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New EWST ( Ossatron ) article in Podiatry Today Magazine

Posted by Donna SL on 8/09/01 at 00:27 (055994)

I don't know if anyone posted this yet, but in case not there is a very interesting article on EWST in this months Podiatry Today magazine.

I'm curious if any of the doctors on the board have used ESWT for Calcaneal Stress Syndrome that Dr. Smith talks about in the article.
Does a very positive (hot) bone scan in the calcaneal area mean this syndrome exist?

It seems to me he's treating more than pain at the insertional point.
Also, he talks about care after the treatment. Has anyone done this?

http://www.podiatrytoday.com/archive/pod_200108/pod_200108f2.html

Donna

Re: New EWST ( Ossatron ) article in Podiatry Today Magazine

Ed Davis, DPM on 8/11/01 at hrmin (056272)

I have been listening to Dr. Smith for years. His longstanding hypothesis is that a lot of the tough cases of heel pain we see are actually calcaneal stress fractures. I have always wished that he was correct because this would give us easier ways of treating more tough heel pain cases. Nevertheless, I have not been able to verify or corroborate his ideas based on my clinical experience.

The article suggests that he has somewhat modified his theory. The calcaneal stress syndrome that he refers to appears to be a hybrid of plantar fasciitis and the calcaneal stress fracture, as he seems to describe a continuum of pathology-- a continuum blending elements of a fracture and microtears in the fascia. We need to categorize and label things with specific diagnoses--it makes doctors and patients feel better and allows insurance companies to pay the bills. Nevertheless, the reality of things often lies in a grey zone in which diagnoses can overlap and meld.

Interestingly, this particular grey zone may be the 'sweet spot' for ESWT.
Ed

Re: for Dr Davis/ Dr. Smith Theory

john h on 8/11/01 at 16:57 (056351)

Dr Smith's theory would seem to vanish in the many cases of bi-laterial PF. It would not seem statistically probable to me that you woud have so many bi-lateral stresss fractures.

Re: for Dr Davis/ Dr. Smith Theory

Donna SL on 8/11/01 at 18:25 (056357)

I think micro bilateral stress fractures could be possible in a runner for example, or someone who has excess stress on their heels like a person with a high arches. Both feet are receiving equal stress. I know with my cavus feet most of my body weight goes to my heels and forefoot, because of the unequal weight distributution. I had a very hot bone scan in the calcaneal area, and areas of the forefoot last year bilaterally, and it's probably a result of many tiny fractures aquired over the years. I think not wearing the proper orthotic to redistribute the weight evenly, and provide adequate padding in the heel area may have also contributed to this.

Donna

Re: Bilateral PF

Glenn X on 8/11/01 at hrmin (056361)

John: Not sure how your bilateral started, but for me I began by straining both feet squatting too much weight. Aggravated it a few days later dancing. Left was better 8 months later. Right lingered longer, then got re-injured. Left remained OK as I nursed right, but gradually left became sore. Right is still the worst, left is where it was at it's worst.

I think the reason my left succumbed is because I was not exercising it sufficiently and naturally enough while nursing my right. Got inflexible and muscles weakened from misuse. For a long time too I wore harsh orthotics on both feet, trying to mend the right, and these aggravated my left as well.

I believe the more 'normally' we can increasingly use both feet, the better, for our feet and for ourselves.

All that said. Since I've been using night splints on both feet, my wrists are all of a sudden sore. The soreness has me wondering if the body mechanisms marshalled to continually repair my nightly 'strained' achilles and fascia don't also have an affect on other similar tissues.

Re: for Dr Davis/ Dr. Smith Theory

Ed Davis, DPM on 8/12/01 at hrmin (056452)

I agree.
Ed

Re: Bilateral PF

Ed Davis, DPM on 8/12/01 at hrmin (056453)

There was a good post about 3 weeks ago concerning 'fasciosis' vs. fasciitis. Getting a bit theoretical but fasciosis implies that the problem or at least some of it is due to intrinsic 'disease' of the tissue itself. That is, there is a loss of normal elasticity in the tissue, excess fibrosis (scar tissue) and possibly the improper remodeling or regeneration of tissue in the area by the body.

My gut feeling is that this area is going to be looked at more closely in the future and may have more relevance than we now think. ESWT, by 'traumatizing' the fascia probably results in increased remodeling or tissue turnover time by the body, that is, induce the body to replace 'diseased' tissue with healthier tissue at a faster rate.

We often see patients who have all the right set of conditions, biomechanical and occupational, to develop plantar fasciitis. Will they develop it? When? The answer may lie in how the tissue responds to the abnormal forces.
Ed

Re: Bilateral PF

john h on 8/12/01 at 14:40 (056472)

glenn: it has been so long since my pf started i cannot remember how soon my second foot developed the condition. i think it was probably some months which sort of goes with my thinking that PF in one foot will alter your gait and create all sorts of new problems in either foot. i was running at the time which is sort of double trouble and continued until the pain stopped me. i also have hallux limitus which i and some of the doctors agree probably have a connection with my PF in that the great toe is limited in its dorsiflexion and causes pain. this of course will influence you both conciously and sub-conciously when you run to strike the ground in the least painful position. i am still into about a 10 day period of only a pain level 1. i am keeping up the jade,cherry extract and it of course has been about 8 weeks since i had dr z perform my 3rd ESWT treatment. any or all of these things could be at work here or tomorrow i could have increased pain. if i can go about 90 days at this pain level then i will have to think that some of these treatments are working. at any rate i am a very long time suffering PF guy who is better today than i was last year or the year before. i will thow something else out there that some may scoff at but just talking to you people might just have something to do with my improvement.

Re: Full curing

Glenn X on 8/12/01 at hrmin (056479)

John: I understand as the years pile on that we heal slower, but eventually we (can) heal.

About eight years ago I got tennis elbow whacking the ball with too aggressive a forehand too many times. Didn't stop right away and eventually got it real bad. Couldn't even shake someone's hand without it hurting. Pain continued for at least a couple of years with frequent aggravation of the injury (but not by playing tennis).

I eventually got serious about fixing things and obsessive about caring for my injury. Rested it as much as I could. Shook hands with my left. Gradually as the pain subsided, maybe after 2 or 3 months, I began light exercising; flexing, rotating, massaging . . . very easy stuff. I continued to add rigor (slowly) and continued to improve.

Today I have zero symptoms and consider myself completely healed.

I believe we can anticipate the same recovery with PF. But being in such a high-use part of the body, it's going to take more diligence and micro management.

Preliminarily I think it's a matter of three factors:
Rest and healing
Flexibility and prevention
Exercise and strengthening

I'm understanding the rest thing pretty good. But I have much more I need to learn about flexibility and about strengthening all the muscles and other bones and tissues that make the foot work.

I have much more to learn about what I haven't mentioned too. I'd mention it if I knew what it was.

Re: Full curing for glenn

john h on 8/22/01 at 17:31 (057599)

your comments are well received. stretching has to be an important factor in health of any sort. i keep putting off Yoga but it is on my list of things to begin not just for PF but for general good physical health but good mental health. the hardest thing to do in any project is to begin it.

Re: Full curing for glenn

Julie on 8/23/01 at 01:40 (057652)

John, your final sentence - the hardest thing to do in any project is to begin it - inspires me to post this poem. It's by Goethe.
I hope it inspires you to find your yoga teacher.

Until there is commitment
There is hesitancy.
The chance to draw back
And ineffectiveness

In all acts of initiative or creation
Ignorance of one elementary truth
Kills countless splendid plans

The moment one commits oneself
Providence moves too
All sorts of things occur to help
That would never otherwise have occurred

A stream of events issues forth
From the decision: incidents, meetings
And material assistance not foreseen

Whatever you can do, or dream you can do,
Begin it
Boldness has genius, power and magic
Begin it now.

Re: Full curing for glenn

john h for julie on 8/23/01 at 11:35 (057676)

julie: that is a wonderful poem and i have read it. it probably was in the back of my mind when i made the comment

Re: Full curing for glenn

nancy s. on 8/23/01 at 11:39 (057677)

i agree, john -- that IS a wonderful poem, one that i've read in the past and then lost. it has several beautiful and true messages. thanks, julie. julie, i think our bookshelves must look a lot alike.
nancy

Re: Great images ... Thanks Julie

Glenn X on 8/23/01 at 15:54 (057702)

Poetry makes the body lighter on the feet.

I am making solid headway these days . . . but only because after three some years I finally got serious about learning and managing and partnering for my recovery.

Goethe got it right. I got committed, and things started happening, sometimes by my initiative, sometimes seemingly of their own accord.

Re: "Stretching" vs "Increasing the Angle of Dorsiflexion"

Glenn X on 8/23/01 at 16:37 (057711)

John: I've been thinking about this stretching stuff for awhile and decided to jump on your message as a place to float a thought ... one of those subtleties that perhaps can help others. I know it has helped me.

