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Totally Confused and frustrated...

Posted by Christy D on 5/31/01 at 14:12 (049483)

I've had foot pain for almost one year now. I have tried everything to avoid surgery. Ice, orthotics, wrapping, 3 cortisone shots, etc, etc. I do not follow in the regular catagory for someone with heel spurs. I am not obese, no high arch, not flat footed, etc. I recently had my third cortisone in each heel. The x-rays revealed that in my right heel, I have a large bone spur and left a small one is not fully developed. Both feet hurt, but the right is worse. I spoke to my doctor and we discussed surgery. I just don't know which is the best treatment. He says there are three stages to surgery. First is minor. If this does not work, go to 2nd surgery, more detailed and 3rd complete removal of bone spur. The first surgery he said can't make worse, but all three surgeries can only guarantee 50%. He is licenced to do ESWT, but the insurance company does not cover this procedure, which costs $4500 a foot! I would be willing to fork out that kind of money, if it meant I could have my feet back! Right now, after walking two blocks my feet are screaming. I just don't know what to do. I can not afford to have my feet any worse as I am very young and active. Can you give me any advise!

Re: Totally Confused and frustrated...

Dr. Biehler on 5/31/01 at 14:26 (049486)

What was your diagnosis and where ( exactly ) is the pain? Did the cortisone shots help at all ? Did any of the treatments help, even if temporary? If the first surgery doesn't help, I would be very hesitant about a second surgery. I feel the same way about cortisone shots. When we do the Orbasone ESWT, the cost is $2500 for one foot or $3500 for both. This would includ follow up treatments of the ESWT if needed. Dr. B.

Re: Totally Confused and frustrated...

Christy D. on 5/31/01 at 16:15 (049494)

Thank you for responding...The diagnosis is PF and heel spurs. As I indicated before, I have one large heel spur in my right foot, which is the most painful, and the beginning stages of one in my left. I do not fit the usual characteristics of people with heel spurs, I am told. At first the pain was my whole foot with heel pain. The anti-inflam meds have mellowed out the pain in my whole foot and now it's more heel pain with some arch pain. But, I can't live on this medication! I don't want to blow my liver out. I take 50mg of Viaox for 4 days, then switch to 25mg. But everytime I switch to the 25mg, the pain comes back. I can't seem to stand for more than 15 minutes w/o major pain in my heels and walk more than two blocks. It's also uncomfortable to drive as I get pain with my foot in that position. AFter a while my feet just start pounding. The first two cortisone shots lasted for about 3 weeks. Woo hoo...at least some relief! The third set of shots did nothing at all. The shoe inserts helped some, as without them I would not be able to walk any distance. The wrapping makes my feet feel worse, so I stopped that all together. I still put my feet on ice every night and stretch as much as I can. As far as the ESWT...Why is your cost so much less? Where are you located? Do you think that this is the BEST treatment?? I am very worried about all of this, because I can not afford to not walk! I work with a police agency and am very active. Also I am only 38 yrs old! This puts a damper on my travels too! Hee hee. I have a very high tolerance to pain, but after a year of constant pain, with exception to three weeks off good behavior for first two shots...it really wears you down!

Thank you very much for your time and response!

Re: Totally Confused and frustrated...

Dr. Zuckerman on 5/31/01 at 20:29 (049511)

Hi,

You are really in bad pain. Dr. Biehler is one of the podiatric physicians that uses the orbasone ESWT machine. This is done in an office setting. There is no local anesthetic needed. The reason that ESWT orbasone is cheaper is due to the procedure being done in an office setting. I have been using ESWT with the orbasone for the past 17 months with very effective pain resolution and increased activity in over two hundred patients.

If you would like an ESWT packet with video just contact our ESWT coordinator and tell her you would like to see Dr. Biehler. He is located in the New York City area. Denise can be reached via e-mail at heelhelp@bee.net

If there is any additonal information I am sure that Dr. Biehler would be very happy to answer any questions you may have.

Re: Totally Confused and frustrated...

Kathy M on 5/31/01 at 22:40 (049528)

I too have all your problems. I have found great relief with night splints. The way I understand why they work is that in the morning when you first step out of bed you reinjure your fascia. The night splints gently stretch the fascia all night. I found out that they might work when I was laying on the couch watching tv -that was about all I could do. I would rest my feet flexed up against the arm of the couch.It was almost pain free. So I tried the night splints. I can now actually get out of bed in the morning and don't have to crawl to the bathroom! Yes my feet still hurt but I can function now.I haven't started working out yet . I am afraid to, but I have started biking. My feet are OK. Next is Power Walking -wish me luck! Good luck to you.

