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Results of Stretching Study...Questions...Thoughts

Posted by Glenn X on 7/08/01 at hrmin (052489)

I'm new to Heelspurs.com, but after roaming for a week, thought the following might be useful to some.

My PT recently shared a Research Report with me on (calf-muscle) flexibility: 'The Effect of Superficial Heat, Deep Heat, and Active Exercise Warm-up on the Extensibility of the Plantar Flexors.' From the Physical Therapy Journal, June 2001, by researchers at Univ of Texas at El Paso. Thought I'd pass highlights along in case it hasn't been referenced here before.

97 subjects, men and women, average age 27 participated. Five control groups had baseline ankle dorsiflexion measures taken using a universal goniometer. (Fancy protractor?) The four groups of 'stretching subjects' stood 3.5 to 4 feet from wall; performed four 20-second runner's stretches with a 10-second rest between stretches. Did this three times a week, same time of day, for six weeks. Measures taken every two weeks. Stretch instructions were to move into stretch slowly and gently until tightness, not pain was felt. Subjects were observed for consistent conformance to this method. Groups and results (Active / Passive Range of Motion - AROM / PROM) were as follows:

Group one: Control, did no stretching . . . plus 1.11 / 1.39 degrees.
Group two: Stretching only . . . plus 4.10 / 6.11 degrees.
Group three: Stretching after some 40 active heel raises . . . plus 4.16 / 4.21 degrees.
Group four: Stretching after 15 minutes of moist heat to plantar flexor muscles . . . plus 4.38 / 4.90 degrees.
Group five: Stretching after 7 minutes of ultrasound to plantar flexor muscles . . . plus 6.20 / 7.35 degrees.

Seems a credible study; and clearly warming the muscles prior to stretching has value. The article has other good information about this subject, such as references to the recommended stretching protocol.

Being a layman, even after three reads I have questions. How does one consistently use a goniometer for AROM and PROM measurements? And what exactly is AROM versus PROM? (Tensioning with one's own muscles and tensioning via external push?) I assume plantar flexor muscles are everything in the lower leg, but I'm not sure. And has anyone found a good way to measure flexibility at home? In my experience (More than 3 years now, almost 2 on crutches) measuring progress, and even the lack of progress has value. Lastly, what exactly could have been ultrasounded in the study?

One last thought. There seems consensus that heel cord flexibility is important in the treatment of PF. I have seen multiple questions about stretching on this site, and I have seen plenty of good comments about the topic, but as yet, no pure and definitive answer as to best practice. So this study aside, why is there no clearly accepted best protocol for increasing the flexibility of the ankle/calf muscles, particularly for PF subjects? And how might we craft such an instruction?

Re: Results of Stretching Study...Questions...Thoughts

john h on 7/09/01 at 10:01 (052538)

i found the article to be very interesting GlenX. Clearly the stretching increased the ROM of ankle dorsoflexion. I am almost afraid of doing toe raises and have seen repeated warnings against doing them. The burning question is still out there and that is 'what is the pain generator in Plantar Fasciaitis'? There are various theories such as micro tears in the fascia, immune problem, pressing on the baxter nerve,etc. There is no scientific evidence that i have read that could prove anyone of these is or is no the culprit. Depending on what theory you subscribe to there are a zillion remedies such as stretching, not stretching,rest, no rest,jade,heat,cold,massage,shots,surgery,orthotics,night splints, ESWT and on and on. most people will be cured of this problem with just minor adjustment to their daily living while a small percentage will be presented with a life altering chronic disease for which nothing seems to help. I wonder if there has ever been a study of the incidence of PF by country? Is there more or less PF in the far east where people go barefooted and squat a lot? we do these studies for other diseases like heart disease or various types of cancer. It is suggested there are 6,000,000 new cases of PF in the U.S. annually. How many in Japan,Iceland,Australia,etc. This might suggest to us some clues to this disease such as diet,activity,type of footware,etc.

Re: Thank you, Glenn!

Julie on 7/11/01 at 02:54 (052764)

Glenn, thanks for your kind words: I appreciate them.

I'm glad to hear that taping is helping you. That's good, but it's also interesting: I recall one of the doctors commenting some time ago that if tape helps you, you are probably a candidate for custom orthotics. So perhaps you should have another go? Richard, our wonderful resident pedorthist, has given people a lot of information about how to go about it: do a search on his name (Richard CPed).

I have a good set of orthotics now, and wear them all the time outdoors (Birkenstocks indoors), but during the months when I needed tape all the time, I used both (the 'belt and braces' approach - and sometimes an elastic ankle support as well).

Let us know how you get on. And keep posting - you've started a good discussion here, and you have a lot to offer.