Many people on heelspurs describe 'stretching' as a regimen they practice regularly to try and heal their PF. I used to do the same.

Now, however, I am working at 'increasing my angle of ankle dorsiflexion' (the angle formed by my foot and lower leg when my foot and toes are bending toward my face). I've mentioned before that in February that angle on me was 105 degrees. (Ankle was very inflexible). Three weeks ago it was 90 degrees, still not enough. Today it might be 85 degrees (I'm getting measured tomorrow). My goal is 70 to 75 degrees, which may take another month or two or three, but which will have my foot well bent towards my face.

As my podiatrist (Ed Davis) explained to me (and as Scott describes in his book) INCREASING ankle dorsiflexion by DECREASING the angle of our foot to leg takes enormous tension off the plantar fascia, which is probably the chief benefit and reason for stretching, and perhaps one of the more certain paths to healing.

But I think it imperative that we stretch with this angle in mind -- and in view. That we start with a baseline angle measurement, establish a target angle to aim for, and then take regular measurements (perhaps every two weeks or so) to ascertain progress.

What gets measured gets done. And while eye-ballng advises, hard numbers define.

It's important that the same person take the measures, as this doesn't seem to be an exact science. I've got a wordworking protractor I use at home to give me some in-between times feedback, but rely on the doc (or PT)for the official number.

In fact, I think a great product for the heelspurs community would be an 'Ankle Angle Guage,' a simple tool for people to consistently and reliably measure their ankle angle. Protractor, t-square, bolt, and a wing-nut ought to do it.

Re: Full curing for glenn

julie and nancie on 8/23/01 at 19:06 (057739)

here in arkansas we are not very poetic but a couple of inspirational thoughts come to mind concering people who just walk down the middle of life's roadway: 'when you walk down the middle of the road you can get hit by traffic going both ways' margaret thatcher.
'when you walkdown the middle of the road all you can see is a painted yellow line and dead armadillos' author unknown. Not very Goethe like but some truths in them. nancy, i would guess poetry above is not on your bookshelf or julies.

Re: "Stretching" vs "Increasing the Angle of Dorsiflexion"

Julie on 8/24/01 at 03:46 (057772)

Glenn, this is absolutely right. 'Stretching' covers a multitude of sins as well as aims and goals, but with PF what we should be doing is specifically targetting the angle of dorsiflexion, increasing it to take the strain off the fascia. Focussing the mind as well as the body on the goal is helpful - to say the least. The question then arises - 'how' to do it? There are many ways of working towards that increase, some safe and effective, some not-so-safe. Would you like to describe the work you are doing that has been so effective in increasing your angle?

Scott used to have a test for calculating one's angle of dorsiflexion somewhere on the site. I don't know if it's still there. If it is, perhaps Scott, or someone who has used it recently, can point us towards it.

Re: Full curing for glenn

nancy s. on 8/24/01 at 04:46 (057773)

well oh my, then by all means you have a good time walking down the middle of the road! farewell!

Re: "Stretching" vs "Increasing the Angle of Dorsiflexion"

john h on 8/24/01 at 13:45 (057837)

dr z reminded me the other day to do some runners stretches lightly which in effect is increasing the angle of dorsiflexion. i am no stretching guru but this makes complete sense to me. you have to lengthen the muscles in your calves and hamstrings and right up to your lower back as well as put some tension on the achilles to allow that foot to get good dorsiflexion and take some tension off the fascia. one of the experts may shoot me down on this but if you watch all the profession sports team they spend a lot of formal time before a game stretching. julie has sort of stayed on my case about yoga which may be the ultimate stretching program and i have got as far as getting the class times. now as john h and Goethe have said i must begin.

Re: Full curing for glenn

Julie on 8/24/01 at 15:41 (057851)

You won't find any book, treatise, or saying by Lady Thatcher anywhere near any bookcase of mine, John dear!

Re: Now Julie

john h on 8/24/01 at 19:26 (057870)

i am not current with British politics but i think you are telling me you are no fan of Lady Thatcher! I alway admired the way she handled the Faulkland situation but never had the British take on what the people thought. I think i could very well picture your library lady julie. I have visited the Prado and Louve and stood atop the Acropolis viewing the past. I suspect this is you library.

Re: Dear John

Julie on 8/25/01 at 02:26 (057895)

That's right, John. I am no fan of Lady Thatcher, who did her utmost to systematically destroy the fabric of British society, and more or less succeeded. During her reign all our social services suffered greatly, the gap between rich and poor widened, and people generally began to believe her dictum 'there is no such thing as society'. And that divisive legacy remains: society has never recovered. The''Falklands' War was an out-and-out political ploy, fabricated to boost her popularity at a low point by playing on and harnessing the nation's inherent jingoism by 'defending' one of the last remaining dregs of the British Empire; it worked, she was re-elected, and continued her mission of destruction.

Living in Britain under her premiership was soul-destroying, and I detested her, as did all left-of-centre people of humanitarian, liberal views. One of the cheeriest days of my life, politics-wise, was the day Geoffrey Howe stood up in the commons to give his resignation speech, and denounced her. Her fall followed. Since leaving office she has gone pretty mad, but has continued to have a poisonous influence on political life, snarling her views from her front door on every important occasion. She is currently doing her best to influence the Tory leadership election by publicly supporting the right-wing, anti-Europe Iain Duncan Smith, the vice-chairman of whose campaign has just been exposed as having British National Party (i.e. fascist) connections.

Enough. I am no fan of Lady Thatcher.

My library now - that's another story. For another time. Watch this space.

Re: Dear John

john h on 8/25/01 at 10:34 (057913)

julie you clearly defined your views on Lady Thatcher for me sparring nothing! Most American only hear of the scandals in your tabloids. We, for the most part do not have an inkling how your government works and what the people think. We learned more about Princes Di than we have about the British government in the last 100 years. My closest experience with Britian is that i was trained by two RAF pilots. If you will look at my picture on the board closely you wll note i have a British regimental tie on. I would not be supprised if your hubby knew what regiment. Bet you cannot figure that one out Julie?

Re: Dear John

Julie on 8/25/01 at 11:56 (057921)

Well, John, Klaus spent four and a half years in the Australian army during and after WW2, so he might - just - recognize an Australian regimental tie. But a British one? I doubt it very much. So please tell! Which regiment?

Your training with RAF pilots was surely the very best!

I guess the British papers, at any rate the broadsheets, are probably better at reporting American politics than vice versa.

Re: "Stretching" vs "Increasing the Angle of Dorsiflexion"

Glenn X on 8/25/01 at 13:29 (057932)

Julie: Thanks for catching the thread. Everyone's at a different time and place with foot stuff, but right now what's steadily decreasing my ankle angle is . . .

30% Active Stretching. I do the classic 'runner's stretch' five times a day. But I do it leaning forward, stretching BOTH legs and feet simultaneously. This gives me a nice therapeutic stretch without placing undue pressure on any one foot. I lean in to tension, no pain, for two reps - 30 seconds, each time. (No bent knees at this point). I circle my toes beforehand to loosen things a bit. About every other set, while tensioning the backs of my legs, I'll actively pull the top of my foot toward my face using the muscles on the front of my leg, about 10 reps. (See thought on compression below).

20% Active dorsiflexion of my ankle when sitting during the day and evening. Perhaps fifty percent of the time, my feet are either under my chair, resting on the ball of my foot, heels off the floor, or my feet are forward but the ball of my foot is resting on something that puts MILD tension on my achilles, and miniscule tension on my fascia. My favorite foot rest is a 15' 4x4. I can easily roll it toward or away from me depending on the tension I want, or roll it out of the way when I get up . . . and it matches my coffee table.

15% Fascia massage. I have my fascia ultrasounded and massaged three times a week. Two different PTs do this. One is Eddie Brewer who works with Dr. Ed Davis in Puyallup, WA. The other is Malia McDevitt, a local therapist. Brewer is particularly artful at massaging and lengthening the fascia. He seems to know and go the limit. Malia too has a skilled touch. She also massages my calves and achilles, and actively stretches me lying face down on the table. (The overall therapeutic value of this particular regimen may be well above 15 percent, but since I'm talking here about what strategies seem to decrease my ankle angle, 15 seems right).

15% night splint. I may be mistaken, but I don't believe the splints ADD to my range of motion. However, they are essential for maintaining any gains I've made through the day with other exercising. Without the splints it would be three steps forward and two back, every day and night. With them, it's three forward, hold, three forward, and so forth.