Re: Totally Confused and frustrated...

Burt H. C.Ped on 6/03/01 at 22:39 (049799)

Kathy,
The night splint actually is strectching your calf muscles and to some degree your achilles tendons. The plantar fascia is a tough grisly non-stretching type of ligament that connects to the front of your heel and runs almost the entire length of the bottom of your foot and connects to the first bone of each toe.It is the over-stretching of this tendon that causes it to tear and become inflamed. When the calf and achilles are tight, they pull forcefully back and up on the heel and in turn, put tension on the plantar fascia which is connected to the other side of the heel.
It has been my experience however, that this is a secondary cause of plantar fasciitis, the primary being over-pronation (although direct trauma to the ligament, leg-length discrepancy, and even supination can lead to it, these reasons being in the minority). When you overpronate, your arches fall and your foot basically extends in two opposite directions--your forefoot goes forward and your heel extends backward. The problem here is that you have a non-stretching ligament attached to either end. Since it's not designed to stretch, it tears, thereby resulting in the inflammation and resultant pain. It generally starts at its' weakest point-the attachment to the heel. At this point it can actually tear away from the bone itself. At this site, the body goes through a process called 'ossification' to try to mend it and reattach it.What it actually does is throw bone tissue at the site of the tear. After repetitive damage and subsequent repair, it becomes a bone spur.
It's been my experience that few practitioners address the spur anymore knowing that it is just a by-product of the repair work on the plantar fascia. The pain that results comes from the inflammation caused by the tearing of the plantar fascia ligament itself. Heel spurs seldom, if ever, cause the pain you are feeling. Instead, focus on the dysfunctional bio-mechanics that are causing the tearing of the PF so you can quit damaging the foot so that it can heal. When the inflammation has totally subsided, the pain should disappear. But, it won't go away until you quit damaging the foot completely! Take your oral anti-inflammatories and ice for only 12 to 14 minutes twice daily. Any more than 15 minutes of icing at one time (according to recent studies) has a rebound effect and it becomes the same as using heat, which is not recommended for this condition.
The last factor causing damage to the PF is overdorsiflexion of the toes. Since the pf crosses the balls of your feet and connects to the first bone of each toe it basically works like a pulley system--the more your toes flex back and up, the more tension and damage to the PF. Therefore, any position that causes this (walking uphill, standing on tiptoes,squatting with foot under hip, etc.) should be avoided. A shoe with good rocker sole will help address this factor. Hope this info. is helpful to all--I work with 20 to 25 PF patients a week and get a lot of feedback from them and the drs. that refer to me so we know what works and what doesn't. Sincerely Burt H. C.Ped

Re: Tendon or ligament? to Burt

Julie on 6/04/01 at 02:53 (049817)

Thank you for your very clear and enlightening explanation. It's particularly interesting to me that you regard shortened calf muscles and achilles tendons as a secondary cause of PF and over-pronation as the main one. My own experience certainly bears this out. My podiatrist (and I would guess most others) blame tight calves, which probably explains why they recommend the wall stretches which in the experience of many people here, including mine, irritate both the achilles and the already torn plantar fascia.

But I would be grateful if you would clarify the nature of the plantar fascia. You describe it alternately as a ligament and as a tendon. Which, exactly, is it? Fascia is connective tissue that encapsulates muscles, so the plantar is obviously not simply fascia. Ligaments protect the joints between two or more bones; tendons connect muscles to bones. So it would seem that the plantar fascia's function more closely approximates that of a tendon (but perhaps its composition is more like that of a ligament?) Could you clarify, please?

If it really is a tendon, that would suggest that it is even less elastic than ligamentous tissue, which in turn would suggest that we need to be even more careful with the kind of stretching we do.

Re: To Dr. Z - Re: Totally Confused and frustrated...

