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Plantar fasciitis: Treatment options to consider when not getting relief with NSAIDs, cortisone injections, custom made orthotics, night splints, foam rollers, or surgery. My goal for you is that you will be up and running again real soon without pain. Oh, and lets avoid surgery all together. It rarely works and has all kinds of risks associated with it. Please note that when you see P.F. it refers to plantar fasciitis for the purpose of this ebook. Brian McKay, DC Core Health Darien 555 Post Road Darien, CT 06820 203-656-3636 [email protected] Introduction Hello, my name is Brian McKay. I am a chiropractor in Darien, CT with over 20 years of clinical practice. You may be wondering why anyone would see a chiropractor for plantar fasciitis. I would think the same thing so let me explain how I got started treating P.F. I studied a soft tissue technique called Graston. It was started by an English osteopath many years ago. Dr. Graston tried to bring this soft tissue technique to physical therapists in the U.S. but failed to gain traction. Instead of giving up on his technique for dealing with chronic soft tissue injuries he put it in the direction of chiropractors. Not every chiropractor really embraces the soft tissue component of chronic injuries. I would like to think that the more enlightened chiropractors truly understand the relationship between muscle, bone and connective tissue. I firmly believe in understanding the relationship between bone, muscle and connective tissue leads to better treatment outcomes. You cannot have bone involvement without muscle involvement. They are all interrelated and need to be addressed together to resolve chronic repetitive sprain strain injuries such as P.F. I was treating a patient for a condition commonly referred to as tennis elbow. I had studied Graston and had been getting some real solid results with tennis elbow cases. This same patient who got incredible results for her tennis elbow asked me to do the same thing for her troubling P.F. We had nothing to lose. The treatments were so successful that her doctor who had been treating her foot asked to meet with me to discuss the treatments. You may not be aware of this but there is a huge wall between chiropractors and real doctors. Breaking down this barrier that still exists today is a huge achievement unto itself. So I was more than happy to meet with him. I explained the treatment which he seemed to understand. He was then happy to tell his physician friends and his patients' that they had to see me when they had difficult cases of P.F. When cases resolve with NSAIDs or cortisone the patients never get to me. Why would they if they got better? My experience has been with the tougher cases that have tried many things that failed. My experience grew with each new case that came in to see me. I got better and started adding additional therapies to the underlying Graston technique. There is no greater feeling in the world than getting results for tough cases. It makes going to work like not working at all. I really enjoy helping people. Truth be told that not all cases get better with my particular treatment for P.F. I do my best to weed these people out as quickly as possible. I only take the cases where I am certain I can make a difference. I hope this information makes a difference for you. Dr. Brian McKay Page 1 Plantar fasciitis is a painful condition that irritates the plantar (bottom) surface of the foot. Typically, it affects only one side. I have seen both sides have it, but it is far less common to have it bilaterally. The diagnosis is fairly easy to derive and 99% of the patients being referred here already have a diagnosis from their referring physician. The pain is unbearable and can prevent the person from doing many activities that are weight bearing. There are many nerve endings in the feet so the pain in the bottom of the foot can be quite intense. Many people have to give up their sports when conventional therapy fails to help. Standing is a problem so people with P.F. will need special footwear just to get through the day, especially if they work on their feet. Most athletes have to curtail their activities around P.F. The pain is often unbearable and it prevents much activity. These people need help. There are many therapies that sometimes offer minimal results. The latest craze is foam rollers to knead the tissue and smooth it out. This is of some value when used throughout the lower extremity. Ice can stop pain but only for so long. Anti-inflamatories are often used with varying degrees of success. The rationale is that if inflammation reduction brings down the tissue swelling there should be a corresponding decrease in pain. This view is rather shortsighted because it does not consider the factors that caused the inflammation to begin with. Custom-made orthotics are very helpful at times. They provide needed support to stabilize the foot. I usually recommend that people try store bought orthotics first. Very often they do the trick and cost a whole lot less. Most people will require additional support for their feet as the aging