In an earlier post, we discussed on what plantar fasciitis is about, including the causes, symptoms and treatment options available. If you think you might be sufferring from plantar fasciitis, read on and find out more about the exercises that you can do to help ease the pain in your foot!

Plantar Fascia Stretch

Pull your toes towards you with your foot pointed up till you feel a slight stretch on the sole of the foot. Do this daily for 3 sets of 10 repetitions holding each stretch for 15 seconds.

Upper Calf Stretch

To stretch the upper calf muscle (gastrocnemius)on the painful side, stand in a stance position with the painful leg behind keeping the knee straight and lunge forward till you feel a gentle stretch on your upper calf. Make sure that your shoulders, hips and knees are pointing front. Do this daily for 3 sets of 10 repetitions holding each stretch for 15 seconds.

Lower Calf Stretch

To stretch the lower calf muscle (soleus)on the painful side, stand in a stance position with the painful leg behind keeping the knee slightly bent and lunge forward till you feel a gentle stretch on your lower calf. Make sure that your shoulders, hips and knees are pointing front. Do this daily for 3 sets of 10 repetitions holding each stretch for 15 seconds.

Intrinsic Foot Muscles Strengthening

Grasp a piece of towel with your toes and slowly try to pick it up. Do this daily for 3 sets of 20 repetitions daily.

Plantar Fascia Stretch

Upper Calf Stretch

Lower Calf Stretch

Intrinsic Foot Muscles Strenthening

What is plantar fasciitis?

Plantar fasciitis is a term given for the painful and inflamed flat, fibrous band of tissue (also known as the plantar fascia or plantar aponeurosis) that connects your heel bone to your toes. The fascia acts as a shock absorber and supports the arch of the foot. With plantar fasciitis, there is an excessive strain placed on the fascia. This excessive strain causes tiny tears in the plantar fascia exceeding the body’s capacity to recover, resulting in inflammation. In turn, this causes weakness, irritation, swelling and pain along the plantar fascia, especially in weight-bearing activities.

What causes plantar fasciitis?

Plantar fasciitis is likely to happen with the following:

• 
  Source: http://en.wikipedia.org/wiki/File:PF-PlantarMove.jpg
  Faulty Windlass Mechanism: The windlass mechanism describes how the plantar fascia supports the foot during weight bearing activities. A ‘windlass’ is the tightening of a rope or cable. The plantar fascia simulates a cable attached to the calcaneus (heel bone) and the metatarsophalangeal (toe) joints. Dorsiflexion (foot up towards the shin) during the push-off phase of gait causes the plantar fascia to shorten as the winding of the plantar fascia shortens the distance between the calcaneus (heel bone) and metatarsals helping to elevate the arch. When there are faulty biomechanics in the foot, the effective use of the windlass mechanism is inhibited and this increases the strain on the plantar fascia.
• Excessive foot pronation: Excessive pronation or inward rolling of the foot also inhibits efficient use of the windlass mechanism. This decreases shock absorption through the plantar fascia which in turn increases the tension on the plantar fascia.
• Tight calf muscles: Having tight calf muscles can cause excessive foot pronation contributing to excessive foot mobility which increases the level of stresses on the plantar fascia.
• High arched foot: A high arched foot lacks the normal joint mobility which reduces the foot’s ability to absorb shock from the ground, thereby increasing the stresses on the plantar fascia.
• Ill-fitting or worn out shoes: Wearing ill-fitting or worn out shoes may change the foot biomechanics, causing undue strain on the plantar fascia.
• Excessive walking and running on hard surfaces: This increases the shock transmitted to the plantar fascia, increasing the strain on the plantar fascia.
• Overweight: Being overweight increases the level of stresses applied to the fascia due to the added body weight on the foot, increasing the strain on the plantar fascia.

What are the symptoms?

Source: Flickr

How is plantar fasciitis diagnosed?

Diagnosis of plantar fasciitis can be done by examination of the feet. During examination of the feet, your physician or physiotherapist will observe how your feet are aligned and how they work (i.e. biomechanics of the feet) in standing and in walking. Your physician or physiotherapist will also look out for any high or low arches, and tight calf muscles that may potentially cause plantar fasciitis. The ankle and foot joints will also be examined to identify if there is a lack of or excessive mobility. X-rays of the heel can be also be done to rule out heel spurs (bony growth). Your physician may send you for an ultrasound scan of the fascia to see if there is any thickening and/ or swelling of the fascia in plantar fasciitis.