Christy D on 6/04/01 at hrmin (049844)

First of all - I think it's wonderful what you do! I am not a baby to pain, as I passed a stone the size of an M&M and went right back to work afterward...I believe in not letting pain rule your life, but this is getting to be a major burden! Yes I am in pain and I did a really stupid thing on Friday, not paying attention to my nightly icing of my heels! I actually BURNED my friggin heels from not watching the time. I look forward every night to relief and now i'm suffering! No ice for a while until the burns heal. Ahhhhhhhhhhhhhhhhhhhhhhh

My question to you is : You think ESWT is the best thing to do? I can no longer live my life with such limitations. Since i've been taking meds and/or my 3rd cortizone shot...my PF pain is not as bad as it was, what's killing me is the constant heel pain. It does not seem to matter whether I'm on my feet or not, they just hurt all the time, but after a short time of being on my feet, the throbbing, burning, sharp pain in my heels is enough to make you crawl out of your skin. Surgery scares me and the 50% better results is very upsetting to me.

What are the downfalls of ESWT? Is it less than surgery? I just want to stress the fact that I can not afford to have my feet worse, I am too young! On a positive note, I am the '10%' because I am not obese, do not have high arch, or flat feet, so I think my recovery chances are better...

What are your thoughts...

Re: To Dr. Z - Re: Totally Confused and frustrated...

Dr. Zuckerman on 6/04/01 at 13:12 (049860)

If the pain is at the insertional point of the plantar fasciitis then ESWT candidate. ESWT is more risk -free then Foot surgery. ESWT does take time to get a reponse. It is very important to rule out such things as stress fracture. Nerve entrapement etc. The down side to ESWT is that it isn't all ove the USA and is very new to this country. The cost for ESWT isn't usually covered by insurance and in fact in 99.9% of the cases no insurance company will cover this whether it is the Ossatron or the orbasone or any ESWT machine. I hope that this is helpful. Please allow me to determine more about your heel spur/plantar fascia by filling out the plantar fascia survey and either faxing it to me at 1-86\56-848-3338 or e-mailing at footcare@home.com

Re: To Dr. Z - Re: Totally Confused and frustrated...

Christy D. on 6/04/01 at hrmin (049895)

Okay Dr. Z..I filled out that survey, I tried to print it and it would not let me! I submitted it, do you see those? I put you wanted to see it in comments area.

Let me know.

Thanks.

Re: To Dr. Z - Re: Totally Confused and frustrated...

Dr Zuckerman on 6/04/01 at 17:00 (049899)

Sorry

You have to print it or e-mail before you submitt. I don't see the results after the submission

Re: Tendon or ligament? To Julie

josh s on 6/04/01 at 18:31 (049906)

Hi There Julie,

An article I read recently by a chiropractor and found here:www.chiroweb.com/archives/17/23/11.html entitled 'The Role of the Plantar Fascia, Gastroc-Soleus Complex and the Windlass Effects of the dynamic foot' has a very interesting first two paragraphs about the achilles tendon/plantar fascia. The author describes it as a continuity, that the calf becomes the achilles tendon becomes the plantar fascia(or aponeurosis sic.), which would make the pf a tendon.

Yesterday I was manually fiddling with my feet and grasped the smaller toes (less the big one) and dorsiflexed them suddenly and harder then I wanted to. I felt a strong stretch where the pf attaches along the length of the phalanges (as shown in the anatomic illustrations on Mike W's FT site). The sensation was sharp with a feeling of sliding tissues.

The physiology of connective tissue is fuzzy to me but aparently there's this gellike 'ground substance' within which the fibrous part is embedded. There's a phenomena I've read of called 'creep' where if a tendon or ligament is subjected to long term excessive stresses or brief very excessive stresses either the 'ground substance' or the fibrous fabric (can't remember which) will 'creep' or attenuate. Traditionally this has been viewed as a permanent form of 'plastic deformation'. Thus when someone overstretches a ligament in some accident they frequently are left with a 'loose joint'. This has been thought to be non-surgically irreversible. There are some (like W.Weintraub in 'Tendon and Ligament Healing') who are challenging this view. W.W. claims that under the proper conditions injured and thus inflamed connective tissue can and does heal with proper length and elasticity.

The same awful thing can happen overstretching I think. I've read in several sources that stretching the plantar fascia is a nono for this reason. People often speak of scar tissue and in general describe it as resulting in a foreshortened or inelastic structure. I would think that in a weightbearing tendon or ligament like all foot tendons and ligaments that an injury would tend to cause a 'crept' or hypermobile area unless properly supported or immobilized. For this reason I've not been personally too keen on stretching the plantar fascia and have considered the supposed shortening that occurs at night as a possible possitive and wise body process. I could be incorrect.

