Injuries and RehabTell us where it hurts! Do a quick search before asking about your shoulder injury to make sure your question hasn't already been answered (about 50 times), and read the sticky post first.
Simpler question this time Bill. Just a long background history.
Background
I have a history of chronic plantar fasciitis that I have been managing for about 7 years. Along with the help of my podiatrist, who is also my friend, I have gotten custom insoles which are checked regularly, modified my activity profile, incorporated different stretches and a night splint, have recently gotten a shot of a corticosteroid (Kenalog 40 just recently). Last year, while playing basketball and jogging up court my PF band partially tore and simultaneously my calcaneous fractured due to too much stress. The fracture healed and I have kept my PF band and Achilles loose through regular stretching and a night splint to keep my foot in a slightly dorsiflexed position. Recently, the PF problem appeared again, and after a ultrasound (I had a MRI last year after the fracture had healed), it was determined that my calcaneal insertion point in that foot was at 9mm thick (up from 7 mm last year; 1 mm is normal). The pain apparently arose because I had kept the band stretched as much as it could and it could not stretch any further. Eventually, I will have to have the non-invasive ultrasound surgery to break apart that thickness, but for the summer I begged my doctor to shoot me up with the Kenalog to allay the inflammation and let me enjoy the summer.
Question
I have been told that I should not do any calf work as it tightens the Achilles and tends to shorten the PF band further. So I didn’t, while I continued my twice weekly work with a DART for the front shin and the band work with eversion and inversion, as well as balance beam and wobble board work. However, as my calf size was shrinking to the point of looking feminine (!), I begged my podiatrist to slowly begin incorporating calf exercises again, esp. since the bootcamp classes that I take twice a week that have a lot of running and calf activity in them were cancelled for the summer – i.e. no calf work at all now. He told me I could do seated, but not standing, calf raises if I were diligent about continuing my stretching.
If I continue to stretch (towel stretch pulling from the ball of the foot back), why would a standing calf raise be any more prone to shorten my Achilles than a seated one? I understand biomechanically why this would put more stress on it, but the continued stretching should keep it long and flexible, no?
I am not trying to heal the plantar fasciitis now, just trying to prevent any major injury (another stress fracture, Achilles tendon blowout) from occurring.
Full ROM strength training is one of the best ways to increase both active and passive flexibility. I see no reason for your podiatrist's recommendations.
Weight training in and of itself does not shorten tissue. Tissues become short from repetitive limited ROM activities. For instance, cyclists have tight hip flexors and adductors because they repeatedly perform in a limited range.
I'm wondering about the PF thickening. If you are reasonably flexible in the ankle, why the thickening? It seems to me you are still compensating rather heavily for something in the forefoot. Just like a callous on your hand, the PF will thicken under constant, progressive loading.
Have you considered some soft-tissue work directly to the plantar musculature and deep posterior compartment (tibialis posterior, flexor digitorum longus, flexor hallucis longus)? With all the trauma and aggressive stretching, you're going to have some serious adhesions in the soft-tissues that stretching won't touch and may be contributing to your current symptom pattern.
Both ASTM and ART have great success in such cases. It seems you're treating a lot of symptoms when there may be a cause that hasn't been addressed.
Just another curiosity. What's your prescription/foot type?
Thanks Bill. The cause: I have severely overpronating ("flat") feet. The custom orthotics (with a heel cup, I might add) only compensate partially for this and don't put my foot into true neutral...if they tried, the pressure on my arch would be so much that I would constantly cramp up. Therefore, I still pronate mildly and I am in a position where the PF band is constantly stetching and suffering microtears...and forming a lot of scar tissue at the calcaneal insertion. I've given up regular running, basketball, volleyball, and many other jumping activities in deference to this and it has helped allay the symptoms some. I am very picky about getting very supportive exercise shoes, which are always of the heavier cross-training type variety with good motion control.
Please tell me more about how ASTM and ART will work in this situation - I'm not familiar with them very much and this is the first I've heard of it, so I am interested! Besides the stretching, I do engage in massage of the affected foot and calf muscles, both manually, and with a Homedics percussion massager that I have at home. I haven't done any ART or special work on the calf or the muscles you mentioned, however...what would cause the adhesions? I have had the local rehab expert (who services local pro athletes and is a PhD, RKT) work on loosening up the calves and hamstrings...he identified tight spots and worked on them. Is this the same as you are suggesting?
I would imagine there are some similarities (as with all forms of soft-tissue work).
