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recalcitrant plantar fasciitis

Posted by Tracey on 7/20/01 at 21:55 (053866)

What does the word recalcitrant mean? I have read Scott's foot page and I am also wondering if a good percentage of p.f. patients also exhibit tenderness/tightness in the achilles area. Any one? Also, an added note, I am a belly sleeper, there is a significant improvement when I prevent my feet from 'dropping'. This means that I consciously sleep with my feet pointed up(if you can imagine) or wear the large clumsy boot ( a light weight less bulky contraption needs invention) or sleep on the floor with my feet up against the wall to prevent the feet from dropping. Truely amazing results but have to stay with it. Belly sleepers have to pick their poison less sleep or more pain. I have become accustomed to lying on my belly with my toes pointed at the sheets. Taping would probably work. unfortunately it is a tremendous hassle unless someone else tapes them. Tracey

Re: recalcitrant plantar fasciitis

Dr. Marlene Reid on 7/20/01 at hrmin (053872)

Yes, there is a high correlation of PF with tight achilles tendons. Tight achilles can cause other problems as well. It's important to streth=ch the achilles as well as the fascia.

Re: recalcitrant plantar fasciitis

Julie on 7/21/01 at 01:41 (053886)

Tracey, recalcitrant means stubborn, resistant to efforts to change. In the case of PF, resistant to treatment.

I like your suggestions for sleeping!

Re: recalcitrant plantar fasciitis

Dr. David S. Wander on 7/21/01 at 19:18 (053934)

Stretching the Achilles is extremely important in the treatment of plantar fasciitis. Many studies have shown the distal fibers (the ones at the insertion into the heel) actually blend with, or communicate with the fibers of the plantar fascia. Therefore, if one is tight, the other is tight. The physical properties of the actual plantar fascia, does not really allow the actual plantar fascia to be stretched. Therefore, the Achilles tendon must be stretched. I have also found it very useful for my patients to also stretch the hamstrings, to allow the entire limb to be more limber/flexible to decrease discomfort.

Re: recalcitrant plantar fasciitis

Julie on 7/22/01 at 02:54 (053950)

Dr Wander, tendons, as I understand it, don't stretch beyond their optimum length, so when we talk about stretching the Achilles, aren't we talking about restoring a tendon whose fibres have shortened to that optimum length?

What concerns me is the danger for someone with an injured plantar fascia (who may not understand that tendons don't stretch as muscles do but who are anxious to improve) of overdoing exercise that targets the Achilles, and over-stretching it.

I would be grateful for your comments on this.

Re: recalcitrant plantar fasciitis

Dr. David S. Wander on 7/22/01 at 09:24 (053960)

Julie, you make a very good point. A tendon is the tissue that actually attaches the muscle to the bone, and tendon is relatively avascular (minimal blood supply). Since it is actually an extension or continuation of the muscle, you are not only restoring the length of the tendon but you are stretching muscle fibers at the same time. Stretching also 'loosens' other soft tissue components and allows for increased flexibility. Patients often aggravate or re-injure an area such as the plantar fascia by over-stretching or stetching improperly. Stretching should be performed when the muscle is 'warm'. Hopping out of bed in the morning and immediately stretching is not recommended. If you participate in an exercise program, it is advised to stretch after walking for a distance or even following the exercise to prevent injury. Additionally, stretching should be performed without bouncing, (ballistic stretching) to decrease the chance of injury. Patients often over do it, in attempt to get a quick fix to the problem. Stretching is one of the most effective treatments for plantar fasciitis, but is also one of the slowest to show results, since stretching has to be done over a prolonged time and must be done consistently and religiously.

Re: Stretching the Achilles

Julie on 7/23/01 at 01:18 (053994)

Thank you for these comments, Dr. Wander. I agree with what you say about stretching. Taking it a little further, these are the things that concern me (the following comments are prompted partly by your remark that patients often over-do it) :

When we stretch to relieve/heal PF, we're working to lengthen the calf muscles: the gastrocnemius, and the soleus which runs into the Achilles Tendon. If all those tissues are in fact tight, and if that tightness is the cause of the PF, careful stretching to restore them to normal length should be effective - as you say, consistently over a period of time. (The question remains: what kind of stretching?)