Re: Feedback on orthos and docs

Glenn X on 7/11/01 at hrmin (052899)

Carmen: Three stretching regimens seem helpful to me. 1) Typical runner's stretch against an obstruction (for me a step banister). I do my good foot well in, and my not-so-good foot, together WITH my good foot (side-by-side), just leaning in enough to feel tension. Doesn't give me the flexibility of my good leg, but it may be enough, with rest and taping, to minimize aggravation to my fascia. Three reps, 20 seconds each, once daily. I do this stretch after taping, though just added that refinement recently. 2) I've had quite a good stretch lying face-down on a therapy table, having a Physical Therapist push the ball of my foot toward my head. PT leans her leg into my foot, holds my leg, pushes strong, and holds a good minute...three reps. Done right, this gives me my fullest, most aggressive stretch and never seems to aggravate my fascia, but I've been unable to duplicate the technique outside the therapist's office. 3) Just yesterday started doing the toe-flex / ankle-bending / foot-circling stretches recommended by Julie in this thread (searched for Rudy). They have quite a good feel. As for Docs ... I've seen three podiatrists and an orthopaedic surgeon the past three-plus years. None have been able to fully and capably connect with me and my injury. My expectations have consistently exceeded their accomplishments. Part of it's my fault though, and sometime soon I'll post a more detailed thought about this. Re orthotics, Julie (again) refers to Richard Graham, a pedorthist(?), as a good resource for foot supporters. I chased after some of his information here in heelspurs and on his web site and find it helpful. By the way, I'm new to message-boarding. Not sure if this is the best way to answer back to someone, particularly when it's a message thread begun several days ago. So if you would, please respond to this message as part of this thread. If I don't hear from you in a couple of days, I'll post this anew. Thanks for your thoughts.

Re: thanks!

Carmen H on 7/17/01 at 13:36 (053491)

Thanks Glenn! I am getting such good information on this board! I have an appt. with a foot and ankle specialist the 1st of August and I am bringing in a plethra of information. He has no idea what he's in for....ha ha. Just kidding...I will keep it brief. But still....lots to cover.

Re: Results of Stretching Study...Questions...Thoughts

john h on 7/09/01 at 10:01 (052538)

i found the article to be very interesting GlenX. Clearly the stretching increased the ROM of ankle dorsoflexion. I am almost afraid of doing toe raises and have seen repeated warnings against doing them. The burning question is still out there and that is 'what is the pain generator in Plantar Fasciaitis'? There are various theories such as micro tears in the fascia, immune problem, pressing on the baxter nerve,etc. There is no scientific evidence that i have read that could prove anyone of these is or is no the culprit. Depending on what theory you subscribe to there are a zillion remedies such as stretching, not stretching,rest, no rest,jade,heat,cold,massage,shots,surgery,orthotics,night splints, ESWT and on and on. most people will be cured of this problem with just minor adjustment to their daily living while a small percentage will be presented with a life altering chronic disease for which nothing seems to help. I wonder if there has ever been a study of the incidence of PF by country? Is there more or less PF in the far east where people go barefooted and squat a lot? we do these studies for other diseases like heart disease or various types of cancer. It is suggested there are 6,000,000 new cases of PF in the U.S. annually. How many in Japan,Iceland,Australia,etc. This might suggest to us some clues to this disease such as diet,activity,type of footware,etc.

Re: Thank you, Glenn!

Julie on 7/11/01 at 02:54 (052764)

Glenn, thanks for your kind words: I appreciate them.

I'm glad to hear that taping is helping you. That's good, but it's also interesting: I recall one of the doctors commenting some time ago that if tape helps you, you are probably a candidate for custom orthotics. So perhaps you should have another go? Richard, our wonderful resident pedorthist, has given people a lot of information about how to go about it: do a search on his name (Richard CPed).

I have a good set of orthotics now, and wear them all the time outdoors (Birkenstocks indoors), but during the months when I needed tape all the time, I used both (the 'belt and braces' approach - and sometimes an elastic ankle support as well).

Let us know how you get on. And keep posting - you've started a good discussion here, and you have a lot to offer.

Re: Feedback on orthos and docs

Glenn X on 7/11/01 at hrmin (052899)

Carmen: Three stretching regimens seem helpful to me. 1) Typical runner's stretch against an obstruction (for me a step banister). I do my good foot well in, and my not-so-good foot, together WITH my good foot (side-by-side), just leaning in enough to feel tension. Doesn't give me the flexibility of my good leg, but it may be enough, with rest and taping, to minimize aggravation to my fascia. Three reps, 20 seconds each, once daily. I do this stretch after taping, though just added that refinement recently. 2) I've had quite a good stretch lying face-down on a therapy table, having a Physical Therapist push the ball of my foot toward my head. PT leans her leg into my foot, holds my leg, pushes strong, and holds a good minute...three reps. Done right, this gives me my fullest, most aggressive stretch and never seems to aggravate my fascia, but I've been unable to duplicate the technique outside the therapist's office. 3) Just yesterday started doing the toe-flex / ankle-bending / foot-circling stretches recommended by Julie in this thread (searched for Rudy). They have quite a good feel. As for Docs ... I've seen three podiatrists and an orthopaedic surgeon the past three-plus years. None have been able to fully and capably connect with me and my injury. My expectations have consistently exceeded their accomplishments. Part of it's my fault though, and sometime soon I'll post a more detailed thought about this. Re orthotics, Julie (again) refers to Richard Graham, a pedorthist(?), as a good resource for foot supporters. I chased after some of his information here in heelspurs and on his web site and find it helpful. By the way, I'm new to message-boarding. Not sure if this is the best way to answer back to someone, particularly when it's a message thread begun several days ago. So if you would, please respond to this message as part of this thread. If I don't hear from you in a couple of days, I'll post this anew. Thanks for your thoughts.

Re: thanks!

Carmen H on 7/17/01 at 13:36 (053491)

Thanks Glenn! I am getting such good information on this board! I have an appt. with a foot and ankle specialist the 1st of August and I am bringing in a plethra of information. He has no idea what he's in for....ha ha. Just kidding...I will keep it brief. But still....lots to cover.