What are some of the treatment options?

Several conservative treatment options are available for patients with plantar fasciitis and includes the following:

• Rest: Reduce the activities that cause you pain. Minimise walking or running on hard surfaces.
• Ice: Apply ice on the affected region that is swollen, painful for about 15 minutes, 2-3 times daily.
• Anti-inflammatory drugs: Taking anti-inflammatories may help to settle the inflammation and curb the pain. However, you may want to check with your doctor on the kinds to take if you have stomach or respiratory problems.
• Injections: Steroid (cortisone) injections can be given to help reduce inflammation if the pain remains bad despite other measures. It may help to relieve the pain in some people but does not always cure the problem.
• Exercises: Stretch your calves or your plantar fascia and do strengthening exercises for the intrinsic muscles of the foot. It is important to strengthen the intrinsic muscles of the foot so that the longitudinal arches of the foot will be stiffened during gait reducing excessive stresses on the plantar fascia.
• Proper footwear: Wear shoes with thicker, well-cushioned midsoles and heels and those with good arch supports. Avoid old or worn out shoes that may not give a good cushion to the heel.
• Orthotics: Use orthotics to correct biomechanical faults in the foot during weight bearing activities.
• Night splints: A special splint may be worn overnight to keep the calves and plantar fascia slightly stretched preventing tightening up of the plantar fascia overnight.

In cases that do not respond to conservative management, surgical release of the plantar fascia called plantar fasciotomy may be considered. Although the success rate of the procedure is about 70 to 90 percent in patients with plantar fasciitis, there are potential risk factors involved. The risks include nerve injury, infection, rupture of the plantar fascia and failure of any improvement of the condition.

An ankle replacement surgery is where the joints of the ankle are fitted with a prosthesis or an implant to replace the existing worn out joints. It is usually recommended for the elderly and relatively inactive person as one of the major complication from such a surgery is loosening of the ankle joint due to overuse. After the surgery, you will be placed on a cast to protect the joint for a period of 6-12 weeks before you can gradually put weight on it. An ankle replacement can generally last 5 – 10 years depending on the activity level of the patient.

Who will need such a surgery?

An ankle replacement surgery is usually recommended for people with a degenerated or arthritic ankle joint that causes them pain and difficulty in moving the ankle or walking. In a degenerated or arthritic joint, the articulating surfaces are not smooth as compared to a normal joint with cartilages that allow for smooth gliding of joint surfaces over each other. The lack of smooth articulating surfaces in a degenerated or arthritic ankle can be due to either wearing away of cartilages or due to osteophytes (also known as bone spurs). This can cause pain in the ankle especially during movements of the ankle joint and on weight bearing activities like walking. With an ankle replacement surgery, an implant can be fitted into the degenerated or arthritic ankle to allow for smooth gliding of the joint surfaces, permitting pain-free movements to take place.

What happens during the surgery?

Ankle Replacement

What happens after the operation?

After the surgery, you will wake up with your leg in a cast or a splint. A tube may be attached to the ankle to drain off excessive bleeding. You will be taught to walk using crutches without putting weight on the operated foot. Your ankle will also be immobilized in a cast or ankle splint to protect the artificial joint for a period of 6 -12 weeks depending on your surgeon. One of the major complications that may arise from the operation is the loosening of the prosthesis. A typical ankle replacement may last for 5 -10 years depending on the activity level of the patient. In fact, research has shown that the artificial ankle joint has a better lifespan in an older patient than in young active patients. One of the reason is that younger patients tend to be more active than sedentary older patients and hence a higher risk of loosening the joint. In such cases, an ankle fusion may be a better alternative for this group of young patients with heavy and prolong activity requirements. Regular X-rays will be taken after the ankle replacement surgery to ensure that the implant has not moved out of place. Gradually your physiotherapist will improve on your rehabilitation exercises and introduce weight bearing activities on your ankle again.

Reference

• http://www.aetna.com/cpb/medical/data/600_699/0645.html
• Wood and Deakin (2003), Total ankle replacement – The results in 200 ankles. J Bone Joint Surg 2003;85-B: 334-41.

Pain in the back of the heel is a very common complaint amongst athletes whose sports require quick, sudden movements. This pain is due to the sudden, forceful pull of the calf muscle onto the Achilles tendon which, in turns, pulls onto the calcaneal bone (heel bone) of the ankle.

