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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 - And also I had replied And also ---------------------------------------------------------------------------------------------------

START OF THIS NEW POST

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

Paul:

I have dorsiflexed the hallux and palpated the tightened plantar fascia that results in probably 30,000 feet over the past 22+ years and still don't see what you are talking about. Is this a large enough range of patients? In addition, I have taught this technique in about 5 different countries and have done the technique both pre and post plantar fasciotomy in my surgical patients.

Maybe a series of photos of what you are actually doing would help me and the others following along understand you better.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Hi Kevin

I was pretty skeptical about this too but feel convinced that FHL is palpable under the metatarsal.

I cut a bit from my initial post since it may have been unclear"

.......... 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.

In my foot at least I was able to have a strong sense of distinguishing the plantar fascia from FHL but only after allowing the metatarso-phalangeal joint to plantarflex against resitance to approximately 0 degrees dorsiflexion.

Have you tried this approach? I am not sure if this is what Paul has in mind.

cheers

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

Dear Martin

As regards to what produces pain and where it hurts are not high in my treatment protocols of foot dysfunction.

What I treat is the dysfunctions I find in the foot. I use the old saying, if you have a piece of string and tied a knot in it,it will be short one end.

What causes the pain to subside in many cases I cannot tell you. All I know is that the patient says the pain has gone and they feel better.

A very consistent heel pain generator is an immobile cuboid-lateral cuneiform joint. Why?I do not know. You can palpate the medial tubercle and they jump. Loosen the joint and they do not jump when palpated. Once they walk around my surgery they are unable to reproduce their pain.

I really do feel that trying to know what causes what pain when and where will just give you ulcers, although it is always nice to be able to say with an air of knowledge your pain is caused by....

I am glad you used your U/Sound to prove what I was saying. Just wait till you get a few patients with very short FLH muscle. The images will be even more striking as the muscle is short and thus great tension is placed upon the tendon. The PF will not have to be placed under any tension or slackness at all.

As regards to nerve irritation. Studies show if you compress a nerve you get paraesthesia and numbness not pain. Asking about these two symptoms will make a diagnosis of nerve compression. Pain is not a result of nerve compression, there must be another reason for the pain.


The failure of the abd hall to work produces many a heel pain. The exact cause I am not at liberty to release as yet. It is part of a large study I am currently conducting.

Regards

musmed

Martin:

Certainly your method makes good sense but this does not seem to be the method that Paul was describing, from what I could understand of it.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Related Threads:
Plantar Fasciitis Discussions
Plantar fasciitis vs FHL tendinitis

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This is an interesting comment and I think probably warrants its own thread to explore the implications of this approach in terms of general philosophy to establishing diagnosis, developing treatment plan, and balancing “evidence based ” vs “empirical findings” . I am aware that I have a fairly mechanistic approach to understanding what I observe and that this has limitations in the short term if dogmaticly applied to every situation, clearly plantar heel pain falls into a category which defies a purely mechanistic approach currently. I am curious if your research strives to identify a mechanism for your findings or simply to act on influencing them, perhaps you might care to discuss this issue, I'd be interested in your view point. My thoughts currently are to attempt to design a sequence of diagnostic anaesthetic blocks to isolate pain generator(s) for plantar heel pain, do you think this is a futile notion?

My initial thought was “but MSK functional units are elastic, contractile and plastic over time and do not behave like pieces of string so the analogy is too loose”. However foot surgeons have used this mantra since they started shortening/lengthening MSK structures so perhaps you have a good way of expressing this.
Naturally this is a very appealing possibility. I am completely ignorant regarding not only examining this joint manually but also how as you say to modify its range of motion. I was unable to find any discussion of this on the arena. Whilst I understand that you would ideally have me attend one of your lectures to learn more on this, realistically, unless we can fly you to Canada (not an impossibility) I will need to figure this out from reading. Any suggestions on this gratefully received.

Ulcers I have so far avoided, intellectual stimulation attempting to learn is certainly satisfying even if understanding on this issue is limited presently. Self righteously I can say that I always honestly tell my patients when I do not feel that I know an answer and do not feel bad about this. This is not always understood by patient but this beats living the illusion which many seem to be comfortable with (don’t get me started on a rant about this unless you have several hours to spare, but I believe discomfort of accepting the joy of uncertainty is one of he key problems with the human condition currently ).

I look forward to studying this when published, and thanks for sharing your ideas in advance.


Cheers

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

Martin at al

I too would ike to be able to say what is the pain generator.

In Back pain : using CT MRI X-Ray Bone scan etc.you only have a 10% chance of finding out the cause from the imaging. Not much use eh? But this is what is used to give a diagnosis in most back pain patients.

A study released this week showing that 7.5% of MRI's of the brain show an abnormality in normal people over the ageof45 years. So its not much chop.

Cervical spine X-Rays: excluding Mrs.Smith fell over and you think she has a fracture, there is only a 33% chance of telling you what is going on, while there is a 42% chance of giving you a 'red herring 'to chase. Not much use again.

Not diagnositic blocks using Lidnocaine.

Sounds good to me butand a big BUT,
if the L/A is less than 0.5% strong it is an apotopic and if stronger is causes necrosis. So where are we again? What are we actually doing?

I do not know. I love it when an answer is found but I jusat tell patients that it is called "GOK" God only knows.

Most of my patients have"OONS disease" .Never heard of it ek? Means out of nick (nick = unfit).

Regards

Paul C.

hi musmed (Paul),

I have used the Flexor Hallucis Longus spray and stretch plus mobs of the lateral cuneiform in three patients with plantarfasciits with surprisingly good results. Not 100% relief but significant relief.

I had a 60% initial relief increasing with time; 100% relief day one and back to 60% after a week; and the last one was 90% relief. And these were patients that were a bit tricky / already tried every trick in the book.

Has anyone else who is new to this got any feedback?

Rebecca

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Hi Rebecca

Sounds interesting. For those of us unfamiliar with your approach please explain what you are doing, and why you think this helps

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

Dear Rebecca

Good to hear that I am not making it up.

As you state the poor patients had been subjected to all and sundry and something basically as simple as spray and stretch and lateral cuneiform mobilisation and the patient got more miles in a few minutes all performed with little effort, just skill and art.

Keep up the good work

Paul C

Hi Martin,


Why: I have nothing to add to what Paul C suggests, I'm quite blindly (but open-mindedly) giving this a go since Paul mentioned it a couple of weeks ago in this forum.

I appreciated your thoughts on the anatomy of the region Martin!

How: I have done Paul's mobilisation and dry needling workshops two years ago. So I use his technique to mobilise. And in regard to the spray and stretch, as per Travell and Simon's trigger point charts, apply the cold spray from the FHL trigger, travelling behind the malleolus and down to the big toe (3 times in quick succession) and then hold a stretch on FHL (dorsiflex the hallux), repeat 3 times in total. This is how Paul taught spray and stretch after doing dry needling.

Rebecca

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Paul,

Are you also treating the soleus trigger point with your dry needling?

Regards,

Stanley

Sorry to add confusion, I have not performed dry needling on these patients, just the spray and stretch.

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