Home The Book Dr Articles Products Message Boards Journal Articles Search Our Surveys Surgery ESWT Dr Messages Find Good Drs video

pf/calf connection

Posted by John in Santa Cruz on 10/14/02 at 11:28 (097469)

I'd be interested to hear from anyone in the know about the connection between calves and pf. Is it that tight and/or weakness in the calves causes over pronation? What is the actual direct biomechanical connection here? There seems to be some real pf benefit to calf stretching & strengthening, but I can't seem to figure this one out. And, is it one particular muscle in the calf, or more the whole system? Benefits to strengthening as well as stretching? I am wondering if excercises that stretch the calf don't inadvertently also stretch the pf and arch muscles. When I stretch my calves, I often also feel the stretch through my arch. Is that where the real benefit lies?

Not that this matters all that much, whatever works, works, right?

John in SC

Re: pf/calf connection

Ellen J. on 10/14/02 at 21:01 (097497)

Hi John,.
Others will be able to explain better, but when you stretch the calves, you also end up stretching the fascia in the bottom of the foot. The doctor described it as 'The windlass effect' (sp?) which I won't attempt to describe since I don't sail.
Tight calf muscles can, in turn, pull on the fascia and stress it. The trick is to gently stretch the calf muscles without overdoing it and ripping the fascia which is in the process of healing. Also, we are discussing (in one of the threads below), the Trigger Point therapy and I posted a link about that. To very generally describe it, tight knots (trigger points) in the calves or other muscles send pain to distant areas of the body. Trigger points in the calves apparently create sensitive areas in the feet. Since I'm not very familiar with that subject either, I won't attempt to elaborate.
From what I have read, there are benefits to both strengthening and stretching and again, the trick is to do both without further irritation of the fascia in the feet. I'm not a doctor or P.T. however, so take my thoughts with a grain of salt.
Ellen

Re: pf/calf connection

Julie on 10/15/02 at 01:53 (097509)

John

The gastrocnemius and soleus muscles run into the achilles tendon, which runs into the plantar fascia: they are a continuum. If the gastro/soleus/achilles complex is tight, there is a constant pull on the plantar fascia, which - combined with other factors such as overweight, ageing, poor footgear, and too much impact exercise such as running or aerobics without sufficient stretching - may lead to the fascia pulling away from the calcaneus resulting in a case of classic PF.

There are other causes of PF, but a tight calf/achilles complex is certainly one of them, and lengthening that complex is one of the aims towards which treatment is directed. The challenge is how to stretch the calves without further injuring the fascia, and without irritating the achilles. My view on this, as a yoga teacher, former PF sufferer, and long-time reader of these message boards, is that weight-bearing exercise, such as the frequently-recommended wall stretch, almost always does more harm than good.

The night splint, which applies a gentle, consistent stretch to the calves is considered by the doctors here to be the most effective means of lengthening the complex and increasing the angle of dorsiflexion. The simple yoga exercises for the feet that I've posted here several times, will help to stretch the complex without irritating the inflamed tissues, strengthen the entire musculature of the foot, and increase blood flow to the area.

I don't think 'strengthening' the calf muscles is an aim in treating PF. Strengthening muscle fibres, unless you're awfully careful and very clued up anatomy-wise, will usually shorten them. But strengthening the muscles of the feet is certainly in order.

I hope this is helpful.

Re: Windlass effect

Julie on 10/15/02 at 02:12 (097511)

Ellen, the 'windlass effect' happens when the toes are pulled back towards the body, as in the towel-around-the-ball-of-the-foot exercise, or when the Strassberg Sock is worn.

Re: pf/calf connection

Ellen J. on 10/15/02 at 08:54 (097519)

Hi Julie,
Thanks for the correction on the windlass effect. Also, here's what my doctor described about the calf-fascia connection: He said that a tight calf muscle is retracted and pulls the heel bone back. Because the plantar fascia is attached to that same bone and the bone gets slightly displaced due to the pulling by the calf muscle, it stresses the fascia. Hopefully I understood his description. Does that sound right?
This is all interesting to me because I have a very tight calf and can't seem to get it to loosen yet. Am stretching and soon to do trigger point therapy.
Ellen J.