10% Rubber tubing stretches. Five or more times a day I loop rubber tubing around my foot and plantar flex (point) my foot forty to eighty times under tension. I let my foot return to a dorsiflexed position each rep with tension on the tubing, occasionally letting my foot 'snap' back. This exercises my calf muscles (sorely needed since I am not active) and also has the effect of adding a little stretch to my achilles.

Perhaps more importantly, the snap-move compresses the front of my ankle and, I believe, loosens cartilage there and elsewhere --- and it 'shortens' (or allows front-foot muscles to shorten more). Increasing flexibility seems a combination of lengthening the 'outside' of my leg-foot dynamic (fascia, calf muscles, and achilles tendon (a tad)) -- and also compressing or somehow lessening resistance in the inside tissues in the front of my foot and leg. i.e., when I dorsiflex my ankle now, I seem to encounter resistance in the front of my ankle prohibiting any more pull, before I reach the lengthening limits of my fascia or calves.

5% Yoga ankle flexes. You taught me these. I do them three times a day, first thing in the morning, mid-day, and when I go to bed. They're great tissue-loosening exercises, good for prepping the foot for more rigorous movements. Since they're accomplished by my own pulling capabilities, they're perhaps too passive to actually increase ROM. But seem important to maintenance.

5% Ankle wobble. This one's a bit off beat, but I think effective. Malia does it and taught it to me. Laying face down on the table, I raise my lower leg perpendicular to the table. She grasps my leg just above the ankle and jerks my leg side to side 8 or 10 times, and then front to back a similar number of reps, 'snapping my ankle.' Repeats 2 or 3 times. Sort of an inverted, non-weight-bearing wobble board. It helps overall ankle flexibility, perhaps by loosening cartilage and other tissues as described above.

My feet (not my fascia) are a little sore doing this regimen. Not painful, but sore. Kinda like how muscles get when fatigued, only edgier. I don't take any pain meds. Helps me listen to my feet better and not overdo anything.

I don't suggest these for everybody. They work for me now. I was measured at 85 degrees (both feet) yesterday. Improved 5 degrees in 3 weeks.

This is a work in progress. A month hence what I've described above will almost certainly be modified some. When I get to 75 degrees, I'll shift to a maintenance routine, yet to be figured out.

Way open to input!

Re: "Stretching" vs "Increasing the Angle of Dorsiflexion"

Glenn X on 8/27/01 at 16:37 (058131)

Some add ons: On second thought, the night splints may in fact be adding to flexibility instead of simply maintaining other efforts. I say this recalling a post by Dr, Davis where he wrote about gently tensioning the achilles tendon, allowing fibers to gradually lay down in parallel to accomodate the 'longer' demands put on it. A slow, VERY SLOW, stretching (or increase in flexibility) of the achilles tendon ensues. Probably takes weeks, but it takes place.

Active stretching, active dorsiflexion (when seated), and the rubber tubing stuff, are done with shoes and orthotics on.

Since lengthening takes considerable time, it is SO tempting to overdue all of this. I have to rigidly discipline myself to NOT overdue. I'd be quite happy with 1 degree a week . . . and would settle for a half.

Re: "Stretching" vs "Increasing the Angle of Dorsiflexion"

john h on 8/27/01 at 17:11 (058137)

glen: if there is one guy i am confident that can do 1 degree a week in dorsiflexion it is you mr. daytimer himself. i really like the nightsplint and have stuck with it because it just plain makes sense.

Re: "Stretching" vs "Increasing the Angle of Dorsiflexion"

Julie on 8/28/01 at 01:56 (058196)

Hi Glenn

Thanks for your description. I greatly admire the thorough, organized, business-like way you're going about this. All the exercises you're using make sense to me, and they are clearly working for you. One degree, or even half a degree, would be 15-30 degrees in a month.Not slow!

I agree that you need to be careful not to overdo it, and also with your add-on about the night splint.

The ankle flexion/extension and rotation (are you doing the rotations?) exercises will contribute to increased range of movement, as long as you do them slowly, with the intention of moving the joints through their full range (not just twiddling and twirling) so I hope you'll continue to include them in your programme.

The only other comment I'd want to make is that strengthening is as important as stretching the gastro-soleus-achilles complex, particularly when one has been seriously resting, as I know you have. The toe curling and stretching exercise is useful here. Do you have Birkenstocks? Using your toes to grip while walking in them is terrific strengthening exercise.

And I have a feeling you would get on nicely with the Personal Foot Trainer, which provides resistance in a group of mainly isometric strengthening exercises. You might want to investigate it. If you decide to order, go for a pair, not just one. (Then you can feel as though you're driving a chariot, not just brandishing (a la John) a riding crop.)

Keep up your good work.

Re: "Stretching" vs "Increasing the Angle of Dorsiflexion"

Glenn X on 8/28/01 at 11:41 (058222)

Julie: Thanks for your words of encouragement. Some times I think I'm analyzing and detailing this recovery trek to death. Other times I appreciate that attention to detail helps.

I will most definitely continue with the yoga foot twiddles. Even when I'm back walking again. They really are helpful. I do think I'm doing them OK: flexing toes forward and back, flexing ankle forward and back, and rotating clockwise and counterclockwise to the extremes of motion I can muster. Do each some 12 times. May move through them a bit fast at times. How important is the breathing partnership?

You are absolutely right about strengthening. Besides the rubber tubing exercises I mentioned, I also toe-grab the carpet, drawing it toward me and then sweeping it to center.

I do have a pair of PFTs. Been using them for a month, twice daily, about seven different routines with them. I agree with you; they are very helpful for strengthening foot muscles, particularly those that have been sorely underused.

Don't have Birks. On my list as soon as my feet hit the ground.

I'm going to pay a little closer attention to my yoga foot exercises in the days ahead, particularly the rotations that can loosen my ankles more.

Thanks heaps for the input.

(Thanks too for your thatcher thoughts in another thread. I applaud your perspective).

Re: Breathing, stretching, angle, hamstrings - Glenn

Julie on 9/04/01 at 03:15 (058983)

Glenn, I'm sorry it has taken me so long to return to this discussion. (It has taken me this long to re-find the thread - things happen too fast at heelspurs.com!)

You asked about the breathing in the yogic foot exercises. It's a good question. They will be effective on the physical level - joints, muscles, ligaments, tendons - if you do them without breath-movement co-ordination: it makes no difference there. The co-ordination of movement with breath involves and influences the mind. It focuses the attention, encouraging what we call 'one-pointedness', so that the effects are deeper. The movements become slower, which enhances relaxation and awareness, so you may find them calming and energizing. Overall (when you work on all the joints, not just the feet) they have effects on the metabolism, and on all the organs and systems, because they speed the removal of toxins.

I was thinking about you last night while teaching. I was observing my class of 16 students on the floor, on their backs, practising their leg stretches. The student with the best angle of dorsiflexion was a woman who has had plantar fasciitis - the only one in the group who has had it. She had told me about her heel pain about six months ago, knowing that I'd know about it (everyone I've taught over the past year knows about PF now) and I gave her some guidance and referred her to my podiatrist. She taped, wore Birks all the time including in class, did everything she was supposed to do, and is now better. But I was surprised to see so healthy an angle in someone who has had PF so recently, and assumed that she had been doing a lot of targetted wall stretching as recommended by Ron the pod. After the class I told her that I'd noticed how good her angle was and asked her what she had been doing. She said she had been doing our toe and ankle exercises every day (along with the other exercises for the joints) and that was all.

I was tickled to read in one of your posts to Carmen yesterday about the effect of plantarflexing the feet when you stretch the hamstrings. This was a fairly recent discovery of mine, too. Dorsiflexing the ankle is of course what brings the calf muscle/achilles complex into play, so when you straighten the leg you're stretching them as well as the hamstrings. When the foot is plantarflexed (better still, held in neutral so that the achilles/calves don't tighten) they are taken out of the picture, the stretch is concentrated in the hamstrings, and is more effective. I've realized that it really is better to isolate these two muscle groups and stretch them individually, so it was very interesting to read about the effect that changing your stretch has had on the soles of your feet. The isolated stretch is always more controllable, but it could also be - I'm guessing - that in not stretching along the entire length of the sciatic nerve, you may be avoiding that burning/tingling in the feet. Any thoughts on this?

All the best

Julie

Re: Breathing, stretching, angle, hamstrings - Glenn

Glenn X on 9/04/01 at 21:06 (059045)

Julie: Thanks for picking up on the breathing question. I'll go for it. Will probably help me slow down and execute the routine more beneficially too.

I like the anecdote about your student. The more I try, and ponder flexibility, the more I appreciate the importance of routine, sustained easy tension -- and the subtle workings of seemingly passive routines. I do the yoga foot moves three times daily and expect them to be a PRIMARY focus once I get the angle I need and move into a maintenance mode. They and the night splints might get me there by themselves, but the other regimens seem to be helping considerably as well. So I'll do them all.