But suppose they are not tight, and suppose the PF originates from some other cause. Then, when the person stretches, the (normal length) muscles will lengthen further, as muscle tissue can and does, and there will be an adverse pull on the (normal length and now un-stretchable) Achilles, which may irritate or even rupture it, and cause knock-on trouble further down the line in the plantar fascia.

There is little danger of this happening in non weight-bearing exercise. The danger arises when an exercise is being carried out with the help of the body's weight. This is especially true when the exercise is done incorrectly, and it is easy for people unused to stretching, who haven't received thorough instructions and who aren't monitored, to exercise incorrectly.

I was advised to do the wall stretches by my podiatrist. I am an experienced 'stretcher' and I did them correctly. They hurt, while I was doing them and afterwards, and I stopped doing them. My calf muscles aren't tight, and my podiatrist agreed that I should stop the stretches. 'When the calves are tight' he said, 'the wall stretches can help. When they aren't tight, the stretches can do more harm than good.' I think that is true. Furthermore, over the past year my 'education' here through reading the experience of many people who have hurt themselves doing these stretches - and the diabolical hanging-off-the-stair exercise - has led me to believe that they can do more harm than good in the majority of cases.

Even if this weren't true, it seems to me ill-advised to prescrribe the same exercises to almost everyone who has PF. This is my other concern. It's a good principle of exercise teaching that exercise should, as far as possible, be tailored to the individual - or at least that individual variations such as age, body structure and life style should be taken into account.

Young, fit, athletic people who are accustomed to exercise and know how to exercise correctly are - I believe - still in danger of worsening their PF if they 'go at it' too enthusiastically in the attempt to get rid of the PF quickly. Older patients, who may not have exercised for years, or who may have little body awareness and are given the same exercises, are even more at risk.

Of course podiatrists aren't exercise teachers and have neither the capacity nor the expertise to spend the kind of time with each patient that good exercise instruction and monitoring need, and it's not realistic to expect them to. That's another good reason not to prescribe weight-bearing stretches that can, and in many cases do, cause further problems.

Re: describe the non weight bearing achilles/calf stretches please

Tracey on 7/23/01 at 09:07 (054009)

If tight muscles are part of the problem, what are some good solid non weight bearing exercises to stretch the calf/achilles area?

Re: Stretching the Achilles

Dr. David S. Wander on 7/23/01 at 13:36 (054034)

Julie, once again you make some excellent points. Although over-stretching can certainly cause harm, it is very rare for a patient to actually cause a tendon rupture by stretching, unless there was a pre-existing injury to the tendon. Although stretching a tendon/muscle that is already at it's 'normal' length may not be necessary, it will rarely do harm to be as limber as possible. Naturally, if the cause of the heel pain is secondary to a stress fracture, arthritic condition, Reiter's syndrome, etc., stretching may cause increased symptoms. One of my favorite stretches was recommended to me by the physical therapist I refer to. The patient sits on a chair with the leg fully extended, and places a long towel around the bottom of the foot. The towel is then gently pulled up with the hands to dorsiflex the foot/ankle to tolerance. The KEY to this stretch is to also 'fire' the muscles in the anterior (front) of the leg/ankle as you are pulling the towel up. This allows the muscles that oppose the gastroc-soleus complex/Achilles to strengthen and allows for additional stretching of the posterior muscles. This may sound confusing, so if it is, write back and I'll attempt to explain it better.

Re: Stretching - Dr Wander and Tracey

Julie on 7/24/01 at 01:51 (054084)

Of course I agree that it's essential to stretch, and it's equally important to maintain strength so that our resting muscles don't atrophy. The question is: what is the best (i.e. the safest as well as the most effective) way to exercise when one has an injury? The stretch you describe is a good one. It's the weight-bearing stretches, and especially the ones I mentioned, that worry me. As I said in a long post a week or so ago, the wall stretches are perfectly good stretches for healthy tissue. When we're dealing with injured, weakened tissue, they can do more damage, and I believe that they can so do in most cases if PF, not just in the ones with secondary causes.

