery time and increase the rehabilitation period. Return to activity guidelines should be clear to the patient with reasonable goals and expectations.
To develop an effective treatment plan, one should consider using what I refer to as a “two pronged” treatment approach for the patient. This approach considers treating the symptoms and treating the cause. Treating the symptoms of pain and inflammation would include any combination of: nonsteroidal anti-inflammatory drugs (NSAIDs); cortisone injection; physical therapy; or cryotherapy. Treating the cause would include any combination of: taping; orthotics; shoe recommendations or modifications; night splints; cross training; and/or modification or restriction of activity.
Too often, a treatment plan will address only one of these areas. For example, the patient receives an injection, which does nothing to address the cause of the heel pain.
I have found taping to be a valuable tool in treating heel pain but it appears to be a lost art. Taping can be therapeutic as well as diagnostic in determining if a patient could benefit from functional orthotics. I like to say, “Orthotics are only as good as the shoes that you put them in.” If shoes are worn out or not recommended for your patient, orthotics will not be as effective in controlling the foot.
The biomechanical exam and gait evaluation are critical to addressing the underlying cause. You need to determine what diagnostic studies are needed to confirm your diagnosis, especially if it does not appear to be your classic plantar fasciitis injury.
Is Stretching Beneficial For Patients With Heel Pain?
To stretch or not to stretch — that is the question. All too often we will recommend stretching to patients for treating heel pain in the acute phase of the injury. Unfortunately, stretching often starts before the area has healed sufficiently. Stretching should not begin until the rehabilitation phase of the injury, after the healing phase has occurred. If stretching starts too early, it creates a vicious cycle and can prolong the healing of the injury.
There is also quite a bit of controversy over the value of stretching so the jury is still out. However, I tend to be a believer in the benefit of stretching both in recovering from an injury as well as helping to prevent injuries. When addressing stretching, one should specifically focus on stretching the calf muscles as well as the plantar fascia for both sides. It should be a gradual approach with slow, long, static stretching that builds up gradually over time as the patient can tolerate. One should avoid rapid, violent stretching (ballistic). I will usually recommend a pre-activity stretch after a brief warm-up and a post-activity stretch after cooling down.
How Cross Training Can Keep Heel Pain Patients Active
Cross training is a very important aspect of the treatment plan. It is important that patients are able to keep up their level of fitness while recovering from heel pain. Ideally, you can have them use pool therapy, bike or elliptical training to stay in shape and avoid stressing their foot.
Limiting or restricting activity is often difficult, especially for the athlete. One should address the intensity and frequency of activity, especially when it comes to those participating in youth sports. Fortunately, children are often involved in varied activities anyway so cross training is helpful in the treatment plan for youth injuries. Cross training is an essential part of the treatment plan for dealing with high school, college and professional athletes.
It is important to realize that exercise prescription is a major part of dealing with the treatment of heel pain. Prescribing exercise and tailoring it to a specific patient is a talent you should develop. Proper exercise prescription can greatly assist in motivating patients to be actively involved in the treatment and help ensure that their fitness level does not drop off significantly. Improper exercise can prolong the recovery time and increase the rehabilitation period. Return to activity guidelines should be clear to the patient with reasonable goals and expectations.
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