I need to dink around with the hamstring / foot connection a bit more. I feel the link between them, but don't really understand why stretching the hamstring leads to my feet burning (slightly) and tingling. There's certainly not much tension on my feet when doing this dorsiflexed, but nonetheles? Perhaps my feet are just more sensitive from all the attention?

Being post PF, do you feel any difference from your feet when you do the hamstring stretches dorsi or planti?

Re: Breathing, stretching, angle, hamstrings - Glenn

Julie on 9/05/01 at 03:00 (059069)

Hi Glenn

I think that if you do integrate breathing with movement you'll enjoy the work more, and get more out of it. You can apply it to all the work that you're doing. When an exercise involves repeating a movement several times, co-ordinate it with your breath. When you are holding a stretch, simply breathe easily and peacefully, and be aware of your breath. Breath awareness, and co-ordination of movement and breath, are really the heart and soul of yoga.

I agree with you completely about routine. Consistency is very important. I would guess that the disappointment so many people feel with this or that exercise or other treatment modality, is due to their not having been consistent with it over a period of time: they jump around from one thing to another, never giving anything a chance to work. And that, I suspect, stems from unrealistic expectations: they want to be better tomorrow morning, or by this time next week, or by next month's tennis match. Maybe you just have to get older to appreciate the virtues and satisfactions, as well as the necessity, of the long haul. I think you and I are definitely on the same wavelength there.

The subtle workings of seemingly passive routines - that's nice! It's a good description of how yoga works. Yes, this is all subtle work you're doing. More power to you, and yes, of course keep up with all of it. You've worked out a comprehensive, consistent programme for yourself and it's working, and you did it by observing yourself and what you need. That's terrific. I also feel that your setting of specific, realistic goals is a model for everyone.

Re the hamstrings. There is a continuum from the lower back down the leg to the foot, so everything along that continuum connects with everything else. I thought you said (correct me if I have this wrong) that when you plantar flex your feet while stretching your hamstrings,you no longer have the burning/tingling sensation in your feet. I still think, as I said yesterday, that this could be due to the fact that you are no longer stretching along the entire length of the sciatic nerve, as you are when the foot is dorsiflexed and the gastro-soleus/achilles complex is also being stretched. So it's not really stretching the hamstrings that's causing the burning/tingling, but involving the calves/achilles - i.e.stretching along the entire length of the SN - when you dorsiflex. That's my theory, but if I misunderstood what you said to Carmen, please clarify me.

Re: Breathing, stretching, angle, hamstrings - Glenn

Glenn X on 9/05/01 at 10:46 (059100)

Julie: As I read more of your thinking about yoga, I increasingly see its value. It's like moving toward and away from a work of art, each perspective adding insight to the intellect and warmth to the inner being. Ultimately it all simply FEELS on the mark. When back on my feet I'm going to search out a class.

When you say, 'Maybe you just have to get older to appreciate the virtues and satisfactions, as well as the necessity, of the long haul. I think you and I are definitely on the same wavelength there.' Are you referring to the long haul part or the older part? (Both fit).

Setting and measuring progress to realistic goals is essential. I've seen a lot of messages here from people who lament that stretching doesn't seem to help. IT ('stretching') perhaps doesn't. But lengthening the fascia, achilles, calf muscles, and hamstrings definitely does, and that has to be the focus, supported by measurements that denote progress.

Yes, no foot tingling when stretching hamstrings, foot plantarflexed (sp). And thanks for your explanation. Makes sense, though I wouldn't have appreciated its importance a month ago. I think what we're saying here is that tight hamstrings have the potential to moderately pull on a healthy plantar fascia, and pergaps further aggravate one that's been strained. Which suggests that lengthening the hamstrings really should be part of treatment. You think?

Re: Hamstrings, sciatic nerve, patience, yoga - Glenn

Julie on 9/05/01 at 19:31 (059159)

Glenn: thoughts on your last paragraph first. I agree with your diagnosis of the hamstrings, and yes, I do think that lengthening them is part of the PF-treatment picture. I've thought for a while that it is better and more effective to stretch them individually, and not at the same time as the gastro/soleus/achilles; and thanks to this discussion I now think it is also safer.

My theory about your tingling/burning was that the stretching of the sciatic nerve along its full length was setting up some kind of response in the soles of your feet. The sciatic nerve has several branches: it divides about 2/3 of the way down the thigh into the tibial nerve and the common peroneal nerve. The latter divides into the deep peroneal and superficial peroneal branches. Other branches and sub-branches of the sciatic nerve are the sural, medial calcanean, medial plantar and lateral plantar nerves. The last three, and the deep peroneal, terminate in the foot. So, if there is adverse neural tension anywhere along that nerve complex, which there probably is if the whole muscle complex of hamstrings/gastro/soleus/achilles is tight, I would not be surprised if there was tingling and burning at the termini when the whole complex was being stretched at once. But, when you don't dorsiflex the foot, you're not only taking the gastro/soleus/achilles out of the equation, you're taking those lower branches of the SN out of it too.

I'm enjoying these speculations during a sleepless night (my husband has a painful earache which is keeping us both awake, so I'm trying to do something useful with the time). It's interesting to me to think about it, because it fits in well with my discovery that it's more effective to stretch the hamstrings and calf muscles individually than to work on them together. If we can also avoid nerve irritation by isolating the stretches for those two muscle groups, that's another good reason to do so.

I particularly meant 'the long haul', but the other is true too. I guess we are both about the same age - I know you have grandchildren (I don't, but I'm old enough to). One of the things I appreciate about you is your patience for the long haul, which is always implicit in your posts. You're prepared to work towards goals, but you're also willing for things to take the time they take, and to enjoy the journey. I remember clearly when my own feeling about PF shifted: after the first few weeks of disbelief and sadness, I got the measure of it, knew it was going to take time and that I had to work at it, and kind of buckled down to it as just one more of life's challenges, knowing it was going to take however long it was going to take. There was something both satifying and liberating in that - not just in the eventual results, but in feeling like that. Does that sound strange to you? I don't think so.

Since you found heelspurs.com you've made a truly important contribution to people's thinking here: I mean about the value of determining goals, working systematically towards them, and measuring progress. I hope people take it on board, because if they do it is certain to affect their progress towards healing. I hope too that you find frequent occasions to reiterate it, because people come and go, and there are always new ones.

If you get interested in yoga, you don't have to wait till you're on your feet. There's a great deal you can do sitting down, on your own. There are all the exercises for the joints that I've mentioned, and a great variety of exercises for the spine, neck and shoulders, as well as breathing, relaxation and meditation exercises. Perhaps you'd like to have a look at my 'Office Yoga' - I hate sounding as though I'm 'selling' my book, but you might like it. The UK/US edition is out of print now, but there are used copies available from abe books, and an Indian edition published by Motilal Banarsidass that turns up on obscure websites.

I feel sure that you would enjoy yoga.

Now I'm going to see if my husband is asleep so I can go to sleep too. Good night: nice talking to you.

Julie

Re: Link - Glenn

Julie on 9/05/01 at 19:37 (059163)

Here's the link for abe books should you feel like following it up:

http://dogbert.abebooks.com/abe/IList

Re: Link - Glenn

Glenn X on 9/05/01 at 22:25 (059179)

Julie: You totally read my mind. Shortly after I sent off the post about yoga I remembered you'd written a book on yoga and was going to check Amazon for it. I thought I recalled you mentioning that site as a source.

Anyway, I'll try Abebooks. I've bought from them before.

Thanks so much for your follow up.

Re: Hamstrings, sciatic nerve, patience, yoga - Glenn

JudyS on 9/06/01 at 14:32 (059245)

Julie, as with so many things you post, a point you've made in your night-time musings caught my eye. The one about patience, and knowing that the PF healing was going to take time....that one. I suspect I've mentioned this before so will beg forgiveness if I'm too repetative but....if I had just known, from the very start, that healing PF would absolutely take time and patience, I would not be here, three years later. I blame two things for that lack of knowledge, one, my own refusal to take the PF seriously in the first six to eight months, and, two, a serious lack of information from my docs. They essentially gave me a shot, some inserts, a shrug and said 'You're a tough jock, you'll lick this in no time'. That was so untrue! In fact, the advice should have been, 'You're a jock and you will find it tough to stay off your feet, but stay off them you must.'
There is no question in my mind that it wasn't until I learned on my own that consistent self-treatment and patience was key to recovery that I started to improve. I'll admit that I really wish the docs had been much more forceful with me. I think I took the PF only as seriously as they did and that was a mistake.
I think what you found to be 'satisfying and liberating' was, in fact, the simple step of acknowledgement, then empowerment in taking charge of your own healing.