I don't think I seriously crept the pf attachment in my toes yesterday, it feels ok today. But, of possible interest to foot tapers is that I had the foot taped using Scott's favorite method while torqueing on it. I have no idea if there's a connection but the tape does travel the entire length of the plantar fascia except for the bottom of the toes. Could be that the heel to ball of foot tape connection effectively shortened the stretchable distance of the pf from the ball to the toe tip. Just a thought, Scott said he used this method for years so the real problem was me yankin' on it.

Re: Tendon or ligament? to Burt

Burt H. on 6/04/01 at 20:29 (049923)

Julie-
I did not proofread my response and as you can see it was getting fairly late. The plantar fascia is a ligament which inserts in front of the calcaneous (or heel) runs across the bottom of the foot, crosses the metatarsal heads (balls of the foot) and connects to the first phalange of each toe--therefore connecting the heel to the first bone of each toe.
It is a very tough grisly ligament that is not designed to stretch. It was a mis-statement that I said tendon. Sorry for the unintended confusion. Burt H.

Re: Tendon or ligament? To Julie

Burt H. on 6/04/01 at 20:53 (049926)

Josh--The way I understand it, Before Man walked upright (before our heels touched the ground) this complex was one continuous tendon. However, when we started walking upright our calcaneous dropped, the tendon seperated, attaching itself to the back of the calcaneous, therefore connecting the calf muscle to the back of the heel via the achilles tendon.
What was the balance of the tendon, became the plantar fascia connecting the front of the heel to the first bone of each toe, thereby evolving into a ligament. This is my understanding of what the evolution was. Burt H.

Re: Tendon or ligament? To Julie

josh s on 6/05/01 at hrmin (049948)

Burt, All previous descriptions of achilles and pf I've read have agreed with you, this article is the first of this perspective I've seen. As I've never dissected anyone's heel I'll leave it to you experts. Must admit I like the idea of it as a continuum. I have heard before that ultimately all fascia is connected just as in a certain sense muscle becomes tendon becomes periosteum becomes bone,etc.
The way that article was worded, author does seem to think that literally the achilles and the pf are one unit.

Re: Tendon or ligament? to Burt

Julie on 6/05/01 at 02:41 (049953)

Many thanks, Burt. Perhaps some of the misconceptions and bewilderments concerning the plantar 'fascia' and plantar fasciitis could be cleared up if we actually called this bothersome structure a ligament!

On your other post, to Josh: it's clear to me now exactly why some of the gastroc-soleus stretching techniques advised for PF are counterproductive.

Re: To Dr. Z - Re: Totally Confused and frustrated...

Christy D. on 6/05/01 at hrmin (050000)

Okay. I am faxing you the survey with other info.

Thank you again.

Re: Totally Confused and frustrated...

Dr. Biehler on 5/31/01 at 14:26 (049486)

What was your diagnosis and where ( exactly ) is the pain? Did the cortisone shots help at all ? Did any of the treatments help, even if temporary? If the first surgery doesn't help, I would be very hesitant about a second surgery. I feel the same way about cortisone shots. When we do the Orbasone ESWT, the cost is $2500 for one foot or $3500 for both. This would includ follow up treatments of the ESWT if needed. Dr. B.

Re: Totally Confused and frustrated...

Christy D. on 5/31/01 at 16:15 (049494)

Thank you for responding...The diagnosis is PF and heel spurs. As I indicated before, I have one large heel spur in my right foot, which is the most painful, and the beginning stages of one in my left. I do not fit the usual characteristics of people with heel spurs, I am told. At first the pain was my whole foot with heel pain. The anti-inflam meds have mellowed out the pain in my whole foot and now it's more heel pain with some arch pain. But, I can't live on this medication! I don't want to blow my liver out. I take 50mg of Viaox for 4 days, then switch to 25mg. But everytime I switch to the 25mg, the pain comes back. I can't seem to stand for more than 15 minutes w/o major pain in my heels and walk more than two blocks. It's also uncomfortable to drive as I get pain with my foot in that position. AFter a while my feet just start pounding. The first two cortisone shots lasted for about 3 weeks. Woo hoo...at least some relief! The third set of shots did nothing at all. The shoe inserts helped some, as without them I would not be able to walk any distance. The wrapping makes my feet feel worse, so I stopped that all together. I still put my feet on ice every night and stretch as much as I can. As far as the ESWT...Why is your cost so much less? Where are you located? Do you think that this is the BEST treatment?? I am very worried about all of this, because I can not afford to not walk! I work with a police agency and am very active. Also I am only 38 yrs old! This puts a damper on my travels too! Hee hee. I have a very high tolerance to pain, but after a year of constant pain, with exception to three weeks off good behavior for first two shots...it really wears you down!