Tracey, do a search under 'Rudy', to whom I posted a description of some foot and ankle exercises a couple of weeks ago. The stretch Dr Wander describes should be a useful one for you too - just don't pull too hard. The important thing is always to be aware of the messages your body gives you, and respect them. Pain is a message to stop doing whatever is causing the pain. So whatever exercise you do, do it with awareness.

Re: recalcitrant plantar fasciitis

Dr. Marlene Reid on 7/20/01 at hrmin (053872)

Yes, there is a high correlation of PF with tight achilles tendons. Tight achilles can cause other problems as well. It's important to streth=ch the achilles as well as the fascia.

Re: recalcitrant plantar fasciitis

Julie on 7/21/01 at 01:41 (053886)

Tracey, recalcitrant means stubborn, resistant to efforts to change. In the case of PF, resistant to treatment.

I like your suggestions for sleeping!

Re: recalcitrant plantar fasciitis

Dr. David S. Wander on 7/21/01 at 19:18 (053934)

Stretching the Achilles is extremely important in the treatment of plantar fasciitis. Many studies have shown the distal fibers (the ones at the insertion into the heel) actually blend with, or communicate with the fibers of the plantar fascia. Therefore, if one is tight, the other is tight. The physical properties of the actual plantar fascia, does not really allow the actual plantar fascia to be stretched. Therefore, the Achilles tendon must be stretched. I have also found it very useful for my patients to also stretch the hamstrings, to allow the entire limb to be more limber/flexible to decrease discomfort.

Re: recalcitrant plantar fasciitis

Julie on 7/22/01 at 02:54 (053950)

Dr Wander, tendons, as I understand it, don't stretch beyond their optimum length, so when we talk about stretching the Achilles, aren't we talking about restoring a tendon whose fibres have shortened to that optimum length?

What concerns me is the danger for someone with an injured plantar fascia (who may not understand that tendons don't stretch as muscles do but who are anxious to improve) of overdoing exercise that targets the Achilles, and over-stretching it.

I would be grateful for your comments on this.

Re: recalcitrant plantar fasciitis

Dr. David S. Wander on 7/22/01 at 09:24 (053960)

Julie, you make a very good point. A tendon is the tissue that actually attaches the muscle to the bone, and tendon is relatively avascular (minimal blood supply). Since it is actually an extension or continuation of the muscle, you are not only restoring the length of the tendon but you are stretching muscle fibers at the same time. Stretching also 'loosens' other soft tissue components and allows for increased flexibility. Patients often aggravate or re-injure an area such as the plantar fascia by over-stretching or stetching improperly. Stretching should be performed when the muscle is 'warm'. Hopping out of bed in the morning and immediately stretching is not recommended. If you participate in an exercise program, it is advised to stretch after walking for a distance or even following the exercise to prevent injury. Additionally, stretching should be performed without bouncing, (ballistic stretching) to decrease the chance of injury. Patients often over do it, in attempt to get a quick fix to the problem. Stretching is one of the most effective treatments for plantar fasciitis, but is also one of the slowest to show results, since stretching has to be done over a prolonged time and must be done consistently and religiously.

Re: Stretching the Achilles

Julie on 7/23/01 at 01:18 (053994)

Thank you for these comments, Dr. Wander. I agree with what you say about stretching. Taking it a little further, these are the things that concern me (the following comments are prompted partly by your remark that patients often over-do it) :

When we stretch to relieve/heal PF, we're working to lengthen the calf muscles: the gastrocnemius, and the soleus which runs into the Achilles Tendon. If all those tissues are in fact tight, and if that tightness is the cause of the PF, careful stretching to restore them to normal length should be effective - as you say, consistently over a period of time. (The question remains: what kind of stretching?)

But suppose they are not tight, and suppose the PF originates from some other cause. Then, when the person stretches, the (normal length) muscles will lengthen further, as muscle tissue can and does, and there will be an adverse pull on the (normal length and now un-stretchable) Achilles, which may irritate or even rupture it, and cause knock-on trouble further down the line in the plantar fascia.