Anatomy of the Achilles Tendon

The Achilles tendon is the biggest and thickest tendon and like all tendons, comprises of mainly fibrous tissues which does not stretch under strain and it joins the calf muscles to the calcaneal bone of the ankle. The role of the Achilles tendon is to bring about plantarflexion (downward pointing) of the ankle, push-off phase of walking and running, and also to aid in shock absorption on jumping. The blood supply to this tendon comes from the calf muscles (gastronemius and soleus) proximally and distally from the tendon-bone insertion. These sites are also the areas where there are the most number of nerve endings, thus explaining why these are the common sites of pain.

Source: www.advancedchiropc.com/footandankle.html

Causes of injury

In the United States, about 230 000 of Achilles injuries are due to overuse, leading to unusually high strains. The strain that the Achilles tendon undergoes ranges from 3 times one’s body weight (in walking) to as high as 12 times (in jumping). Due to such high levels of strain, injuries tend to be multi-factorial: poor training technique, structural abnormality, improper footwear. The table below indicates some common examples that increase the risk of injury.

Nature of Pain

Achilles tendinopathy normally starts off as morning stiffness and pain on the first step either on the bony insertion or at the muscle-tendon junction. Soreness might also be felt on light pinching of the tendon. As the condition worsens, there might be pain on running and in severe cases, walking would also be painful. If this pain or soreness is ignored, it might lead to a partial or complete rupture of the Achilles tendon which would require immediate surgical intervention and a long rehab process.

Conservative Management

Commonly, athletes with Achilles tendinopathy are advised to stretch their tight calf muscles and also do calf raises to strengthen their calf muscles. Ultrasound, TENS, IFC (Interferential Current) are common physiotherapy modalities used to manage the pain while deep tissue mobilization is used to manually loosen up the tightness in the calf and at the tendon-bone insertion. In recent years, research has advocated eccentric loading of the tendon to further strengthen the tendon. Eccentric loading just means strengthening the tendon while it is being lengthened. Doing calf drops slowly has been incorporated into the rehab of Achilles tendinopathy. In cases where the pain is stubborn and does not respond to rehabilitation, ultrasound guided ESWT (Extracorporeal Shock Wave Therapy) may be employed to stimulate revascularization of the tendon at the pain site. Acupuncture has also been tried to manage the pain with varied success.

Prevention is better than cure

Achilles injury, in a matter of fact, can be prevented through regular stretches, proper warm-up and proper biomechanics. Choosing the right kind of footwear that supports your arch and gives adequate cushioning can help reduce the strain and loading of the tendon. Staying in shape and proper progression of one’s training is the best way to prevent Achilles injury.

Flickr: LoreleiRanveig

Michael Merzenich

One of the foremost researchers of neuroplasticity, Michael Merzenich’s work has shown that the brain retains its ability to alter itself well into adulthood — suggesting that brains with injuries or disease might be able to recover function, even later in life. He has also explored the way the senses are mapped in regions of the brain and the way sensations teach the brain to recognize new patterns.

Merzenich wants to bring the powerful plasticity of the brain into practical use through technologies and methods that harness it to improve learning. He founded Scientific Learning Corporation, which markets and distributes educational software for children based on models of brain plasticity. He is co-founder and Chief Science Officer of Posit Science, which creates "brain training" software also based on his research.

Merzenich is professor emeritus of neuroscience at the University of California, San Francisco.

One of the most common foot pain is Plantar fasciitis. It is an inflammation of the strong tissue that runs along the bottom of the foot and connects the heel to the base of the toes (see image). This injury essentially comes about from overuse. On the symptoms is heel pain that is worse in the morning with the first few steps. Since it is difficult to rest the foot, this problem gradually worsens. If left untreated, pain will worsen and may start interfering with activities of daily living.

Plantar fascia taping can provide some relief of your symptoms. The tape will decrease your pain by distributing force away from the stressed plantar fascia. Watch the video below:

 Sports Taping for Plantar Fasciatis Video

A rotator cuff tear is a common injury of the shoulder. It can be due to a traumatic event where the tendon gets torn in a fall or due to overuse where repetitive overhead activities causes wear and tear of the tendon. Pain is the most significant symptom with a rotator cuff tear followed by loss of range of movement in the shoulder. Arthroscopic rotator cuff repair, which involves minimally invasive surgical techniques, helps to heal the tendon back to the bone. Such surgeries are usually done as a day operation. Rehabilitation of the shoulder post operation takes about 6 months before patients return to functional activities.

