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The latest Dynamic Chiropractic has this article:
Plantar Fasciitis: A Unique Approach
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Related threads:
Other threads on plantar fasciitis
Trigger points & Podiatry
Other threads on trigger points

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For anyone interested, I'll just add a couple of comments.

There is nothing new about this. The sloppy diagnosis of 'plantar fasciitis' has been covered in other threads.

Pain in the heel and arch of the foot responds almost universally to the release of trigger points in intrinsic and extrinsic foot muscles.

The location of the pain myotomally indicates which muscles are involved.
If triggers are found and released then the pain resolves. Long term management may also include mechanical intervention and joint mobilisation.

I have treated chronic and severe 'plantar fasciitis' with this perspective for years and achieve extremely high resolution rates.

For mine the fascia is there to reinforce and protect the intrinsic musculature, which are the active components of foot function. It is failure within the intrinsics which overload the fascia causing it to thicken. It generally does not get inflammed and is not in itself the cause of the pain experienced. The pain is coming from the intrinsics.

Cheers
Shane

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Shane Toohey

Shane,

While I agree that the terminology "myofascial" pain is inclusive of the muscular components of the pain experienced in PF I wonder how we can separate nociceptive stimulation via the type C receptors in the fascia itself from mechanoreceeptor involvement in the muscular component when treating trigger points?

Interesting to find so many Pods who perform manual therapies and acupuncture. I am learning new things about Podiatry everyday and the wide scope of practice and interests in your profession.

I've always maintained that DPM's and DC's share more in common than most of us realize.

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"If we all worked on the assumption that what is accepted as true is really true, there would be little hope of advance." - Orville Wright

David G. Wedemeyer, D.C., C.Ped.

I can highly recommend "The Trigger Point Therapy Workbook" by Davies and Davies, pulished by New Harbinger Publications. An excellent and easy to use book giving treatment regimes for myofascial pain through out the body.

I have used these techniques on myself and patients with good results.

Trigger point therapy should be part of everyone's toolkit.

Itchyfeet

Dear Itchyfeet! ( I really much prefer a name to deal with)

Thanks very much for the reference.
You will find that your wish about the inclusion of TrP therapy in undergraduate training will be starting very soon in some courses.


Dear David (Wedemeyer),

Sorry for my delay in responding. I went away for a few days with my wife for the first time in too long and didn't even open a computer.
And thank you for your comments.

You wrote;
Whilst I'm focused on getting the result more than on the theory, which is a weakness I'll have a go at my practical explanations.
For example with heel pain (usually diagnosed as plantar fasciitis), tender points can be found in abductor hallucis, soleus and peroneus tertius without applying any pressure to the plantar fascia. Obviously, one cannot for Quadratus Plantae.
One can needle all of these (including QP) without passing needles through the fascia and achieve the desired result. These TrP's are usually pretty close to the locations described and illustrated by Travel and Simons.
It is far more useful for me to approach this condition called plantar fasciitis as TrP's. I will also needle, nevertheless, through the fascia and there may be triggers in the fascia itself, but I think that the evidence starting to merge will show that most courses of the pain do not involve inflammation of the fascia. To treat it as such may be the prolongation of less effective results and unnecessary pain. So my problem is with the diagnosis "plantar fasciitis" as being inaccurate and therefor causing less effective treatment
Hopefully, there is link somewhere in my reply about the fallacy of fascial traction on ther calcaneus as being the cause of most heel pain.

You also wrote:
I'm afraid that the use of acupuncture, whilst growing, is still regarded, as to put it kindly, unscientific. The 'leaders' within our profession also regard manual therapies in the same light. Nevertheless, the methodology of treatment involving the use of acupuncture alongside manual therapies is growing exponentially in professions such as yours, physiotherapy and even occupational therapists working in "pain clinics") and remedial therapists in Australia.

Cheers
Shane

Attached Files

Plantar calcaneal enthesophytes new observations.pdf (510.4 KB, 45 views)

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Shane Toohey

Hi Shane:

"Pain in the heel and arch of the foot responds almost universally to the release of trigger points in intrinsic and extrinsic foot muscles."

Can you translate this for me? What do you mean by "responds almost universally"?

I assume you mean a positive response. Are you saying that heel pain "almost" always is alleviated with trigger point treatment?


Steve

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DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA

Shane,

Good on you getting away with your spouse. I tend to forget to plan regular vacations which probably isn't wise.

Interesting observation on trigger points, acupuncture and fascial pain. I would dissent a bit on the efficacy of needling for fascial pain syndromes, in my experience acupuncture seems to be more suited to neurologic pain control. I could be very wrong who knows.