Re: pf/calf connection

Julie on 10/15/02 at 09:28 (097523)

Yes.

Ellen, I can't remember: have you tried the night splint in your struggle with your tight calf?

Good luck with the trigger point therapy.

Re: pf/calf connection

A Manoli MD on 10/15/02 at 14:25 (097548)

John,

you are correct.

This paper was presented at a recent American Orthopaedic Foot & Ankle Society Meeting:

The Effects of Duration and Frequency of Achilles Tendon Stretching on Dorsiflexion and Outcome in Painful Heel Syndrome: A Randomized, Blinded, Control Study
David Porter, M.D., Ph.D.; Erin Barrill, P.T., A.T.C.; Kathy Oneacre, A.T.C.; Benjamin D. May, M.S.

The American Orthop¾dic Foot and Ankle Society recommends at least six months of nonsurgical treatment before considering surgical intervention for painful heel syndrome. Achilles tendon stretching exercises are consistently reported to be one of the more effective nonsurgical modalities for treatment of painful heel syndrome. However, the optimal duration and frequency of the exercises has not been reported. The purpose of this study was to evaluate and compare the effectiveness of sustained and intermittent Achilles tendon stretching for the relief of pain associated with painful heel syndrome. This prospective, randomized, blinded study was performed from May 1997 to July 2000. A total of 94 people (122 affected feet) fit the inclusion criterion and agreed initially to participate in a treatment study group. To achieve our purpose, study participants were randomized into two stretching groups. One group performed sustained Achilles tendon stretches (three minutes, three times daily), the other performed intermittent stretches (five sets, 20 seconds each, two times daily). Participants were evaluated once a month for a period of four months subsequent to diagnosis. At each monthly visit, participants completed subjective questionnaires about their pain. Also, a physical therapist measured each participantÕs Achilles tendon flexibility. The study determined that both sustained and intermittent Achilles tendon stretching exercises increase Achilles tendon flexibility. This increase in flexibility correlated with a decrease in pain. There was no significant difference in outcome between the sustained and intermittent stretching groups. The data suggest that both sustained and intermittent Achilles tendon stretching exercises were effective nonsurgical treatments for painful heel syndrome.

i believe it may have been published recently, as well.

i fact, in cases of very refractory plantar fasciitis, at our clinic we will release the gastrocnemius muscle, when all conservative/other surgical measures fail. even in these very difficult cases, we have had 90% relief of pain.

am2

Re: pf/calf connection

Pauline on 10/15/02 at 15:02 (097550)

Dr. Manoli,
Is your practice including ESWT as part of the conservative treatment given before you attempt any surgical measures for plantar fasciitis? If so, what machine do you use? If not, are you considering incorporating it into your treatment for P.F. as a standard form of treatment.

I'd appreciate hearing your opinion on ESWT.

Re: pf/calf connection

Ellen J. on 10/15/02 at 15:43 (097553)

Hi Julie,
I have to admit I'm guilty of not trying the night splint because it looks so bulky and uncomfortable. I think I may try the strassburg sock, however, as it looks like something I could live with for awhile.
If the trigger point therapy works (when the doctor finally does it), I'll let people know. I have no idea if it will be a good thing or a bad thing, but it's worth a try. Thanks for wishing me luck on it!
Ellen J.

Re: pf/calf connection

John I on 10/15/02 at 15:56 (097556)

Thanks Dr. Manoli. In doing a bit of research on lower leg anatomy I found out that the posterior tibial tendon actually attaches to a small muscle in calf (which one?) and then to the underside of the foot, thereby supporting the arch and allowing the foot to turn inward. Could the PTT actually have a stronger direct impact on pf than the AT itself? This would make some degree of sense. I am still trying to figure out how the calf/pf connection actually works from a biomechanical standpoint. Of course it is never enough for me to know that something works and leave it at that. Am skeptical of a direct causal relationship between the Achilles and pf, but certainly do accept that stretching the Achillies is helpful for some reason. Am I correct that the the AT does not actually insert into the pf directly?

Re: pf/calf connection

pala on 10/15/02 at 18:18 (097562)

i have post tib dysfunction caused by tight calf weak ankles and flat feet. according to docs,

Re: pf/calf connection--where do hamstring stretches fit in?