Thank you very much for your time and response!

Re: Totally Confused and frustrated...

Dr. Zuckerman on 5/31/01 at 20:29 (049511)

Hi,

You are really in bad pain. Dr. Biehler is one of the podiatric physicians that uses the orbasone ESWT machine. This is done in an office setting. There is no local anesthetic needed. The reason that ESWT orbasone is cheaper is due to the procedure being done in an office setting. I have been using ESWT with the orbasone for the past 17 months with very effective pain resolution and increased activity in over two hundred patients.

If you would like an ESWT packet with video just contact our ESWT coordinator and tell her you would like to see Dr. Biehler. He is located in the New York City area. Denise can be reached via e-mail at heelhelp@bee.net

If there is any additonal information I am sure that Dr. Biehler would be very happy to answer any questions you may have.

Re: Totally Confused and frustrated...

Kathy M on 5/31/01 at 22:40 (049528)

I too have all your problems. I have found great relief with night splints. The way I understand why they work is that in the morning when you first step out of bed you reinjure your fascia. The night splints gently stretch the fascia all night. I found out that they might work when I was laying on the couch watching tv -that was about all I could do. I would rest my feet flexed up against the arm of the couch.It was almost pain free. So I tried the night splints. I can now actually get out of bed in the morning and don't have to crawl to the bathroom! Yes my feet still hurt but I can function now.I haven't started working out yet . I am afraid to, but I have started biking. My feet are OK. Next is Power Walking -wish me luck! Good luck to you.

Re: Totally Confused and frustrated...

Burt H. C.Ped on 6/03/01 at 22:39 (049799)

Kathy,
The night splint actually is strectching your calf muscles and to some degree your achilles tendons. The plantar fascia is a tough grisly non-stretching type of ligament that connects to the front of your heel and runs almost the entire length of the bottom of your foot and connects to the first bone of each toe.It is the over-stretching of this tendon that causes it to tear and become inflamed. When the calf and achilles are tight, they pull forcefully back and up on the heel and in turn, put tension on the plantar fascia which is connected to the other side of the heel.
It has been my experience however, that this is a secondary cause of plantar fasciitis, the primary being over-pronation (although direct trauma to the ligament, leg-length discrepancy, and even supination can lead to it, these reasons being in the minority). When you overpronate, your arches fall and your foot basically extends in two opposite directions--your forefoot goes forward and your heel extends backward. The problem here is that you have a non-stretching ligament attached to either end. Since it's not designed to stretch, it tears, thereby resulting in the inflammation and resultant pain. It generally starts at its' weakest point-the attachment to the heel. At this point it can actually tear away from the bone itself. At this site, the body goes through a process called 'ossification' to try to mend it and reattach it.What it actually does is throw bone tissue at the site of the tear. After repetitive damage and subsequent repair, it becomes a bone spur.
It's been my experience that few practitioners address the spur anymore knowing that it is just a by-product of the repair work on the plantar fascia. The pain that results comes from the inflammation caused by the tearing of the plantar fascia ligament itself. Heel spurs seldom, if ever, cause the pain you are feeling. Instead, focus on the dysfunctional bio-mechanics that are causing the tearing of the PF so you can quit damaging the foot so that it can heal. When the inflammation has totally subsided, the pain should disappear. But, it won't go away until you quit damaging the foot completely! Take your oral anti-inflammatories and ice for only 12 to 14 minutes twice daily. Any more than 15 minutes of icing at one time (according to recent studies) has a rebound effect and it becomes the same as using heat, which is not recommended for this condition.
The last factor causing damage to the PF is overdorsiflexion of the toes. Since the pf crosses the balls of your feet and connects to the first bone of each toe it basically works like a pulley system--the more your toes flex back and up, the more tension and damage to the PF. Therefore, any position that causes this (walking uphill, standing on tiptoes,squatting with foot under hip, etc.) should be avoided. A shoe with good rocker sole will help address this factor. Hope this info. is helpful to all--I work with 20 to 25 PF patients a week and get a lot of feedback from them and the drs. that refer to me so we know what works and what doesn't. Sincerely Burt H. C.Ped

Re: Tendon or ligament? to Burt

Julie on 6/04/01 at 02:53 (049817)

Thank you for your very clear and enlightening explanation. It's particularly interesting to me that you regard shortened calf muscles and achilles tendons as a secondary cause of PF and over-pronation as the main one. My own experience certainly bears this out. My podiatrist (and I would guess most others) blame tight calves, which probably explains why they recommend the wall stretches which in the experience of many people here, including mine, irritate both the achilles and the already torn plantar fascia.