process takes place. Cortisone injections I find to be of little value and a last ditch attempt at fixing the pain associated with P.F. Cortisone injections are super powerful anti-inflammatory that suppress everything including your immune system. You can only have so many cortisone injections before you do real damage to the joints. Only in extreme cases is this recommended and should be used judiciously to say the least. Let's try to explain the basic concept of what I feel is the underlying cause of plantar fasciitis. The tissue in the foot becomes bogged down as a result of muscle imbalances as far up as the stomach muscles. The connective tissue of the foot is very sensitive because it is nerve rich. The brain relies on sensory input from the feet for balance purposes. The unusually large number of nerve fibers contribute to the intensity of the pain. It is like having several alarms going off all at once making even more noise. To you this is pain but think of pain as an alarm telling you that something is wrong. Understanding the Adhesion and its Role in P.F. I have often referred to plantar fasciitis tissue as bacon after it has been cooked when it needs to be like precooked bacon. Try to picture the difference and relate it to living tissue to get an understanding what adhesions look like. An adhesion is a small nodule that forms in the fascial plane when stress is placed on the tissue over and over again. The more stress, the more the adhesions form. The adhesions form in the fascia hindering free movement. Fascia is connective tissue that wraps around the outside of bone and muscle. Fascia has its own nerve supply making it sensitive. Adhesions restrict motion. The small nodules prevent the muscles from moving freely without friction. I want you to imagine two plastic baggies filled with hamburger meat. Rub the two bags together. They should glide against each other nice and smooth. There is no friction and it seems effortless. This is how different muscle groups should move when in close proximity to each other. Now when the fascia becomes dysfunctional, more adhesions form. Little tiny nodules that cause friction form in the surface of the fascial plane. There is much pain as the number of adhesions increase. Blood flow becomes diminished and the tissue becomes stagnant . The shape of the covering of the muscle changes as more stress is placed on the dysfunctional tissue. The muscle stops working efficiently. If you have ever seen someone's arm after a cast has been removed you will notice changes in the muscle versus the healthy arm. Fascial restriction will do the same thing but is not as obvious to the naked eye. The more dysfunctional the muscle becomes the more painful it gets. The adhesions then act as a choking point preventing normal muscle function. Preventing the removal of toxins with normal venous return and is some cases even restrict lymphatics. This causes the muscle to become engorged with lactic acid and muscle waste products which further restricts healthy muscle movement. More pain ensues. Picture the plastic baggy becoming more like bubble wrap. As the bubble wrap drags across more bubble wrap there is increased surface friction. More friction equals more pain. More adhesions then form. My immediate job is to identify these adhesions and start removing then using Graston. This is not a fun procedure, but it is highly effective. Since your foot is where the pain is, this is the most logical place to start. The adhesions are easy to find because your patient will become very apprehensive and pull away as soon as you land on a painful adhesion. Their eyes will also tell you a lot about how much pain they are in. Usually the patient's eyes will widen when you get near a bad spot loaded with adhesions. The worst pain is often found past the heel in the arch of the foot. This tissue is called the Plantar Aponeurosis and it covers many muscles, particularly Flex or Digitorum Breves, Flexor Hallicus Longus and Abductor Hallicus. These are all hotbeds for adhesions. The dysfuncion starts higher in the kinetic chain. So we must examine the whole chain to really understand and fix this problem of Plantar fasciitis. Here is where I need to get radical and turn this on its head. From here you need to understand that muscles in your torso affect your leg and foot. They are connected. Any exam that leaves out part of the whole kinetic chain will result in partial outcomes. You want results right? The Abdomen The trunk Flexor Iliopsoas and iliacus are in your abdomen. They help flex the trunk at the hip. So if you were to do a crunch you would be activating these muscles. The Psoas is a powerful muscle that flexes the thigh, bringing the knee up and forward. Lie on your back and make cycling movements and you will understand what the psoas does. It has been my experience that the trunk flexors are often inhibited on the side of P.F. Almost to say that the body recognizes an imbalance and tightens down one side of the trunk to add stability where it is lacking. Think of it as a protective mechanism that prevents you from doing further damage to yourself. This does result in less