Mike D on 10/15/02 at 23:40 (097592)

Where do stretches of the hamstrings fit into this? I found that achilles tendon stretches with calf stretches were very helpful, but when I added hamstring stretches, things really began to improve for me.

Re: pf/calf connection

Julie on 10/16/02 at 03:37 (097599)

Ellen have a look at the night splint that Scott sells on the website. It's said to be softer and much more comfortable than other brands, and there have been many good reports of it.

Re: pf/calf connection--where do hamstring stretches fit in?

Ellen J. on 10/16/02 at 07:59 (097604)

I too am interested in this, as I am finding a connection between hamstrings and the feet. Hopefully someone can answer this one. The tighter my hamstrings are, the worse my feet get.
Ellen

Re: Re:night splint vs Strassburg sock

Ellen J. on 10/16/02 at 08:01 (097605)

Hi Julie,
I had just looked at that a couple of weeks ago and it does look much better than the old version. How does the Strassburg Sock compare? Have you heard anything about that?
Ellen

Re: To John, calf tightness/pf pain

A Manoli MD on 10/16/02 at 09:44 (097615)

it was once common belief that the achilles insertion and the plantar fascia were a continuous sheet, but somebody in the foot society presented a paper a couple of years ago which showed that, actually, they were discontinuous, with a bit of the calcaneus sticking out between the achilles insertion and the pf origin.

it probably doesn't really matter that this is the case, as the achlles still has a tremendous effect on the pf origin, anyway. imagine a real tight achilles pushing the metatarsal heads into the ground. the fascia, muscles, and tendons on the bottom of the foot are all under stretch, as the are the 'string of the bow, resisting the arch flattening.'

also, if the toes dorsiflex a bit, the windlass mechanism also comes into effect, pulling on the pf and understructures, as well. if you passively dorsiflex your great toe, notice that the arch increases. this is the windlass effect.

both of these increase the tension in the pf. maybe this strain is the cause of the pain that is felt. zingas has shown that the pf tissue at the origin actually changes into fibrocartilage with time. we've shown that the post tibial tendon does the same in post tib insufficiency, which is also driven by a tight achilles (primarily the gastroc portion). as the ankle can only dorsiflex by everting through the subtalar joint, strain is put in the pt tendon, and spring lig, causing failure, and metaplasia into fibrocartilage.

yes, the hamstrings are often tight when the gastroc is tight. both atavistic traits.

enough.....eh?

am2

Re: To John, calf tightness/pf pain

John In Santa Cruz on 10/16/02 at 10:08 (097617)

Thanks alot Doc. That was just the explanation I was looking for. Appreciate the freebie anatomy lesson.

John

Re: Re:night splint vs Strassburg sock

Julie on 10/16/02 at 11:05 (097624)

Hi Ellen

I would think the night splint would be better. I'm not sure about the effectiveness of engaging the windlass effect (which is what the Strassberg Sock does). But I really don't know, and this is an unfounded opinion which I've raked up only because you've asked me! I've thought about it - but I haven't used either.

Dr Wander was talking about the SS a few weeks ago, but I don't recall any reports of it from users in the past couple of years. Have you done a search? Perhaps there are some contributions from the more distant past. There have been lots of favourable reports on the N'Ice Stretch night splint.

Re: pf/calf connection--where do hamstring stretches fit in?

Julie on 10/16/02 at 11:09 (097625)

All these structures are related: calves, hamstrings, lower back. Tightness anywhere along that continuum will effect all the other bits of the continuum. The aim - right through the body - is nicely stretched, lengthened muscles that allow free, optimum movement. So yes, stretching the hamstrings will help PF. I suppose the reason the focus here is on the gastro/soleus/achilles complex is that tightness there is the main PF culprit.

Re: Achilles and plantar fascia

Julie on 10/16/02 at 11:24 (097626)

This question, John, has been occupying me all day - and your reply, Dr Manoli, is really interesting.

When I saw the question this morning I would have said that yes, the tendon and the fascia were continuous, but as it happened I was just going out to revisit the Bodyworlds exhibition this morning, so I reserved judgement and made a point of investigating it there.