But I would be grateful if you would clarify the nature of the plantar fascia. You describe it alternately as a ligament and as a tendon. Which, exactly, is it? Fascia is connective tissue that encapsulates muscles, so the plantar is obviously not simply fascia. Ligaments protect the joints between two or more bones; tendons connect muscles to bones. So it would seem that the plantar fascia's function more closely approximates that of a tendon (but perhaps its composition is more like that of a ligament?) Could you clarify, please?

If it really is a tendon, that would suggest that it is even less elastic than ligamentous tissue, which in turn would suggest that we need to be even more careful with the kind of stretching we do.

Re: To Dr. Z - Re: Totally Confused and frustrated...

Christy D on 6/04/01 at hrmin (049844)

First of all - I think it's wonderful what you do! I am not a baby to pain, as I passed a stone the size of an M&M and went right back to work afterward...I believe in not letting pain rule your life, but this is getting to be a major burden! Yes I am in pain and I did a really stupid thing on Friday, not paying attention to my nightly icing of my heels! I actually BURNED my friggin heels from not watching the time. I look forward every night to relief and now i'm suffering! No ice for a while until the burns heal. Ahhhhhhhhhhhhhhhhhhhhhhh

My question to you is : You think ESWT is the best thing to do? I can no longer live my life with such limitations. Since i've been taking meds and/or my 3rd cortizone shot...my PF pain is not as bad as it was, what's killing me is the constant heel pain. It does not seem to matter whether I'm on my feet or not, they just hurt all the time, but after a short time of being on my feet, the throbbing, burning, sharp pain in my heels is enough to make you crawl out of your skin. Surgery scares me and the 50% better results is very upsetting to me.

What are the downfalls of ESWT? Is it less than surgery? I just want to stress the fact that I can not afford to have my feet worse, I am too young! On a positive note, I am the '10%' because I am not obese, do not have high arch, or flat feet, so I think my recovery chances are better...

What are your thoughts...

Re: To Dr. Z - Re: Totally Confused and frustrated...

Dr. Zuckerman on 6/04/01 at 13:12 (049860)

If the pain is at the insertional point of the plantar fasciitis then ESWT candidate. ESWT is more risk -free then Foot surgery. ESWT does take time to get a reponse. It is very important to rule out such things as stress fracture. Nerve entrapement etc. The down side to ESWT is that it isn't all ove the USA and is very new to this country. The cost for ESWT isn't usually covered by insurance and in fact in 99.9% of the cases no insurance company will cover this whether it is the Ossatron or the orbasone or any ESWT machine. I hope that this is helpful. Please allow me to determine more about your heel spur/plantar fascia by filling out the plantar fascia survey and either faxing it to me at 1-86\56-848-3338 or e-mailing at footcare@home.com

Re: To Dr. Z - Re: Totally Confused and frustrated...

Christy D. on 6/04/01 at hrmin (049895)

Okay Dr. Z..I filled out that survey, I tried to print it and it would not let me! I submitted it, do you see those? I put you wanted to see it in comments area.

Let me know.

Thanks.

Re: To Dr. Z - Re: Totally Confused and frustrated...

Dr Zuckerman on 6/04/01 at 17:00 (049899)

Sorry

You have to print it or e-mail before you submitt. I don't see the results after the submission

Re: Tendon or ligament? To Julie

josh s on 6/04/01 at 18:31 (049906)

Hi There Julie,

An article I read recently by a chiropractor and found here:www.chiroweb.com/archives/17/23/11.html entitled 'The Role of the Plantar Fascia, Gastroc-Soleus Complex and the Windlass Effects of the dynamic foot' has a very interesting first two paragraphs about the achilles tendon/plantar fascia. The author describes it as a continuity, that the calf becomes the achilles tendon becomes the plantar fascia(or aponeurosis sic.), which would make the pf a tendon.