Treatment

Treatment for rotator cuff tears ranges from conservative rehabilitation to surgical interventions to repair the torn tendon. Conservative treatment involving rehabilitative exercises is usually the primary course of action. Surgical repair is indicated for a rotator cuff tear that does not respond to conservative management or the tear was found to be large causing severe weakness, loss of movement and function. The decision for conservative management or surgical repair also depends on the patient’s severity of symptoms, functional requirements, and presence of other illnesses that may complicate treatment.

Source: http://www.dryaco.com

Arthroscopic rotator cuff repair

Arthroscopic rotator cuff repair involves small incisions on the outside of the shoulder where small surgical instruments are passed through to allow the surgeon to suture or stitch the torn tendon back to the arm bone and allow it to heal. Sometimes the surgeon may remove any scar tissues or bone spurs that may disrupt the healing process.

The advantage of arthroscopic surgery is that a smaller incision causes less pain in the shoulder joint following surgery because it does not require splitting up muscle layers in the shoulder as with the traditional approach. Smaller incisions also mean less superficial scars which is aesthetically more appealing. However, recovery time for the arthroscopic repair is the same as the traditional surgical approach.

After the surgery, you will be placed on a sling to protect the repaired tendons. Rehabilitation with a physiotherapist will start early to reduce the post-operative pain and stiffness. The rehabilitation will progress towards increasing shoulder range and strength after 6 weeks when the tendon heals into the bone. It takes motivation and commitment from the patient to take part in the rehabilitation progress as the whole process takes about 6 months before return to sports or function.

Although most arthroscopic rotator cuff repairs are done as a day surgery, it may sometimes be necessary to stay overnight in the hospital if the doctor needs to monitor the recovery, especially if there is an underlying medical condition.

Knee replacement is the resurfacing of the worn out surfaces of the knee and replacing the lost cartilage and diseased bone with metal and plastic. Knees wear out for a variety of reasons, including injury, simple wear and tear, and arthritis. The video shows the knee replacement procedure.

Mr Kim Robinson, a leading figure in manual therapy education and Director of Manual Concepts, recently stopped over at Singapore to conduct a workshop. Musculoskeletal Consumer Review took an opportunity to sit with Mr Kim Robinson to discuss about his views on Manual Therapy.

MCR: How would you define manual therapy?

Mr Robinson: I believe manual therapy is a blend of a science and an art form, using skills and dexterity of hands-on technique to benefit individuals with a variety of disorders, and in particular, neuromusculoskeletal disorders.

MCR: What are some of the effects that manual therapy has on people with back pain?

Mr Robinson: The primary effect of manual therapy is the relief of pain. The is obviously driven by the needs of our patients, who often present to our clinics for pain relief. Hand in hand with this effect is the return of function. Particularly with respect to chronic back pain, the restoration of function is of particular importance. With pain relief and restoration of function, comes rehabilitation of a patient to return to meaningful work and activities of daily life, including sports, and other leisure activities. However, manual therapy plays an extremely important role in the treatment of acute disorders. If the acute disorder is effectively treated with manual therapy and other interventions, it is possible to prevent a condition becoming chronic. This creates a massive saving of cost and suffering in the community.

MCR: With advancement in technology do you see a possibility of manual therapy being replaced by robots in the future and why?

Mr Robinson: I believe this to be unthinkable! Manual therapy is as much an artform as it is a science. For manual therapy to be applied effectively, it requires deft touch and sensitive handling. The therapist can gain immense feedback from a patients tissues, something that a robot would be totally unable to sense. Manual therapy is not just the application of techniques but a process of clinical reasoning which enables the therapist to work through a problem solving process utilizing sensitive manual assessment and examination skills in order to make a clinical diagnosis which, in turn, enables the therapist to apply the most appropriate treatment technique for that stage of a particular patient’s disorder.

MCR: Is there any difference in terms of treatment techniques between a manual therapist, physiotherapist and a chiropractor?