Re: Healing and Liberation - Judy

Julie on 9/07/01 at 09:18 (059353)

Yes. Acknowledgement and empowerment, taking charge, but also just simple acceptance of the reality of PF, and of the open-ended time frame. I was luckier than you, though, in discovering heelspurs.com two weeks into PF pain. I wish you had been as lucky! But you've learned good lessons from it. Patience is a great lesson - one of the better ones, isn't it!?

Re: New EWST ( Ossatron ) article in Podiatry Today Magazine

Ed Davis, DPM on 8/11/01 at hrmin (056272)

I have been listening to Dr. Smith for years. His longstanding hypothesis is that a lot of the tough cases of heel pain we see are actually calcaneal stress fractures. I have always wished that he was correct because this would give us easier ways of treating more tough heel pain cases. Nevertheless, I have not been able to verify or corroborate his ideas based on my clinical experience.

The article suggests that he has somewhat modified his theory. The calcaneal stress syndrome that he refers to appears to be a hybrid of plantar fasciitis and the calcaneal stress fracture, as he seems to describe a continuum of pathology-- a continuum blending elements of a fracture and microtears in the fascia. We need to categorize and label things with specific diagnoses--it makes doctors and patients feel better and allows insurance companies to pay the bills. Nevertheless, the reality of things often lies in a grey zone in which diagnoses can overlap and meld.

Interestingly, this particular grey zone may be the 'sweet spot' for ESWT.
Ed

Re: for Dr Davis/ Dr. Smith Theory

john h on 8/11/01 at 16:57 (056351)

Dr Smith's theory would seem to vanish in the many cases of bi-laterial PF. It would not seem statistically probable to me that you woud have so many bi-lateral stresss fractures.

Re: for Dr Davis/ Dr. Smith Theory

Donna SL on 8/11/01 at 18:25 (056357)

I think micro bilateral stress fractures could be possible in a runner for example, or someone who has excess stress on their heels like a person with a high arches. Both feet are receiving equal stress. I know with my cavus feet most of my body weight goes to my heels and forefoot, because of the unequal weight distributution. I had a very hot bone scan in the calcaneal area, and areas of the forefoot last year bilaterally, and it's probably a result of many tiny fractures aquired over the years. I think not wearing the proper orthotic to redistribute the weight evenly, and provide adequate padding in the heel area may have also contributed to this.

Donna

Re: Bilateral PF

Glenn X on 8/11/01 at hrmin (056361)

John: Not sure how your bilateral started, but for me I began by straining both feet squatting too much weight. Aggravated it a few days later dancing. Left was better 8 months later. Right lingered longer, then got re-injured. Left remained OK as I nursed right, but gradually left became sore. Right is still the worst, left is where it was at it's worst.

I think the reason my left succumbed is because I was not exercising it sufficiently and naturally enough while nursing my right. Got inflexible and muscles weakened from misuse. For a long time too I wore harsh orthotics on both feet, trying to mend the right, and these aggravated my left as well.

I believe the more 'normally' we can increasingly use both feet, the better, for our feet and for ourselves.

All that said. Since I've been using night splints on both feet, my wrists are all of a sudden sore. The soreness has me wondering if the body mechanisms marshalled to continually repair my nightly 'strained' achilles and fascia don't also have an affect on other similar tissues.

Re: for Dr Davis/ Dr. Smith Theory

Ed Davis, DPM on 8/12/01 at hrmin (056452)

I agree.
Ed

Re: Bilateral PF

Ed Davis, DPM on 8/12/01 at hrmin (056453)

There was a good post about 3 weeks ago concerning 'fasciosis' vs. fasciitis. Getting a bit theoretical but fasciosis implies that the problem or at least some of it is due to intrinsic 'disease' of the tissue itself. That is, there is a loss of normal elasticity in the tissue, excess fibrosis (scar tissue) and possibly the improper remodeling or regeneration of tissue in the area by the body.

My gut feeling is that this area is going to be looked at more closely in the future and may have more relevance than we now think. ESWT, by 'traumatizing' the fascia probably results in increased remodeling or tissue turnover time by the body, that is, induce the body to replace 'diseased' tissue with healthier tissue at a faster rate.

We often see patients who have all the right set of conditions, biomechanical and occupational, to develop plantar fasciitis. Will they develop it? When? The answer may lie in how the tissue responds to the abnormal forces.
Ed

Re: Bilateral PF

john h on 8/12/01 at 14:40 (056472)

glenn: it has been so long since my pf started i cannot remember how soon my second foot developed the condition. i think it was probably some months which sort of goes with my thinking that PF in one foot will alter your gait and create all sorts of new problems in either foot. i was running at the time which is sort of double trouble and continued until the pain stopped me. i also have hallux limitus which i and some of the doctors agree probably have a connection with my PF in that the great toe is limited in its dorsiflexion and causes pain. this of course will influence you both conciously and sub-conciously when you run to strike the ground in the least painful position. i am still into about a 10 day period of only a pain level 1. i am keeping up the jade,cherry extract and it of course has been about 8 weeks since i had dr z perform my 3rd ESWT treatment. any or all of these things could be at work here or tomorrow i could have increased pain. if i can go about 90 days at this pain level then i will have to think that some of these treatments are working. at any rate i am a very long time suffering PF guy who is better today than i was last year or the year before. i will thow something else out there that some may scoff at but just talking to you people might just have something to do with my improvement.

Re: Full curing

Glenn X on 8/12/01 at hrmin (056479)

John: I understand as the years pile on that we heal slower, but eventually we (can) heal.

About eight years ago I got tennis elbow whacking the ball with too aggressive a forehand too many times. Didn't stop right away and eventually got it real bad. Couldn't even shake someone's hand without it hurting. Pain continued for at least a couple of years with frequent aggravation of the injury (but not by playing tennis).

I eventually got serious about fixing things and obsessive about caring for my injury. Rested it as much as I could. Shook hands with my left. Gradually as the pain subsided, maybe after 2 or 3 months, I began light exercising; flexing, rotating, massaging . . . very easy stuff. I continued to add rigor (slowly) and continued to improve.

Today I have zero symptoms and consider myself completely healed.

I believe we can anticipate the same recovery with PF. But being in such a high-use part of the body, it's going to take more diligence and micro management.

Preliminarily I think it's a matter of three factors:
Rest and healing
Flexibility and prevention
Exercise and strengthening

I'm understanding the rest thing pretty good. But I have much more I need to learn about flexibility and about strengthening all the muscles and other bones and tissues that make the foot work.

I have much more to learn about what I haven't mentioned too. I'd mention it if I knew what it was.

Re: Full curing for glenn

john h on 8/22/01 at 17:31 (057599)

your comments are well received. stretching has to be an important factor in health of any sort. i keep putting off Yoga but it is on my list of things to begin not just for PF but for general good physical health but good mental health. the hardest thing to do in any project is to begin it.

Re: Full curing for glenn

Julie on 8/23/01 at 01:40 (057652)

John, your final sentence - the hardest thing to do in any project is to begin it - inspires me to post this poem. It's by Goethe.
I hope it inspires you to find your yoga teacher.

Until there is commitment
There is hesitancy.
The chance to draw back
And ineffectiveness

In all acts of initiative or creation
Ignorance of one elementary truth
Kills countless splendid plans

The moment one commits oneself
Providence moves too
All sorts of things occur to help
That would never otherwise have occurred

A stream of events issues forth
From the decision: incidents, meetings
And material assistance not foreseen

Whatever you can do, or dream you can do,
Begin it
Boldness has genius, power and magic
Begin it now.

Re: Full curing for glenn

john h for julie on 8/23/01 at 11:35 (057676)

julie: that is a wonderful poem and i have read it. it probably was in the back of my mind when i made the comment

Re: Full curing for glenn

nancy s. on 8/23/01 at 11:39 (057677)

i agree, john -- that IS a wonderful poem, one that i've read in the past and then lost. it has several beautiful and true messages. thanks, julie. julie, i think our bookshelves must look a lot alike.
nancy

Re: Great images ... Thanks Julie

Glenn X on 8/23/01 at 15:54 (057702)

Poetry makes the body lighter on the feet.

I am making solid headway these days . . . but only because after three some years I finally got serious about learning and managing and partnering for my recovery.

Goethe got it right. I got committed, and things started happening, sometimes by my initiative, sometimes seemingly of their own accord.

Re: "Stretching" vs "Increasing the Angle of Dorsiflexion"

Glenn X on 8/23/01 at 16:37 (057711)

John: I've been thinking about this stretching stuff for awhile and decided to jump on your message as a place to float a thought ... one of those subtleties that perhaps can help others. I know it has helped me.

Many people on heelspurs describe 'stretching' as a regimen they practice regularly to try and heal their PF. I used to do the same.