ASTM (augmented soft-tissue mobilization) uses tools applied to the soft-tissues to literally break up the adhesions. It's a bit of a pain, but works quite well. I get some done on my knees or shoulders on a regular basis. It has allowed me to continue lifting.
ART uses manual tension and active motion (a terrific combination) to do the same (I feel there is also a rather strong neurologic component as well). I just got a new patient yesterday with PF. After one treatment she reported about 75% improvement.
Usually with chronic PF it's not the fascia that's the big problem but adhesions in and between the layers of musculature on plantar aspect of the foot. With big pronators, the flexor hallucis brevis, flexor digitorum brevis, and quadratus plantae take a regular beating.
Adhesions also show up in and between the deep posterior compartment muscles. This prevents normal slide of the tissues over one another and they end up all "stuck together". Rather than absorbing shock and producing efficient movement, they end up functioning like a rope and just translate abnormal amounts of tension and alter joint mechanics. The result is repetitive trauma and cumumlative injuries like PF.
www.activereleasetechniques.co m and www.graston-hall.com should have some info for you to read up on. They may also be able to help you find a practitioner in your area. Chicago should be full of them. One of my courses was up there.
After such soft-tissue work you will also experience immediate changes in force production which may reduce the loading you're getting on the plantar muscles.
Thanks Bill. I'm going to check out a DC who specializes in ART...there is a Level 3 guy only 3 miles from where I am (although I can't tell if Level 3 is any better than Level 2, or just specializes in endurance related problems).
Question #3 - the biggie re a problem around the sciatic - is on the way and I have a feeling you'll tell me to go to an ART guy for that as well. Best of luck with your patellar problem.
Level 3 means he worked at an Ironman triathalon and had some related biomechanics training. They are actually doing away with the Level 1, Level 2, Level 3 terminology as it is too confusing. Regardless, he should be qualified.
Yes, sciatica is treated very effectively with ART (as are many soft-tissue problems) as well depending on the source of the problem. Go ahead an post some history and symptom pattern. Maybe we can narrow things down a bit.
Bill
P.S. Let me know who you're seeing...I may know him or her.
These are the guys who came up on my search. What is a CCSP versus a DC?
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3.3 Miles Bannockburn Chiropractic & Sports Injury Center
Dr Stuart Yoss, CCSP
2101 Waukegan Rd Suite 100
Bannockburn IL USA 60015 847-236-1194
Current ART Rating: 3
Types of care certified in: *Upper Extremity *Lower Extremity *Spine
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6.9 Miles Arlington N. Chiropractic Ctr & Sports Injury Clinic
Joseph Vistitsky, D.C
1635 N. Arlington Heights. Rd., Suite 105
Arlington Heights IL 60004 847-870-7980
Current ART Rating: 2
Types of care certified in: *Upper Extremity *Lower Extremity *Spine
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Bill not to steal away from Kaiser. But I too suffer from PF. Not to the degree that he does. But recently I seem to be having the same symptoms only on the oposite side of my foot. instead of the pain being on the bottom just in front of my heal it's on the top of my foot toward the outside just forward of the base of my ankle. I like Kaiser do not buy cheap shoes anymore, and use the heal cups given to me by my Dr. I only get this pain when not wearing shoes. Like I said it's the same symptoms as PF. But the wrong area of the foot. I know I should see the Dr. But I'm trying to get an idea of what this may be first.
If you have any ideas I would apprediate hearing them.
NO history of sprains and no I only run when chased
The pain is not there when I where my work boots. But when bare foot or in sandles it's there. When I first get up in the morning or from sitting and goes away after a few steps. That's what has me stumped.
The worst pain is when I get up from bed or after sitting for a while. I would say only when barefoot. If I'm wearing my workboots I don't notice it. When sitting I try to do the stretches and such to keep my PF under control(that's doing fine lately). I will sometimes get some pain from rotating my foot. How to describe this? Well I guess the motion would be like drawing circles with my big toe moving only at the ankle joint. But this does not occur every time. I will be getting my wisdom teeth pulled the 15th. I think I will make an appt. with the Dr. sometime while I'm off work anyway. Part of why I'm putting this off is my Dr's office closed and now I must break in a new one. It seems the M.D.s in my area like to suck several visits(and copays) out of you before refering you to a specialist that knows what's up. I had the old Dr trained not to screw around. But that's another issue about insurance companies controlling our health care no matter what the Dr. says.
Trying to better describe where the pain is. It's my right foot. On the top and to the right. Almost directly 180 degrees from where PF pain would be which is bottom and to the left. I don't know about a stress fracture. But I can palpate the whole area with no pain. If it were a regular break this would hurt like hell.
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