The notion of plantar heel pain being related to Fl Hal Long dysfunction was introduced a couple of weeks ago and I have taken the liberty to create a new thread to add to the growing topic concerned with plantar heel pain.
The discussion to date can be found under the
'Inflammatory' vs 'mechanical' plantar fasciitis thread.
“musmed” who initiated this idea based on some yet to be published research went on to say -
Quote:
“One of the functions (I believe) is to help raise the medial side of the foot at the time the sesamoids hit the ground. That is to cushion the hit by the sesamoids as thewy are driven into the ground.
When its co-helper the abductor hallucis cannot fire ( the muscle will not work in any one with PF) the Fl Hall longus has now got an extra job. The muscle fires for a much longer period and with time becomes chronically shortened.
In each of these patients the FL. Hall Longus tendon is easily palpable and if you slightly dorsiflex the foot (that is put the PF on Slack) and dorsiflex the great toe, the tendon again is easily palpable.It is NOT the PF, yet I see many who have this problem and when I asked them how much time was spent looking at the foot, the patient mostly says nil to 20 seconds.
I use a Travell and Simons spray and stretch technique with great results.
If this is their ONLY problem, (rare to have one foot problem), it will solve their painful foot then and there.
Trust this helps.
Regards
Musmed”
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And also
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The role of the sesamoids, according to me (study under way) is to purely reduce the size of the great toe and increase the ground force and they work like two ball bearings and this allows you to enter the coronal plain what Serge Gatovesky says in his spinal engine theory.
How do I know the and hall does not work. Simply get them the resist you pulling their great toe laterally while palpating the muscle belly, doing the same while ultrasounding the muscle and finally EMG. I have done the lot. Got heaps of data on this.
The Fl hall longus can easily be palpated through the PF. As I said slightly doresiflex the foot and great toe. Palpate the tension in the PF all over, then raise the great toe slowly. Suddenly there will be pain in a narrow band ie the FHLongus. The rest of the PF is still slack. The important thing is to do it slowly and gently a hard thing to teach people in this ever speeding world.
Regards
musmed
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I had replied
Quote:
Sorry . . . . I am a little unsure of your use of terminology.
Are you suggesting using other words that the sesamoids reduce surface area of ground contact of the prox phallanx with the ground, increase GRF (by improved mechnical advantage of flexors) and reduce friction (by providing a synovial articulating surface between flexor tendons and Met head.
These characteristics then facilitate pivoting of the foot in saggital plane at what Perry descibed as the "3rd Rocker"
If so, although I have never thought about the prox phallanx contact area, this strikes me as consistent with conventional ideas of functional anatomy.
How do you see this as different to the current established ideas?
Abductor hallucis strain and possible impingement on branches of calcaneal nerve are on most peoples radar screen as possible DD for heel pain.
Compensatory increased use of FHL in responce to AB Hal deficit I have negelected to think about, and appreciate you theoretical concern about this and look forward to your research findings.
What to you see as the pain generator in this phenomenon which you have considered?
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And also
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Hi Paul
I just sat down for 10 minutes a tried differentiating the AB HAL, FHL and PLF. What I think I noticed was this;
When I slightly dorsiflex my Hallux I can clearly differentiate the central thickened band of the plantar fascia easily, when I then plantarflex my Hallux I can feel AB HAL contract medial to plantar fascia and easily see it’s short axis expansion on medial side of calcaneus.
If I allow the Hallux to slightly plantarflex against resistance I can feel the FHL pushing against the underneath of the plantar fascia. Best spot seems to be between points 2 and 3 on the attached image.
Any suggestions regarding location of a “sweet spot” in relation to the image?
I will go and look at this with US next week and see how this appears, hopefully be able to identify some tendon motion, I have never tried this before.
If I understand you correctly then subjects with FHL contractures will have tighter than normal palpable FHL tendons and likely absence of AB HAL contraction with resisted Hallux plantarflexion.
Please could you confirm this is your notion?
This being the case, please elaborate on how you see this foot effecting function and how it relates to heel pain, also I did not understand your therapy, are you treating TrPs or somehow treating contractures?
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Hi Paul
I spent some time this evening exploring the relationship on ultrasound between palpability of FHL tendon and plantar fascia and trying, as you suggested to get a feel for intimate examination of these structures.
In spite of my skepticism, with some practice I agree that this is possible and have found this interesting because I have never really though much about FHL dysfunction and heel pain.
What I noticed in my foot, aided with US, was that at around the level of the 1st metatarsal/cuneiform joint the FHL tendon swings from an oblique medial direction to lay parallel and beneath the central thick (but thinning) band of the plantar fascia. This is nicely differentiated in sag view.
Just proximal to metatarsal head 1 the FHL tendon because of its thickness is far more visible that the plantar fascia.
Now with dorsiflexion of Hallux, my plantar fascia, as might be expected, is easily palpated from heel to forefoot, but I find it impossible to tell if proximal to metatarsal head the FHL is pushing against the plantar fascia from below or if the tension comes from plantar fascia.
I had always assumed the later.
What I noticed was this;
With resisted contraction of Hallux plantar flexors (allowing plantar fascia to relax) (metatarso-phalangeal joint approximately 0 degrees dorsiflexion) the FHL tendon could be palpated just proximal to metatarsal head and seen to move in saggital view plantarwise on US along course approximating to metatarsal 1. Also notable was visible contraction of Add Hal, and motion of FHL medially around proximal AD Hal insertion into calcaneus.
So thanks for your inspiration to perform a neglected exam.
I still however would appreciate your explanation for the following.
The FHL deviates from the central band of the plantar fascia far more distally than the typical palpable pain associated with insertional heel pain, how does FHL contracture, be it compensation for Add Hal incompetency or otherwise explain plantar heel pain other than possibly tibial nerve branch irritation?
What do you regard as pain generating structure(s) in this regard?
How does your treatment effect FHL function
Thanks
Martin
The St. James Foot Clinic
1749 Portage Ave.
Winnipeg
Manitoba
R3J 0E6
Phone [204] 837 FOOT (3668)
Fax [204] 774 9918
www.winnipegfootclinic.com
Plantar heel pain and Flexor Hallcis Longus dysfunction
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