Yesterday I was manually fiddling with my feet and grasped the smaller toes (less the big one) and dorsiflexed them suddenly and harder then I wanted to. I felt a strong stretch where the pf attaches along the length of the phalanges (as shown in the anatomic illustrations on Mike W's FT site). The sensation was sharp with a feeling of sliding tissues.

The physiology of connective tissue is fuzzy to me but aparently there's this gellike 'ground substance' within which the fibrous part is embedded. There's a phenomena I've read of called 'creep' where if a tendon or ligament is subjected to long term excessive stresses or brief very excessive stresses either the 'ground substance' or the fibrous fabric (can't remember which) will 'creep' or attenuate. Traditionally this has been viewed as a permanent form of 'plastic deformation'. Thus when someone overstretches a ligament in some accident they frequently are left with a 'loose joint'. This has been thought to be non-surgically irreversible. There are some (like W.Weintraub in 'Tendon and Ligament Healing') who are challenging this view. W.W. claims that under the proper conditions injured and thus inflamed connective tissue can and does heal with proper length and elasticity.

The same awful thing can happen overstretching I think. I've read in several sources that stretching the plantar fascia is a nono for this reason. People often speak of scar tissue and in general describe it as resulting in a foreshortened or inelastic structure. I would think that in a weightbearing tendon or ligament like all foot tendons and ligaments that an injury would tend to cause a 'crept' or hypermobile area unless properly supported or immobilized. For this reason I've not been personally too keen on stretching the plantar fascia and have considered the supposed shortening that occurs at night as a possible possitive and wise body process. I could be incorrect.

I don't think I seriously crept the pf attachment in my toes yesterday, it feels ok today. But, of possible interest to foot tapers is that I had the foot taped using Scott's favorite method while torqueing on it. I have no idea if there's a connection but the tape does travel the entire length of the plantar fascia except for the bottom of the toes. Could be that the heel to ball of foot tape connection effectively shortened the stretchable distance of the pf from the ball to the toe tip. Just a thought, Scott said he used this method for years so the real problem was me yankin' on it.

Re: Tendon or ligament? to Burt

Burt H. on 6/04/01 at 20:29 (049923)

Julie-
I did not proofread my response and as you can see it was getting fairly late. The plantar fascia is a ligament which inserts in front of the calcaneous (or heel) runs across the bottom of the foot, crosses the metatarsal heads (balls of the foot) and connects to the first phalange of each toe--therefore connecting the heel to the first bone of each toe.
It is a very tough grisly ligament that is not designed to stretch. It was a mis-statement that I said tendon. Sorry for the unintended confusion. Burt H.

Re: Tendon or ligament? To Julie

Burt H. on 6/04/01 at 20:53 (049926)

Josh--The way I understand it, Before Man walked upright (before our heels touched the ground) this complex was one continuous tendon. However, when we started walking upright our calcaneous dropped, the tendon seperated, attaching itself to the back of the calcaneous, therefore connecting the calf muscle to the back of the heel via the achilles tendon.
What was the balance of the tendon, became the plantar fascia connecting the front of the heel to the first bone of each toe, thereby evolving into a ligament. This is my understanding of what the evolution was. Burt H.

Re: Tendon or ligament? To Julie

josh s on 6/05/01 at hrmin (049948)

Burt, All previous descriptions of achilles and pf I've read have agreed with you, this article is the first of this perspective I've seen. As I've never dissected anyone's heel I'll leave it to you experts. Must admit I like the idea of it as a continuum. I have heard before that ultimately all fascia is connected just as in a certain sense muscle becomes tendon becomes periosteum becomes bone,etc.
The way that article was worded, author does seem to think that literally the achilles and the pf are one unit.

Re: Tendon or ligament? to Burt

Julie on 6/05/01 at 02:41 (049953)

Many thanks, Burt. Perhaps some of the misconceptions and bewilderments concerning the plantar 'fascia' and plantar fasciitis could be cleared up if we actually called this bothersome structure a ligament!

On your other post, to Josh: it's clear to me now exactly why some of the gastroc-soleus stretching techniques advised for PF are counterproductive.

Re: To Dr. Z - Re: Totally Confused and frustrated...

Christy D. on 6/05/01 at hrmin (050000)

Okay. I am faxing you the survey with other info.

Thank you again.