movement. The examiner must consider the trunk flexor muscles when trying to understand P.F. The Upper Thigh front portion. The Tensor Fascia Lata (TFL) is a muscle that inserts into the strong band of connective tissue that runs down the side of the leg called Iliotibal band. Notice a connection from the iliopsoas a muscle that inserts onto the ilium and the ilioitibial band which has its origin on the ilium and inserts onto the fibula below the knee. It is thick and very deep. The TFL is a hot bed for painful adhesions that go unnoticed until you deeply palpate the tissue. The Sartorius muscle starts at the Ilium laterally and goes across the the front thigh to below the knee on the inside of the leg. I have found a number of adhesions in the area closest to the inside of the knee on my P.F. patients. We need to release the the overall tension in the kinetic chain where it originates. To locate this on yourself feel the inside of your knee and press. This muscle is more superficial so you should be right on it when palpating the area. If it hurts you may have adhesions here that can cause P.F. all the way down the foot. Let's go down to the front part of the lower leg. You will find more muscles with adhesions when you start looking deeper. By now you should be adept at locating adhesions. Press hard and feel for pain. If you reach down the outside of your leg below the knee there are long muscles called the Peroneus longus and brevis that go down the outside of the leg into the sole or Plantar surface of the foot. These are big hotbeds for adhesions. It also can shed some light on why the foot can hurt so bad from a muscle in a different location. The adhesions will be found higher up closer to the knee and they really add complexity to P.F. I feel that addressing these areas outside the box are a major reason I am able to deliver solid results for my patients. It really is not crucial for you to remember the names of these muscles. Just make sure that the doctor examining you checks for them. We are still on the front of the leg. The next big muscle to pay close attention to is the tibialias Anterior. This muscle can be found closer to the front of the tibia, which is the larger lower leg bone towards the inside of the leg. Its job is to invert the foot bringing the heel down and toes up. Quite often I find a nest of painful adhesions here. Fortunately Graston does a wonderful job of fixing them. The next spot on the lower front leg to pay attention to is the Extensor Digitorum Longus. This muscle attaches to the four outer toes. If you palpate closer to the middle of the leg between the Tibialis Anterior and the Peroneus you will find the Extensor Digitorum. The Tibialis and Extensor Digitorum are in the front of the leg and insert on the top of the foot. This action allows the foot to dorsiflex, an important action in the ankle. The more important the activity of the muscle the more likely it will be to have adhesions present. Let's turn you over and examine the calf muscles. The calf muscles are real close to the perceived problem point. These muscles are the more obvious ones related to P.F. since they are so close to the heel. Almost always there is also involvement of the Achilles due to its insertion point on the superior aspect of the calcaneus at the calcaneal tuberosity. Many professional athletes have Achilles problems that sideline them for extended periods. It would be in their best interests to go up the kinetic chain for answers as to why their Achilles are involved. The first muscle of the lower posterior leg to consider is the Gastrocnemius. This is very big and close to the surface of the calf. It has two heads that join to form the Achilles tendon. If you look you will almost always find adhesions all over the gastrocnemius on both sides. When I first got into treating p.f. area I concentrated on the most was the Gastrocnemius. I got really good results back then. I am now amazed that I keep finding more areas to examine the more I study this fascinating topic. Lucky for me the results keep getting better as well. The Soleus muscle goes under the Gastrocnemius. It is a powerful muscle that aids in balance while standing. What is important here is because it is nerve rich, you have more potential pain. It can be found close to the ankle on both sides. Find these adhesions and reduce them with Graston. The bottom of the foot will hold many tender painful adhesions needing work. Let's look at the major muscle groups that offer the fastest response when working with the plantar surface of the foot. Flexor Digitorum Brevis flexes the lateral four toes and can be quite painful especially when applying the Graston technique. Next to this hotspot is the Flexor hallucis longus that goes to the big toe. Overlying these muscle groups is a layer of fascia called the Plantar Aponeurosis. It is thick and loaded with adhesions. While I have not pointed out every single muscle that affects P.F. I have certainly told you about the muscles most often involved. An exam should involve these at a minimum. Do not be afraid to ask your physician about them. You could be doing them a favor by educating