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Random Thinking

Posted by john h on 1/25/02 at 10:30 (071240)

I know some of you are on crutches and some in wheelchairs with PF. I would like some of the Doctors to address my question/thoughts. If we imobilize the foot as when using crutches or splints for any length of time the muscles do atrophy. What happens to the tendons (fascia)? As the muscles atrophy and I suspect the tendons tend to contract. are we not now set up for an immediate reinjury of the fascia when weight is once again put on it? Would a person with PF not be better off not to stay on crutches for an extended period of time. Might they be doing more harm than good? I have not experienced a pain level that forced me to want to be on crutches so I am in the dark on that point but even with significant pain would it be more beneficial to use the foot some? If the fascia and muscles stay in a constant state of atrophy/contraction how can you not help but continuously reinjure yourself each time you do put weight on that foot? These are question for the doctors.

Re: Random Thinking

Dr. Zuckerman on 1/25/02 at 11:45 (071256)

John,

You bring up a very good point that needs to be addressed. Tendon, muscle atrophy can and does happen with any period of immoblization. Physical therapy needs to be a part of any type of casting or non-weight bearing treatment.

Re: Random Thinking

JudyS on 1/25/02 at 11:58 (071260)

Yes, a very good question, John h. If you think about it, it's the same as the issue with morning pain, right? The theory being that, in PF's acute stages, we reinjure the fascia with first steps each morning. So we try to warm it and flex it before getting up. And we use nite splints to keep the foot flexed a bit so it's not as stiff with first steps. If I recall correctly, one of the purposes of a cast or removable cast is to keep the foot flexed also. I remember also one or two of my pods saying that if we focused on eliminating the morning pain, we'd have most of the problem licked.
Isn't it true that most of us have found atrophy to be as much a problem as the original injury?

Re: Random Thinking

Carole C on 1/25/02 at 12:19 (071265)

I think this is quite true. I try to do my stretching regularly to combat this effect. My orthotics have a little bit of a heel lift, and it occurred to me when I first wore them that this might actually cause my tendons to become shorter and more prone to being strained, unless I look for ways to gently stretch them out. On the other hand, I don't think my tendons would have healed as fast as they did if I didn't have the heel lift.

It's a fine balance... we need to give our tendons some slack and rest them if we want them to heal, but we also need to maintain flexibility through limited gentle stretching and motion. Physical therapy is very interesting and I wish that I knew more about it.

Carole C

Re: Random Thinking/Dr Z.

john h on 1/25/02 at 12:59 (071269)

It sure seems that way Judy. I cannot remember many post that people said they were a lot better after a month in a cast. At least the cast is holding the foot in a neutral or dorsiflex position. If you are on crutches for several months your foot could very well be and more than likely in less than a neutral position with perhaps contracting muscles and tendons. Dr. Z made a statement if I understood him correctly that I had not realized. I think he said if you do not have 'first step morning pain' it is unlikely a fascia release will benefit you. Tell me if that is correct Dr. Z. That being the case I should never have had surgery.

Re: Random Thinking/Dr Z.

JudyS on 1/25/02 at 13:37 (071275)

The other thing about having any kind of cast or crutch immobilization is this - if one CAN walk on it, one WILL walk on it. I wonder if any of us can honestly say that we actually kept our weight off that cast during the entire treatment time.

Re: Random Thinking/Dr Z.

Glennx on 1/25/02 at 14:49 (071280)

John,
I've been battling this for many months. Foot isn't healed enough to safely put weight on. Atrophy is inevitable. Right calf is 2 centimeters less around than left, and the left isn't normal size. I manage to exercise the rest of my muscles good and I think that generally helps even my lower legs.

What else helps is using the PFT to mildly exercise my toe and foot muscles twice a day. (Suspect Alan K's device might work similarly and intend on getting one). PFT doesn't get foot tissues bulked up, but I think the muscles there remember their role better as a consequence. I also tape and do cautionary walking once a day. My theory here is that, similar to workouts on, say biceps, a few sets and reps can maintain a credible degree of tone even in the face of little use.

I'll sit on an exercise ball regularly and roll small (10') circles and figure eights for awhile. This gets my foot muscles and calves firing in a lot of different directions with minimal weight bearing. This doesn't build mass, and may not even tone, but I think it helps remind muscles of their role. I can even do this barefoot, but usually don't.

With passive stretching and night splints I've been able to maintain and improve achilles flexibility, so that's not an issue.

Lastly, diminished bone strength is a problem. Bones that aren't used lose mass. I take calcium and hope the occasional weight-on helps.