I also feel that because acupuncturists adhere to the meridians as the locus of their treatment that it has diminished the acceptance of acupuncture from allopathy somewhat, although I do know pain managment doctors who refer out to LAc's and OMD's here in the U.S. but not as a primary treatment. Like many of the treatments and medications in use we still understand very little about their mechanism but know that they work in clinical practice.

Have you ever read "The Body Electric" by Robert O. Becker, M.D.? He did many of the early studies on the effects of acupuncture during the Nixon administration. I gleaned from his work that the neuroepidermal junction is what is affected in needling and that direct manual stimulation would perform similarly.

I do perform acupressure among other manual therapies of course. I have treated a great deal of PF over the years and physcial medicine in my mind is far superior to injections and orthoses alone. Just an observation. I am not familiar with any patients who have tried acupuncture as the sole treatment for PF who resolved.

I know some of the practitioners here view manual therapies with a skeptical eye but I feel that as a part of the total care of PF that a combined conservative treatment regimen including orthoses/inserts and quality footwear is far superior to the more invasive treatments, at least at the onset of acute PF. Some of the orthopedic doctors here are catching on and referring them to me right out of the gate, they realize that many of these problems are tissue related as a consequence of biomechanical issues and I am also a C.Ped who can afford them orthoses.

It does seem as though the providers outside the U.S. are more open to acupuncture and myofascial therapies?

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"If we all worked on the assumption that what is accepted as true is really true, there would be little hope of advance." - Orville Wright

David G. Wedemeyer, D.C., C.Ped.

Dear Steve,

You wrote:

Pardon my poor expression! I'm always trying to say a lot with as few words as possible. Yes, I'm saying that I find in the great majority of cases of heel pain that I see and despite them being mostly chronic cases, that I can have a substantial (>70%) reduction in pain within three treatments by using acupuncture needling techniques on trigger points in muscles that refer pain into the heel. In straightforward cases it is not uncommon to get this result with the first treatment.

The referral pattern for each muscle is reasonably standard and hence the location of the pain directs me where to look first.
For the heel, medial heel pain check abductor hallucis (very common), for central plantar pain check quadratus plantae, for posterior & plantar, particularly the posterior rim, try soleus and for lateral heel pain I've had most success with peroneus tertius. These patterns overlap and the more chronic the condition the more likely that multiple triggers are involved. I only needle triggers that I can find by palpation (tender points) and follow up with cold spray and stretch.

As mentioned previously I also will be looking into mechanics and footwear.

I find that with these chronic cases that it is not unusual for a small amount of residual pain to linger on for a good few weeks. I generally stop treatment when I think we have reached this point and review again 6-8 weeks later. Generally that lingering pain has resolved by then without any further intervention.

Hopefully this has been a clearer explanation. I'm always looking for improvements in the efficiency of my treatment.

Cheers
Shane

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Shane Toohey

Dear David, thanks for your reply and discussion.

You wrote:

I simply voice my opinions and they are subject to change over time, but they are based also on my observations on what is happening in my clinic all day long ( so you'll have to pardon me always being so opinionated).

Personally, I find needles the easiest way (for me) of releasing myofascial trigger points, particularly in chronic/complex cases as I can treat a large area in a short time. I still do sometimes use manual methods when dealing with a straightforward isolated trigger. I look for the Tr P's along the patterns described by Travel and Simons but only use dry needling and no injection therapy (which, I stopped doing 15 years ago).
In conjunction with this and also for pain not principally involving Tr P's I do also use a number of acupoints, mostly well known in TCM.

There is growing evidence about the effects of the stimulation by needles on the nervous system (exact pathways in CNS imaging). The explanations about the observed phenomena by the Chinese and others predated science and I regard them as metaphorical and poetic. Having learned the meridians I find them useful for remembering point locations and metaphors such as 'surrounding the dragon" as useful techniques for particular problems. So I agree completely with you that the TCM explanation of the phenomena creates a huge barrier to the acceptance of acupuncture techniques including the acupuncture that is called dry needling.
Really it is not hard to accept that needling causes stimulation in the nervous system. If you know that the needle has punctured your skin and you can feel it still there, then a message has reached the cortex (and where else on the way?)
Currently I am reading a book "Acupuncture, An Anatomical Approach" by, Dung, Clogston and Dunn, , CRC Press, 2004. (I got it on Amazon). They describe their acupuncture technique as 'neuromodulation' to emphasise the intellectual underpinning of principle acupoints overlying the afferent nerves of the PNS.
The fascination is in how predictable the development of Tr P's is depending on one's history of painful experiences and how to intervene in these patterns.