them about P.F. Let's move on how we treat these painful adhesions. First we apply a local cleansing agent with anti-bacterial properties. Starting with the area furthest away that you have determined has adhesions you will apply a topical lubricant of your own choosing. A thin layer will do. Take a Graston tool that best suits the affected muscle and apply a scraping motion in several different directions. Stay on the muscle for about five minutes per area. You must do this up to the tolerance of your patient. Some patients will be more sensitive than others. Try to understand that the tissue is nerve rich and that this treatment can and will be very painful. If you hurt them too much they may not return and they will not get the help that this treatment can deliver. Go down the leg, repeating the cleansing process and application of topical lubricant until you get to the sole of the foot. This should take about half an hour. I have found it helpful to then apply Class IV Cold Laser Therapy to the affected areas. The cold laser acts to start the cellular healing process. Light is energy. Laser light provides packets of photon light energy to ramp up the tissue healing after the traumatic Graston procedure to rid the muscle of the dysmorphic adhesions. The Class IV Laser is a highly effective way to stimulate cellular regrowth. I recommend that it be used every time a Graston procedure is performed. It speeds up the healing time and does a more efficient job than just doing Graston alone. The laser light acts like photosynthesis allowing the tissue to grow back normally. I want to add a final piece to the P.F. puzzle. The affected leg in most cases has a bone component that needs explaining from a chiropractic vantage point. The P.F. foot is associated with what we call the long leg syndrome. What happens in this case is that the leg moves inferior from the hip joint. Therefore that leg hits the ground harder because it is closer to the ground when upright. While lying face down it is clearly evident if one leg is shorter then the other. Most of the cases I have treated have this on the side of P.F. I would strongly urge you to get checked out by a chiropractor on a regular basis. If you leave this piece of the puzzle out I think P.F. Can come raging back in a few years. Because your foundation is not solid and the muscles in the chain will have to work harder to accommodate the imbalance. The A.S.I.S. is the attachment site for the Psoas and iliacus muscles as well as the origin of the sartorius and tensor fascia lata so there is a big tie in. In the absence of chiropractic care a self remedy would be to lie face down on the floor and to place a sneaker under the P.F. side facing towards the opposite hip. This will ease the pelvis back into a more anatomical efficient position lessening the length of the Longer p.f. leg. Let's Review. If you think you have P.F. you should try an over-the- counter hard orthotic. I suggest Superfeet which can be purchased at running stores, athletic departments or online. Custom made orthotics should come from a podiatrist. I can fit people for orthotics but prefer to get the Podiatrist's opinion. It is really their specialty and I feel they do a more thorough job when fitting them properly. Reasons for orthotics are many. As we age the arch breaks down. If you want to stay active you will need arch support at some time or another. Getting it before you really need it will keep you upright longer and with less pain. Your footwear should be supportive most of the time. Sandals and high heels are okay once in a while. When purchasing shoes seek a good store that has knowledgeable salespeople who can guide you. You would be better served by purchasing one good pair than several inexpensive pairs. Invest in yourself. You will save money over time with less doctors visits. Then when you do make it to the golden years you will be running circles around your peers. I always feel like a chiropractic heretic when I harp on shoes and supports but they help form a foundation. The more solid your foundation is the less you will need my care. So this advice is not self-serving, it is just good advice. It is hard to Graston on yourself. You might be able to get the front of the legs and the top and side of the thighs but it just is not the same. I will give my email address and I would be happy to recommend a practitioner close to you. Your body is mechanical and needs work as we age and stay active. Do you stop changing your car's oil when the odometer hits 85,000 miles? A common sense approach to staying in the game should include some ongoing chiropractic care with your exercise program. I really do not see too many people with P.F. who are not active. It is a curse you will have to deal with but your life will be longer and fuller with exercise and activity. I would like to thank you for reading this ebook. I hope you have learned from my experience and that it helps you find relief from Plantar Fasciitis. Dr.Brian McKay Darien, CT Give the night splint the boot ! The End Copyright protected 2-7-14 All rights protected Any use requires express permission of the author.