Re: Random Thinking/Dr Z.

nancy s. on 1/25/02 at 15:24 (071282)

yes, i agree here that atrophy can be a big problem. i HAD to seriously rest my pf foot after 8 months of worsening, and am a big believer in rest -- it helped my pf enormously -- but i think the atrophy led to the development of achilles, peroneal, and post. tib. tendonitis, in both feet.

during the rest i tried to do wall stretches, but weight-bearing exercises only made the pf worse. i halfheartedly tried other exercises, but stuck to nothing regularly. i think if i had found a good and gentle and nonweightbearing stretching and strengthening routine, i might well have been saved from the tendonitises that developed during my rest period.

they took as long as the pf to heal, if not longer. time in an aircast, along with simultaneous physical therapy and then use of the acu-flex, eventually got me back on my feet.
nancy

Re: Random Thinking

DJ on 1/25/02 at 18:20 (071301)

John,

In the two years I've been injured, I've spend two different periods on the crutches and in the boot. Both times I felt like I actually got WORSE after coming off the cruthes and outta the boot. I was on crutches for one month both times and in the boot for two months. Even after extensive physical therapy, I never have felt like I've gotten back to where I was BEFORE the crutches. This is something that I'm always hesitant to add when I discuss my condition with new doctors becuase it just doesn't make any sense at all and sometimes I think I may have just forgotten how bad it hurt. How can immobilization lead to more pain??? I have never had more pain in the morning. My pain increases with more activity so it actually hurts more in the afternoon. I also remember that the first day off crutches I was left with an incredible tightness in my calf and foot. There was no pain until the second or third day off back. It does seem that I caused more injury by inactivity.

Re: Would a brace be a compromise?

Beverly on 1/25/02 at 18:34 (071303)

Would a brace be a compromise - especially if you walk naturally/brace-free for short trips to the bathroom or to get a cup of coffee.

Muscle weakening is certainly something that has been on my mind since wearing this brace the last six weeks. I wear it whenever it leave the house and if I am on my feet in the house for more than about five minutes at a time - such as cooking dinner.

But I usually don't put it on just to get a cup of coffee, heat up my cereal for breakfast, or get up to go to the bathroom or other short trips about the house that take less than five minutes.

I also do range of motion stretching 3x a day although it is gentle nonweightbearing stuff.

I can see the brace is helping my PTTD. I hope I don't have to wear it indefinitely.
Beverly

Re: no first step pain no pf release

DR Zuckerman on 1/25/02 at 19:45 (071313)

I have found that the indication and sucess of pf release is to a great degree dependent on having the limping first step pain usually in the AM. Any doctor who doesn't agree please jump in here and explain

This is very important and every pf patient should know this before undergoing pf foot surgery release

Re: Random Thinking

Ed Davis, DPM on 1/25/02 at 19:55 (071316)

We place the foot in dorsiflexion when applying a cast for plantar fasciitis. That is, the cast is placed with the fascia under light tension, maintaining it in an elongated position. I recommend not casting for more than 3 weeks at a time in order to prevent atrophy.
Ed

Re: Random Thinking

Marie P on 1/28/02 at 09:24 (071613)

i agree
i was on crutches after my pf surgery also after getting BOTH achilles done but walked on feet when i felt i could to stop tendons 'shrinking' or worse like you said getting a fresh injury

Re: Random Thinking

Dr. Zuckerman on 1/25/02 at 11:45 (071256)

John,

You bring up a very good point that needs to be addressed. Tendon, muscle atrophy can and does happen with any period of immoblization. Physical therapy needs to be a part of any type of casting or non-weight bearing treatment.

Re: Random Thinking

JudyS on 1/25/02 at 11:58 (071260)

Yes, a very good question, John h. If you think about it, it's the same as the issue with morning pain, right? The theory being that, in PF's acute stages, we reinjure the fascia with first steps each morning. So we try to warm it and flex it before getting up. And we use nite splints to keep the foot flexed a bit so it's not as stiff with first steps. If I recall correctly, one of the purposes of a cast or removable cast is to keep the foot flexed also. I remember also one or two of my pods saying that if we focused on eliminating the morning pain, we'd have most of the problem licked.
Isn't it true that most of us have found atrophy to be as much a problem as the original injury?

Re: Random Thinking

Carole C on 1/25/02 at 12:19 (071265)

I think this is quite true. I try to do my stretching regularly to combat this effect. My orthotics have a little bit of a heel lift, and it occurred to me when I first wore them that this might actually cause my tendons to become shorter and more prone to being strained, unless I look for ways to gently stretch them out. On the other hand, I don't think my tendons would have healed as fast as they did if I didn't have the heel lift.

It's a fine balance... we need to give our tendons some slack and rest them if we want them to heal, but we also need to maintain flexibility through limited gentle stretching and motion. Physical therapy is very interesting and I wish that I knew more about it.

Carole C

Re: Random Thinking/Dr Z.

john h on 1/25/02 at 12:59 (071269)

It sure seems that way Judy. I cannot remember many post that people said they were a lot better after a month in a cast. At least the cast is holding the foot in a neutral or dorsiflex position. If you are on crutches for several months your foot could very well be and more than likely in less than a neutral position with perhaps contracting muscles and tendons. Dr. Z made a statement if I understood him correctly that I had not realized. I think he said if you do not have 'first step morning pain' it is unlikely a fascia release will benefit you. Tell me if that is correct Dr. Z. That being the case I should never have had surgery.