One of my missions is to dissociate the concept that acupuncture = TCM



You also wrote:

I was advised that the use of acupuncture needles does not carry an insurance code in the U.S. It doesn't here either but I'm happy to regard this as a consultation anyway.

Anyway, it's getting late, thanks again for your discussion.

Cheers
Shane

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Shane Toohey

Hi Shane:
Thanks for the explanation.
Unlike you, I cannot say that I have good success treating chronic heel pain non surgically.
As I may have said before on the arena, most of my chronic (more than six months) heel pain patients have already had various conservative treatments prior to my seeing them. As a result perhaps I'm a little quicker to suggest surgery since these patients are, by and large, fed up and desperate for a "cure". I cannot suggest another treatment that will take weeks and that may or may not help.

I'd be interested in any studies you may have done or read that support your observations.

Thanks again

Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA

Hi Steve,

Thanks for your reply. I can only reply with observations based on my experience and that of others using this modality. As I run workshops which include the treatment of heel pain using acupuncture I get feedback from participants which also include positive results in similar cases.

So..... on that first visit when they outline the saga of the treatment they have had I always ask about the location and behaviour of the pain in their heel
It is not uncommon for me to use needles on this day if there is a fit between palpable TrP's and the area of pain experienced.
I will also review their orthoses and if they seem to have any possibility of interfering with the "windlass" i.e. are high in the arch for the foot or too long etc
then I will also ask them to temporarily not wear the devices and just use the simple soft off the shelf devices I have. To these I may add mild extra forefoot or rearfoot wedges, raises, domes etc.
I also check for joint mobility/play and may do a couple of joint mobilisations.

When I review them in a week or so it is not unusual to have between 50 and 100% improvement. If zero then consider surgery (although, I don't, but will review my whole assessment and revise if it changes).
However, the positive results at this stage do not mind a couple more treatments to finish off the problem. This may include modifying or replacing their current devices.

My point is that it's not at all necessarily a large process to go through to shift heel pain from severe to mild in many cases. and that you can find out quickly if your intervention is working.

You also wrote, Steve: Sorry, none available or in the pipeline. I'd be willing to participate in any at our local university, but not as the student designing and writing up the study.

Cheers
Shane

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Shane Toohey

Does anyone know of any courses for trigger point therapy in the uk????

Hi Podpaul

You could try the SOBSART folks in Nottinghamshire way. Alternatively try the Society of Sports Therapists to see if they run one. Not sure if these folk cover the ground in the same way as Shane or Paul Coneely

Ian

Hi Podpaul,

Ian wrote (thanks):
I thought that I'd better add a note to that.
In the UK you need to qualify for an Acupuncture Certificate from the Society before you are covered by insurance for penetrating the skin with an acupuncture needle (although you base qualification allows you to penetrate by injection).
A couple of years ago Dr Paul Conneely and I presented workshops with a dry needling component in the UK. Our participants needed to already have or then obtain an Acupuncture Certificate form the Society for insurance purposes.
It seemed appropriate then for us to get our workshop re-jigged to comply for approval and reduce duplication for our participants.
It took us 14 months to be granted approval for our submitted "Acupuncture for Podiatrists" workshop (which includes that area of acupuncture termed 'dry needling') We did organise venues and dates to bring it to the UK in 2008 only to get caught out by the fact that notice in your journal has to be presented 3 months in advance of publication and we only had everything ready 4 months before workshop dates. This would have meant only one month of notice, which obviously is not enough and so we had to cancel. We will try again for 2009.
My plug for our workshop is that it designed for treating conditions commonly being presented to Podiatrists. I have spent 17 years on clarifying a core amount of acupuncture that enables a Podiatrist to make good use of the modality and obviously am enthusiastic about a very conservative modality that is exceptional in reducing suffering.

Cheers
Shane

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Shane Toohey

A comment on the article posted at the top of this thread:


The author then goes on in the following paragraph:


This is a bold statement, and while the article only appears in an on-line magazine, should be substantiated by scientific evidence (especially after pointing the finger at “most HCP’s” who “do not know the latest research”)

There is recent evidence to suggest that areas of focal myofascial stiffness are objectively demonstrable:



Followed up this year by the same author:

In my view, a case-control study using MRE for objective findings of plantar fasciitis is required to substantiate the chiropractors claim that “Muscle knots, technically known as myofascial trigger points (MTPs), are a factor in almost all cases.”

Without scientific evidence, this statement is meaningless.

Just my thoughts,

Andrew