There is little danger of this happening in non weight-bearing exercise. The danger arises when an exercise is being carried out with the help of the body's weight. This is especially true when the exercise is done incorrectly, and it is easy for people unused to stretching, who haven't received thorough instructions and who aren't monitored, to exercise incorrectly.

I was advised to do the wall stretches by my podiatrist. I am an experienced 'stretcher' and I did them correctly. They hurt, while I was doing them and afterwards, and I stopped doing them. My calf muscles aren't tight, and my podiatrist agreed that I should stop the stretches. 'When the calves are tight' he said, 'the wall stretches can help. When they aren't tight, the stretches can do more harm than good.' I think that is true. Furthermore, over the past year my 'education' here through reading the experience of many people who have hurt themselves doing these stretches - and the diabolical hanging-off-the-stair exercise - has led me to believe that they can do more harm than good in the majority of cases.

Even if this weren't true, it seems to me ill-advised to prescrribe the same exercises to almost everyone who has PF. This is my other concern. It's a good principle of exercise teaching that exercise should, as far as possible, be tailored to the individual - or at least that individual variations such as age, body structure and life style should be taken into account.

Young, fit, athletic people who are accustomed to exercise and know how to exercise correctly are - I believe - still in danger of worsening their PF if they 'go at it' too enthusiastically in the attempt to get rid of the PF quickly. Older patients, who may not have exercised for years, or who may have little body awareness and are given the same exercises, are even more at risk.

Of course podiatrists aren't exercise teachers and have neither the capacity nor the expertise to spend the kind of time with each patient that good exercise instruction and monitoring need, and it's not realistic to expect them to. That's another good reason not to prescribe weight-bearing stretches that can, and in many cases do, cause further problems.

Re: describe the non weight bearing achilles/calf stretches please

Tracey on 7/23/01 at 09:07 (054009)

If tight muscles are part of the problem, what are some good solid non weight bearing exercises to stretch the calf/achilles area?

Re: Stretching the Achilles

Dr. David S. Wander on 7/23/01 at 13:36 (054034)

Julie, once again you make some excellent points. Although over-stretching can certainly cause harm, it is very rare for a patient to actually cause a tendon rupture by stretching, unless there was a pre-existing injury to the tendon. Although stretching a tendon/muscle that is already at it's 'normal' length may not be necessary, it will rarely do harm to be as limber as possible. Naturally, if the cause of the heel pain is secondary to a stress fracture, arthritic condition, Reiter's syndrome, etc., stretching may cause increased symptoms. One of my favorite stretches was recommended to me by the physical therapist I refer to. The patient sits on a chair with the leg fully extended, and places a long towel around the bottom of the foot. The towel is then gently pulled up with the hands to dorsiflex the foot/ankle to tolerance. The KEY to this stretch is to also 'fire' the muscles in the anterior (front) of the leg/ankle as you are pulling the towel up. This allows the muscles that oppose the gastroc-soleus complex/Achilles to strengthen and allows for additional stretching of the posterior muscles. This may sound confusing, so if it is, write back and I'll attempt to explain it better.

Re: Stretching - Dr Wander and Tracey

Julie on 7/24/01 at 01:51 (054084)

Of course I agree that it's essential to stretch, and it's equally important to maintain strength so that our resting muscles don't atrophy. The question is: what is the best (i.e. the safest as well as the most effective) way to exercise when one has an injury? The stretch you describe is a good one. It's the weight-bearing stretches, and especially the ones I mentioned, that worry me. As I said in a long post a week or so ago, the wall stretches are perfectly good stretches for healthy tissue. When we're dealing with injured, weakened tissue, they can do more damage, and I believe that they can so do in most cases if PF, not just in the ones with secondary causes.

Tracey, do a search under 'Rudy', to whom I posted a description of some foot and ankle exercises a couple of weeks ago. The stretch Dr Wander describes should be a useful one for you too - just don't pull too hard. The important thing is always to be aware of the messages your body gives you, and respect them. Pain is a message to stop doing whatever is causing the pain. So whatever exercise you do, do it with awareness.