Re: Random Thinking/Dr Z.

JudyS on 1/25/02 at 13:37 (071275)

The other thing about having any kind of cast or crutch immobilization is this - if one CAN walk on it, one WILL walk on it. I wonder if any of us can honestly say that we actually kept our weight off that cast during the entire treatment time.

Re: Random Thinking/Dr Z.

Glennx on 1/25/02 at 14:49 (071280)

John,
I've been battling this for many months. Foot isn't healed enough to safely put weight on. Atrophy is inevitable. Right calf is 2 centimeters less around than left, and the left isn't normal size. I manage to exercise the rest of my muscles good and I think that generally helps even my lower legs.

What else helps is using the PFT to mildly exercise my toe and foot muscles twice a day. (Suspect Alan K's device might work similarly and intend on getting one). PFT doesn't get foot tissues bulked up, but I think the muscles there remember their role better as a consequence. I also tape and do cautionary walking once a day. My theory here is that, similar to workouts on, say biceps, a few sets and reps can maintain a credible degree of tone even in the face of little use.

I'll sit on an exercise ball regularly and roll small (10') circles and figure eights for awhile. This gets my foot muscles and calves firing in a lot of different directions with minimal weight bearing. This doesn't build mass, and may not even tone, but I think it helps remind muscles of their role. I can even do this barefoot, but usually don't.

With passive stretching and night splints I've been able to maintain and improve achilles flexibility, so that's not an issue.

Lastly, diminished bone strength is a problem. Bones that aren't used lose mass. I take calcium and hope the occasional weight-on helps.

Re: Random Thinking/Dr Z.

nancy s. on 1/25/02 at 15:24 (071282)

yes, i agree here that atrophy can be a big problem. i HAD to seriously rest my pf foot after 8 months of worsening, and am a big believer in rest -- it helped my pf enormously -- but i think the atrophy led to the development of achilles, peroneal, and post. tib. tendonitis, in both feet.

during the rest i tried to do wall stretches, but weight-bearing exercises only made the pf worse. i halfheartedly tried other exercises, but stuck to nothing regularly. i think if i had found a good and gentle and nonweightbearing stretching and strengthening routine, i might well have been saved from the tendonitises that developed during my rest period.

they took as long as the pf to heal, if not longer. time in an aircast, along with simultaneous physical therapy and then use of the acu-flex, eventually got me back on my feet.
nancy

Re: Random Thinking

DJ on 1/25/02 at 18:20 (071301)

John,

In the two years I've been injured, I've spend two different periods on the crutches and in the boot. Both times I felt like I actually got WORSE after coming off the cruthes and outta the boot. I was on crutches for one month both times and in the boot for two months. Even after extensive physical therapy, I never have felt like I've gotten back to where I was BEFORE the crutches. This is something that I'm always hesitant to add when I discuss my condition with new doctors becuase it just doesn't make any sense at all and sometimes I think I may have just forgotten how bad it hurt. How can immobilization lead to more pain??? I have never had more pain in the morning. My pain increases with more activity so it actually hurts more in the afternoon. I also remember that the first day off crutches I was left with an incredible tightness in my calf and foot. There was no pain until the second or third day off back. It does seem that I caused more injury by inactivity.

Re: Would a brace be a compromise?

Beverly on 1/25/02 at 18:34 (071303)

Would a brace be a compromise - especially if you walk naturally/brace-free for short trips to the bathroom or to get a cup of coffee.

Muscle weakening is certainly something that has been on my mind since wearing this brace the last six weeks. I wear it whenever it leave the house and if I am on my feet in the house for more than about five minutes at a time - such as cooking dinner.

But I usually don't put it on just to get a cup of coffee, heat up my cereal for breakfast, or get up to go to the bathroom or other short trips about the house that take less than five minutes.

I also do range of motion stretching 3x a day although it is gentle nonweightbearing stuff.

I can see the brace is helping my PTTD. I hope I don't have to wear it indefinitely.
Beverly

Re: no first step pain no pf release

DR Zuckerman on 1/25/02 at 19:45 (071313)

I have found that the indication and sucess of pf release is to a great degree dependent on having the limping first step pain usually in the AM. Any doctor who doesn't agree please jump in here and explain

This is very important and every pf patient should know this before undergoing pf foot surgery release

Re: Random Thinking

Ed Davis, DPM on 1/25/02 at 19:55 (071316)

We place the foot in dorsiflexion when applying a cast for plantar fasciitis. That is, the cast is placed with the fascia under light tension, maintaining it in an elongated position. I recommend not casting for more than 3 weeks at a time in order to prevent atrophy.
Ed

Re: Random Thinking

Marie P on 1/28/02 at 09:24 (071613)

i agree
i was on crutches after my pf surgery also after getting BOTH achilles done but walked on feet when i felt i could to stop tendons 'shrinking' or worse like you said getting a fresh injury