Now, however, I am working at 'increasing my angle of ankle dorsiflexion' (the angle formed by my foot and lower leg when my foot and toes are bending toward my face). I've mentioned before that in February that angle on me was 105 degrees. (Ankle was very inflexible). Three weeks ago it was 90 degrees, still not enough. Today it might be 85 degrees (I'm getting measured tomorrow). My goal is 70 to 75 degrees, which may take another month or two or three, but which will have my foot well bent towards my face.

As my podiatrist (Ed Davis) explained to me (and as Scott describes in his book) INCREASING ankle dorsiflexion by DECREASING the angle of our foot to leg takes enormous tension off the plantar fascia, which is probably the chief benefit and reason for stretching, and perhaps one of the more certain paths to healing.

But I think it imperative that we stretch with this angle in mind -- and in view. That we start with a baseline angle measurement, establish a target angle to aim for, and then take regular measurements (perhaps every two weeks or so) to ascertain progress.

What gets measured gets done. And while eye-ballng advises, hard numbers define.

It's important that the same person take the measures, as this doesn't seem to be an exact science. I've got a wordworking protractor I use at home to give me some in-between times feedback, but rely on the doc (or PT)for the official number.

In fact, I think a great product for the heelspurs community would be an 'Ankle Angle Guage,' a simple tool for people to consistently and reliably measure their ankle angle. Protractor, t-square, bolt, and a wing-nut ought to do it.

Re: Full curing for glenn

julie and nancie on 8/23/01 at 19:06 (057739)

here in arkansas we are not very poetic but a couple of inspirational thoughts come to mind concering people who just walk down the middle of life's roadway: 'when you walk down the middle of the road you can get hit by traffic going both ways' margaret thatcher.
'when you walkdown the middle of the road all you can see is a painted yellow line and dead armadillos' author unknown. Not very Goethe like but some truths in them. nancy, i would guess poetry above is not on your bookshelf or julies.

Re: "Stretching" vs "Increasing the Angle of Dorsiflexion"

Julie on 8/24/01 at 03:46 (057772)

Glenn, this is absolutely right. 'Stretching' covers a multitude of sins as well as aims and goals, but with PF what we should be doing is specifically targetting the angle of dorsiflexion, increasing it to take the strain off the fascia. Focussing the mind as well as the body on the goal is helpful - to say the least. The question then arises - 'how' to do it? There are many ways of working towards that increase, some safe and effective, some not-so-safe. Would you like to describe the work you are doing that has been so effective in increasing your angle?

Scott used to have a test for calculating one's angle of dorsiflexion somewhere on the site. I don't know if it's still there. If it is, perhaps Scott, or someone who has used it recently, can point us towards it.

Re: Full curing for glenn

nancy s. on 8/24/01 at 04:46 (057773)

well oh my, then by all means you have a good time walking down the middle of the road! farewell!

Re: "Stretching" vs "Increasing the Angle of Dorsiflexion"

john h on 8/24/01 at 13:45 (057837)

dr z reminded me the other day to do some runners stretches lightly which in effect is increasing the angle of dorsiflexion. i am no stretching guru but this makes complete sense to me. you have to lengthen the muscles in your calves and hamstrings and right up to your lower back as well as put some tension on the achilles to allow that foot to get good dorsiflexion and take some tension off the fascia. one of the experts may shoot me down on this but if you watch all the profession sports team they spend a lot of formal time before a game stretching. julie has sort of stayed on my case about yoga which may be the ultimate stretching program and i have got as far as getting the class times. now as john h and Goethe have said i must begin.

Re: Full curing for glenn

Julie on 8/24/01 at 15:41 (057851)

You won't find any book, treatise, or saying by Lady Thatcher anywhere near any bookcase of mine, John dear!

Re: Now Julie

john h on 8/24/01 at 19:26 (057870)

i am not current with British politics but i think you are telling me you are no fan of Lady Thatcher! I alway admired the way she handled the Faulkland situation but never had the British take on what the people thought. I think i could very well picture your library lady julie. I have visited the Prado and Louve and stood atop the Acropolis viewing the past. I suspect this is you library.

Re: Dear John

Julie on 8/25/01 at 02:26 (057895)

That's right, John. I am no fan of Lady Thatcher, who did her utmost to systematically destroy the fabric of British society, and more or less succeeded. During her reign all our social services suffered greatly, the gap between rich and poor widened, and people generally began to believe her dictum 'there is no such thing as society'. And that divisive legacy remains: society has never recovered. The''Falklands' War was an out-and-out political ploy, fabricated to boost her popularity at a low point by playing on and harnessing the nation's inherent jingoism by 'defending' one of the last remaining dregs of the British Empire; it worked, she was re-elected, and continued her mission of destruction.

Living in Britain under her premiership was soul-destroying, and I detested her, as did all left-of-centre people of humanitarian, liberal views. One of the cheeriest days of my life, politics-wise, was the day Geoffrey Howe stood up in the commons to give his resignation speech, and denounced her. Her fall followed. Since leaving office she has gone pretty mad, but has continued to have a poisonous influence on political life, snarling her views from her front door on every important occasion. She is currently doing her best to influence the Tory leadership election by publicly supporting the right-wing, anti-Europe Iain Duncan Smith, the vice-chairman of whose campaign has just been exposed as having British National Party (i.e. fascist) connections.

Enough. I am no fan of Lady Thatcher.

My library now - that's another story. For another time. Watch this space.

Re: Dear John

john h on 8/25/01 at 10:34 (057913)

julie you clearly defined your views on Lady Thatcher for me sparring nothing! Most American only hear of the scandals in your tabloids. We, for the most part do not have an inkling how your government works and what the people think. We learned more about Princes Di than we have about the British government in the last 100 years. My closest experience with Britian is that i was trained by two RAF pilots. If you will look at my picture on the board closely you wll note i have a British regimental tie on. I would not be supprised if your hubby knew what regiment. Bet you cannot figure that one out Julie?

Re: Dear John

Julie on 8/25/01 at 11:56 (057921)

Well, John, Klaus spent four and a half years in the Australian army during and after WW2, so he might - just - recognize an Australian regimental tie. But a British one? I doubt it very much. So please tell! Which regiment?

Your training with RAF pilots was surely the very best!

I guess the British papers, at any rate the broadsheets, are probably better at reporting American politics than vice versa.

Re: "Stretching" vs "Increasing the Angle of Dorsiflexion"

Glenn X on 8/25/01 at 13:29 (057932)

Julie: Thanks for catching the thread. Everyone's at a different time and place with foot stuff, but right now what's steadily decreasing my ankle angle is . . .

30% Active Stretching. I do the classic 'runner's stretch' five times a day. But I do it leaning forward, stretching BOTH legs and feet simultaneously. This gives me a nice therapeutic stretch without placing undue pressure on any one foot. I lean in to tension, no pain, for two reps - 30 seconds, each time. (No bent knees at this point). I circle my toes beforehand to loosen things a bit. About every other set, while tensioning the backs of my legs, I'll actively pull the top of my foot toward my face using the muscles on the front of my leg, about 10 reps. (See thought on compression below).

20% Active dorsiflexion of my ankle when sitting during the day and evening. Perhaps fifty percent of the time, my feet are either under my chair, resting on the ball of my foot, heels off the floor, or my feet are forward but the ball of my foot is resting on something that puts MILD tension on my achilles, and miniscule tension on my fascia. My favorite foot rest is a 15' 4x4. I can easily roll it toward or away from me depending on the tension I want, or roll it out of the way when I get up . . . and it matches my coffee table.

15% Fascia massage. I have my fascia ultrasounded and massaged three times a week. Two different PTs do this. One is Eddie Brewer who works with Dr. Ed Davis in Puyallup, WA. The other is Malia McDevitt, a local therapist. Brewer is particularly artful at massaging and lengthening the fascia. He seems to know and go the limit. Malia too has a skilled touch. She also massages my calves and achilles, and actively stretches me lying face down on the table. (The overall therapeutic value of this particular regimen may be well above 15 percent, but since I'm talking here about what strategies seem to decrease my ankle angle, 15 seems right).

15% night splint. I may be mistaken, but I don't believe the splints ADD to my range of motion. However, they are essential for maintaining any gains I've made through the day with other exercising. Without the splints it would be three steps forward and two back, every day and night. With them, it's three forward, hold, three forward, and so forth.

10% Rubber tubing stretches. Five or more times a day I loop rubber tubing around my foot and plantar flex (point) my foot forty to eighty times under tension. I let my foot return to a dorsiflexed position each rep with tension on the tubing, occasionally letting my foot 'snap' back. This exercises my calf muscles (sorely needed since I am not active) and also has the effect of adding a little stretch to my achilles.