Mr Robinson: Manual therapy has evolved very much over the last few decades. There have been a variety of disciplines in manual therapy that have contributed to this evolution. Many of the techniques at the disposal of the current day manual therapist, physiotherapist and chiropractor are a result of this evolution. So there is a developing "blurring" of the boundaries and differences between these disciplines. Having said that, I believe effective technique is in the hands of the clinician or the therapist. It takes many years of clinical practice, treating many, many patients, to become an effective and skilled therapist. I believe physiotherapists undertake an exhaustive and rigorous undergraduate training and then many of them put themselves through postgraduate training to further develop their skills and knowledge. This places physiotherapists in an excellent position to utilize the manual techniques available to them.

MCR: Do you see yourself as a physiotherapist or a manual therapist and why?

Mr Robinson: I have recently (and successfully) sat examinations to become a Fellow of the Australian College of Physiotherapists. This rigorous examination process has enabled me to achieve the qualification of Specialist Musculoskeletal Physiotherapist. So I see myself, first and foremost, as a physiotherapist. My postgraduate training qualified me, then, as a manipulative therapist, then as a musculoskeletal physiotherapist and more recently a specialist musculoskeletal physiotherapist.

Mr Kim Robinson

Qualifications Bachelor of Science Graduate Diploma in Manipulative Therapy (Distinctions) Fellow of the Australian College of Physiotherapists Professional Highlights Specialist Musculoskeletal Physiotherapist Adjunct Senior Teaching Fellow (Curtin University, Perth) Associate and Visiting Lecturer (Trinity College, Dublin) Accredited Mulligan Concept Teacher Director Manual Concepts (Mt Claremont, Western Australia) Quick Facts Kim Robinson has developed a reputation as a leading figure in manual therapy education. He was formerly a lecturer and clinical teacher on the Postgraduate Diploma in Manipulative Therapy programme at Curtin University of Technology for many years before establishing Manual Concepts. He now conducts a variety of lectures and clinical programmes around the world. Kim is an active member of the Australian Physiotherapy Association and the Musculoskeletal Physiotherapists Association of Australia. Kim is an accredited teacher of the Mulligan Concept and also the Australasian Regional Manager of the Mulligan Concept Teachers Association. His research interests and publications include manual diagnosis, cervicogenic headache, neck pain and the application of the Mulligan Concept.

A recent study found that the routine use of radiography (X-ray), MRI, or CT scans in patients with low-back pain but no indication of a serious underlying condition does not improve clinical outcomes. Meaning scans taken without first having an idea that it might be more than just a muscle strain. The study suggests that clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low-back pain and without features suggesting a serious underlying condition.

click for larger view

Sylvia Ho says, "Given that imaging such as MRI and CT scans are relatively costly and have no significant impact in such cases, it would be wise not take them unnecessarily. Even in cases of X-rays which are now relatively cheap, unnecessary exposure to the radiation should be considered." Sylvia Ho is a Principal Physiotherapist with Core Concepts, a musculoskeletal healthcare group.

Authors of the study added, "Rates of utilisation of lumbar MRI are increasing, and implementation of diagnostic-imaging guidelines for low-back pain remains a challenge. However, clinicians are more likely to adhere to guideline recommendations about lumbar imaging now that these are supported by consistent evidence from higher-quality randomised controlled trials. Patient expectations and preferences about imaging should also be addressed, because 80% of patients with low-back pain in one trial would undergo radiography if given the choice, despite no benefits with routine imaging. Educational interventions could be effective for reducing the proportion of patients with low-back pain who believe that routine imaging should be done. We need to identify back-pain assessment and educational strategies that meet patient expectations and increase satisfaction, while avoiding unnecessary imaging."

"You first need to know what you are looking for when ordering a scan. If the scan is not properly directed, it can sometimes miss crucial pieces of information.” says Sylvia Ho.

To further compound the issue on the utility of the use of routine imaging, detailed scans such as MRIs can reveal too much and mislead the clinician on the diagnosis. A report on the New York Times website (8 December 2008), The Pain May Be Real, but the Scan Is Deceiving, as part of their Evidence Gap series provides an excellent read on this issue.

Reference:

1. Imaging strategies for low-back pain: systematic review and meta-analysis, The Lancet, Volume 373, Issue 9662, Pages 463 - 472, 7 February 2009 doi:10.1016/S0140-6736(09)60172-0

2. The Pain May Be Real, but the Scan Is Deceiving (http://www.nytimes.com/2008/12/09/health/09scan.html)