Perhaps more importantly, the snap-move compresses the front of my ankle and, I believe, loosens cartilage there and elsewhere --- and it 'shortens' (or allows front-foot muscles to shorten more). Increasing flexibility seems a combination of lengthening the 'outside' of my leg-foot dynamic (fascia, calf muscles, and achilles tendon (a tad)) -- and also compressing or somehow lessening resistance in the inside tissues in the front of my foot and leg. i.e., when I dorsiflex my ankle now, I seem to encounter resistance in the front of my ankle prohibiting any more pull, before I reach the lengthening limits of my fascia or calves.

5% Yoga ankle flexes. You taught me these. I do them three times a day, first thing in the morning, mid-day, and when I go to bed. They're great tissue-loosening exercises, good for prepping the foot for more rigorous movements. Since they're accomplished by my own pulling capabilities, they're perhaps too passive to actually increase ROM. But seem important to maintenance.

5% Ankle wobble. This one's a bit off beat, but I think effective. Malia does it and taught it to me. Laying face down on the table, I raise my lower leg perpendicular to the table. She grasps my leg just above the ankle and jerks my leg side to side 8 or 10 times, and then front to back a similar number of reps, 'snapping my ankle.' Repeats 2 or 3 times. Sort of an inverted, non-weight-bearing wobble board. It helps overall ankle flexibility, perhaps by loosening cartilage and other tissues as described above.

My feet (not my fascia) are a little sore doing this regimen. Not painful, but sore. Kinda like how muscles get when fatigued, only edgier. I don't take any pain meds. Helps me listen to my feet better and not overdo anything.

I don't suggest these for everybody. They work for me now. I was measured at 85 degrees (both feet) yesterday. Improved 5 degrees in 3 weeks.

This is a work in progress. A month hence what I've described above will almost certainly be modified some. When I get to 75 degrees, I'll shift to a maintenance routine, yet to be figured out.

Way open to input!

Re: "Stretching" vs "Increasing the Angle of Dorsiflexion"

Glenn X on 8/27/01 at 16:37 (058131)

Some add ons: On second thought, the night splints may in fact be adding to flexibility instead of simply maintaining other efforts. I say this recalling a post by Dr, Davis where he wrote about gently tensioning the achilles tendon, allowing fibers to gradually lay down in parallel to accomodate the 'longer' demands put on it. A slow, VERY SLOW, stretching (or increase in flexibility) of the achilles tendon ensues. Probably takes weeks, but it takes place.

Active stretching, active dorsiflexion (when seated), and the rubber tubing stuff, are done with shoes and orthotics on.

Since lengthening takes considerable time, it is SO tempting to overdue all of this. I have to rigidly discipline myself to NOT overdue. I'd be quite happy with 1 degree a week . . . and would settle for a half.

Re: "Stretching" vs "Increasing the Angle of Dorsiflexion"

john h on 8/27/01 at 17:11 (058137)

glen: if there is one guy i am confident that can do 1 degree a week in dorsiflexion it is you mr. daytimer himself. i really like the nightsplint and have stuck with it because it just plain makes sense.

Re: "Stretching" vs "Increasing the Angle of Dorsiflexion"

Julie on 8/28/01 at 01:56 (058196)

Hi Glenn

Thanks for your description. I greatly admire the thorough, organized, business-like way you're going about this. All the exercises you're using make sense to me, and they are clearly working for you. One degree, or even half a degree, would be 15-30 degrees in a month.Not slow!

I agree that you need to be careful not to overdo it, and also with your add-on about the night splint.

The ankle flexion/extension and rotation (are you doing the rotations?) exercises will contribute to increased range of movement, as long as you do them slowly, with the intention of moving the joints through their full range (not just twiddling and twirling) so I hope you'll continue to include them in your programme.

The only other comment I'd want to make is that strengthening is as important as stretching the gastro-soleus-achilles complex, particularly when one has been seriously resting, as I know you have. The toe curling and stretching exercise is useful here. Do you have Birkenstocks? Using your toes to grip while walking in them is terrific strengthening exercise.

And I have a feeling you would get on nicely with the Personal Foot Trainer, which provides resistance in a group of mainly isometric strengthening exercises. You might want to investigate it. If you decide to order, go for a pair, not just one. (Then you can feel as though you're driving a chariot, not just brandishing (a la John) a riding crop.)

Keep up your good work.

Re: "Stretching" vs "Increasing the Angle of Dorsiflexion"

Glenn X on 8/28/01 at 11:41 (058222)

Julie: Thanks for your words of encouragement. Some times I think I'm analyzing and detailing this recovery trek to death. Other times I appreciate that attention to detail helps.

I will most definitely continue with the yoga foot twiddles. Even when I'm back walking again. They really are helpful. I do think I'm doing them OK: flexing toes forward and back, flexing ankle forward and back, and rotating clockwise and counterclockwise to the extremes of motion I can muster. Do each some 12 times. May move through them a bit fast at times. How important is the breathing partnership?

You are absolutely right about strengthening. Besides the rubber tubing exercises I mentioned, I also toe-grab the carpet, drawing it toward me and then sweeping it to center.

I do have a pair of PFTs. Been using them for a month, twice daily, about seven different routines with them. I agree with you; they are very helpful for strengthening foot muscles, particularly those that have been sorely underused.

Don't have Birks. On my list as soon as my feet hit the ground.

I'm going to pay a little closer attention to my yoga foot exercises in the days ahead, particularly the rotations that can loosen my ankles more.

Thanks heaps for the input.

(Thanks too for your thatcher thoughts in another thread. I applaud your perspective).

Re: Breathing, stretching, angle, hamstrings - Glenn

Julie on 9/04/01 at 03:15 (058983)

Glenn, I'm sorry it has taken me so long to return to this discussion. (It has taken me this long to re-find the thread - things happen too fast at heelspurs.com!)

You asked about the breathing in the yogic foot exercises. It's a good question. They will be effective on the physical level - joints, muscles, ligaments, tendons - if you do them without breath-movement co-ordination: it makes no difference there. The co-ordination of movement with breath involves and influences the mind. It focuses the attention, encouraging what we call 'one-pointedness', so that the effects are deeper. The movements become slower, which enhances relaxation and awareness, so you may find them calming and energizing. Overall (when you work on all the joints, not just the feet) they have effects on the metabolism, and on all the organs and systems, because they speed the removal of toxins.

I was thinking about you last night while teaching. I was observing my class of 16 students on the floor, on their backs, practising their leg stretches. The student with the best angle of dorsiflexion was a woman who has had plantar fasciitis - the only one in the group who has had it. She had told me about her heel pain about six months ago, knowing that I'd know about it (everyone I've taught over the past year knows about PF now) and I gave her some guidance and referred her to my podiatrist. She taped, wore Birks all the time including in class, did everything she was supposed to do, and is now better. But I was surprised to see so healthy an angle in someone who has had PF so recently, and assumed that she had been doing a lot of targetted wall stretching as recommended by Ron the pod. After the class I told her that I'd noticed how good her angle was and asked her what she had been doing. She said she had been doing our toe and ankle exercises every day (along with the other exercises for the joints) and that was all.

I was tickled to read in one of your posts to Carmen yesterday about the effect of plantarflexing the feet when you stretch the hamstrings. This was a fairly recent discovery of mine, too. Dorsiflexing the ankle is of course what brings the calf muscle/achilles complex into play, so when you straighten the leg you're stretching them as well as the hamstrings. When the foot is plantarflexed (better still, held in neutral so that the achilles/calves don't tighten) they are taken out of the picture, the stretch is concentrated in the hamstrings, and is more effective. I've realized that it really is better to isolate these two muscle groups and stretch them individually, so it was very interesting to read about the effect that changing your stretch has had on the soles of your feet. The isolated stretch is always more controllable, but it could also be - I'm guessing - that in not stretching along the entire length of the sciatic nerve, you may be avoiding that burning/tingling in the feet. Any thoughts on this?

All the best

Julie

Re: Breathing, stretching, angle, hamstrings - Glenn

Glenn X on 9/04/01 at 21:06 (059045)

Julie: Thanks for picking up on the breathing question. I'll go for it. Will probably help me slow down and execute the routine more beneficially too.

I like the anecdote about your student. The more I try, and ponder flexibility, the more I appreciate the importance of routine, sustained easy tension -- and the subtle workings of seemingly passive routines. I do the yoga foot moves three times daily and expect them to be a PRIMARY focus once I get the angle I need and move into a maintenance mode. They and the night splints might get me there by themselves, but the other regimens seem to be helping considerably as well. So I'll do them all.

I need to dink around with the hamstring / foot connection a bit more. I feel the link between them, but don't really understand why stretching the hamstring leads to my feet burning (slightly) and tingling. There's certainly not much tension on my feet when doing this dorsiflexed, but nonetheles? Perhaps my feet are just more sensitive from all the attention?

Being post PF, do you feel any difference from your feet when you do the hamstring stretches dorsi or planti?

Re: Breathing, stretching, angle, hamstrings - Glenn

Julie on 9/05/01 at 03:00 (059069)

Hi Glenn

I think that if you do integrate breathing with movement you'll enjoy the work more, and get more out of it. You can apply it to all the work that you're doing. When an exercise involves repeating a movement several times, co-ordinate it with your breath. When you are holding a stretch, simply breathe easily and peacefully, and be aware of your breath. Breath awareness, and co-ordination of movement and breath, are really the heart and soul of yoga.

I agree with you completely about routine. Consistency is very important. I would guess that the disappointment so many people feel with this or that exercise or other treatment modality, is due to their not having been consistent with it over a period of time: they jump around from one thing to another, never giving anything a chance to work. And that, I suspect, stems from unrealistic expectations: they want to be better tomorrow morning, or by this time next week, or by next month's tennis match. Maybe you just have to get older to appreciate the virtues and satisfactions, as well as the necessity, of the long haul. I think you and I are definitely on the same wavelength there.

The subtle workings of seemingly passive routines - that's nice! It's a good description of how yoga works. Yes, this is all subtle work you're doing. More power to you, and yes, of course keep up with all of it. You've worked out a comprehensive, consistent programme for yourself and it's working, and you did it by observing yourself and what you need. That's terrific. I also feel that your setting of specific, realistic goals is a model for everyone.

Re the hamstrings. There is a continuum from the lower back down the leg to the foot, so everything along that continuum connects with everything else. I thought you said (correct me if I have this wrong) that when you plantar flex your feet while stretching your hamstrings,you no longer have the burning/tingling sensation in your feet. I still think, as I said yesterday, that this could be due to the fact that you are no longer stretching along the entire length of the sciatic nerve, as you are when the foot is dorsiflexed and the gastro-soleus/achilles complex is also being stretched. So it's not really stretching the hamstrings that's causing the burning/tingling, but involving the calves/achilles - i.e.stretching along the entire length of the SN - when you dorsiflex. That's my theory, but if I misunderstood what you said to Carmen, please clarify me.

Re: Breathing, stretching, angle, hamstrings - Glenn

Glenn X on 9/05/01 at 10:46 (059100)

Julie: As I read more of your thinking about yoga, I increasingly see its value. It's like moving toward and away from a work of art, each perspective adding insight to the intellect and warmth to the inner being. Ultimately it all simply FEELS on the mark. When back on my feet I'm going to search out a class.

When you say, 'Maybe you just have to get older to appreciate the virtues and satisfactions, as well as the necessity, of the long haul. I think you and I are definitely on the same wavelength there.' Are you referring to the long haul part or the older part? (Both fit).

Setting and measuring progress to realistic goals is essential. I've seen a lot of messages here from people who lament that stretching doesn't seem to help. IT ('stretching') perhaps doesn't. But lengthening the fascia, achilles, calf muscles, and hamstrings definitely does, and that has to be the focus, supported by measurements that denote progress.

Yes, no foot tingling when stretching hamstrings, foot plantarflexed (sp). And thanks for your explanation. Makes sense, though I wouldn't have appreciated its importance a month ago. I think what we're saying here is that tight hamstrings have the potential to moderately pull on a healthy plantar fascia, and pergaps further aggravate one that's been strained. Which suggests that lengthening the hamstrings really should be part of treatment. You think?

Re: Hamstrings, sciatic nerve, patience, yoga - Glenn

Julie on 9/05/01 at 19:31 (059159)

Glenn: thoughts on your last paragraph first. I agree with your diagnosis of the hamstrings, and yes, I do think that lengthening them is part of the PF-treatment picture. I've thought for a while that it is better and more effective to stretch them individually, and not at the same time as the gastro/soleus/achilles; and thanks to this discussion I now think it is also safer.

My theory about your tingling/burning was that the stretching of the sciatic nerve along its full length was setting up some kind of response in the soles of your feet. The sciatic nerve has several branches: it divides about 2/3 of the way down the thigh into the tibial nerve and the common peroneal nerve. The latter divides into the deep peroneal and superficial peroneal branches. Other branches and sub-branches of the sciatic nerve are the sural, medial calcanean, medial plantar and lateral plantar nerves. The last three, and the deep peroneal, terminate in the foot. So, if there is adverse neural tension anywhere along that nerve complex, which there probably is if the whole muscle complex of hamstrings/gastro/soleus/achilles is tight, I would not be surprised if there was tingling and burning at the termini when the whole complex was being stretched at once. But, when you don't dorsiflex the foot, you're not only taking the gastro/soleus/achilles out of the equation, you're taking those lower branches of the SN out of it too.

I'm enjoying these speculations during a sleepless night (my husband has a painful earache which is keeping us both awake, so I'm trying to do something useful with the time). It's interesting to me to think about it, because it fits in well with my discovery that it's more effective to stretch the hamstrings and calf muscles individually than to work on them together. If we can also avoid nerve irritation by isolating the stretches for those two muscle groups, that's another good reason to do so.

I particularly meant 'the long haul', but the other is true too. I guess we are both about the same age - I know you have grandchildren (I don't, but I'm old enough to). One of the things I appreciate about you is your patience for the long haul, which is always implicit in your posts. You're prepared to work towards goals, but you're also willing for things to take the time they take, and to enjoy the journey. I remember clearly when my own feeling about PF shifted: after the first few weeks of disbelief and sadness, I got the measure of it, knew it was going to take time and that I had to work at it, and kind of buckled down to it as just one more of life's challenges, knowing it was going to take however long it was going to take. There was something both satifying and liberating in that - not just in the eventual results, but in feeling like that. Does that sound strange to you? I don't think so.

Since you found heelspurs.com you've made a truly important contribution to people's thinking here: I mean about the value of determining goals, working systematically towards them, and measuring progress. I hope people take it on board, because if they do it is certain to affect their progress towards healing. I hope too that you find frequent occasions to reiterate it, because people come and go, and there are always new ones.

If you get interested in yoga, you don't have to wait till you're on your feet. There's a great deal you can do sitting down, on your own. There are all the exercises for the joints that I've mentioned, and a great variety of exercises for the spine, neck and shoulders, as well as breathing, relaxation and meditation exercises. Perhaps you'd like to have a look at my 'Office Yoga' - I hate sounding as though I'm 'selling' my book, but you might like it. The UK/US edition is out of print now, but there are used copies available from abe books, and an Indian edition published by Motilal Banarsidass that turns up on obscure websites.

I feel sure that you would enjoy yoga.

Now I'm going to see if my husband is asleep so I can go to sleep too. Good night: nice talking to you.

Julie

Re: Link - Glenn

Julie on 9/05/01 at 19:37 (059163)

Here's the link for abe books should you feel like following it up:

http://dogbert.abebooks.com/abe/IList

Re: Link - Glenn

Glenn X on 9/05/01 at 22:25 (059179)

Julie: You totally read my mind. Shortly after I sent off the post about yoga I remembered you'd written a book on yoga and was going to check Amazon for it. I thought I recalled you mentioning that site as a source.

Anyway, I'll try Abebooks. I've bought from them before.

Thanks so much for your follow up.

Re: Hamstrings, sciatic nerve, patience, yoga - Glenn

JudyS on 9/06/01 at 14:32 (059245)

Julie, as with so many things you post, a point you've made in your night-time musings caught my eye. The one about patience, and knowing that the PF healing was going to take time....that one. I suspect I've mentioned this before so will beg forgiveness if I'm too repetative but....if I had just known, from the very start, that healing PF would absolutely take time and patience, I would not be here, three years later. I blame two things for that lack of knowledge, one, my own refusal to take the PF seriously in the first six to eight months, and, two, a serious lack of information from my docs. They essentially gave me a shot, some inserts, a shrug and said 'You're a tough jock, you'll lick this in no time'. That was so untrue! In fact, the advice should have been, 'You're a jock and you will find it tough to stay off your feet, but stay off them you must.'
There is no question in my mind that it wasn't until I learned on my own that consistent self-treatment and patience was key to recovery that I started to improve. I'll admit that I really wish the docs had been much more forceful with me. I think I took the PF only as seriously as they did and that was a mistake.
I think what you found to be 'satisfying and liberating' was, in fact, the simple step of acknowledgement, then empowerment in taking charge of your own healing.

Re: Healing and Liberation - Judy

Julie on 9/07/01 at 09:18 (059353)

Yes. Acknowledgement and empowerment, taking charge, but also just simple acceptance of the reality of PF, and of the open-ended time frame. I was luckier than you, though, in discovering heelspurs.com two weeks into PF pain. I wish you had been as lucky! But you've learned good lessons from it. Patience is a great lesson - one of the better ones, isn't it!?