(Bodyworlds, in case you're not familiar with it in the States, is an exhibition of human bodies preserved by a process called plastination, devised by a German professor of anatomy. One can view bones, joints, muscles, ligaments, tendons, nerves, organs. It sounds ghoulish, but it's both highly educational and astonishingly beautiful, and if it comes to the States I hope some of you can see it.)

Anyway. I got down on the floor to examine closely the calves, heels and arches of every one of the bodies, and it certainly looked to me as though the tendon passes uninterruptedly into the fascia. If there was a bit of the calcaneus sticking out between the achilles origin and the PF insertion, I couldn't see it!

I'm not arguing with you, Dr M, or with the paper you cited, and as you say, it really makes no difference: the effect of one on the other is there whether continuous or discontinuous. But now I don't know what to think.

Back to the anatomy textbooks.

Re: pf/calf connection

john h on 10/16/02 at 12:10 (097627)

Dr. Manoli: Your data is actually the first medical data/paper I have seen on achilles stretching. Appreciate your input. Some years ago I had a severe case of achilles tendonitis with a large knot on the tendon. I could barely walk. Two weeks of physical thearapy wich included vigorous stretchng using both an incline board and the runners stretch were instrumental in curing this problem Also the thearapist used very very vigorous massage of the tendon which was super painful. It all worked but of course I was not dealing with PF at the time.

Re: pf/calf connection

john h on 10/16/02 at 12:13 (097628)

Ellen: You really need to give the night splint a try. Not one of those bulky uncomfortable ones but one like Scott sells or used to sell. It is easy to sleep in, very adjustable, and can be very effective. I have about worn mine out and may have to buy another one from Scott.

Re: Re:night splint vs Strassburg sock

john h on 10/16/02 at 12:19 (097630)

Ellen: I used the straussberg sock for about a month and did not like it compared to a conventional night splint. It would come loose at night and seemed to concentrate on bending my great toe.

Re: pf/calf connection

Ellen J. on 10/16/02 at 12:36 (097634)

Thanks, I'll give it a try and I sure hope it works. After having this for 3 yrs. I would love to become as active as I was before this problem set in.
Sounds like you have been wearing yours for awhile and I'm glad you are finding it beneficial.
Ellen

Re: Re:night splint vs Strassburg sock

Ellen J. on 10/16/02 at 12:42 (097636)

Sounds like the night splint is the way to go. I was just reading somewhere that massaging the calves has also been very beneficial to some people so I'm doing that too. The massage is in addition to a night splint--not in place of it. The big question in my mind these days is whether simple stretching over a long period of time, will in and of itself remove adhesions, or whether massage is necessary to break them up.
Well, thanks for all the input on the night splint. Time for me to bite the bullet on this, I guess.
Ellen

Re: question for Dr. Manoli

elliott on 10/16/02 at 12:51 (097640)

Any reason this study didn't have a control group that didn't stretch at all? Just as with ESWT, this may be important, since many having PF, especially those in the earlier stages (as I gather those in this study were), get better doing nothing.

Thanks.

[]

Re: To John, calf tightness/pf pain

Mike W on 10/16/02 at 13:37 (097643)

Hello Dr. Manoli,

Do you know which achilles tendon stretches were performed in the study?

Regards,

Mike W

Re: Re:night splint vs Strassburg sock

Julie on 10/16/02 at 16:03 (097651)

Ellen, if you have adhesions (do you? what from?) I think massage is called for. I seriously doubt whether stretching will do the job.

After my mastectomy some years ago my PT made very clear that vigorous massage along the line of the scar was necessary to avoid adhesions. That was in addition to some quite aggressive stretching to undo all the muscle spasms and regain my lost movement. Both worked.

Different part of the anatomy of course, but an adhesion is an adhesion.

Re: Re:adhesions/massage

Ellen J. on 10/16/02 at 16:25 (097656)

Hi Julie,
It sounds like the massage and stretching really helped you. What a thing to go through for you, and I've had a few of my friends who went through the same thing. All are doing well, even years afterward.
Anyway, the doctor said that after years of chronic inflammation in the fascia, that adhesions would probably be in the area. I don't know if that's true or not. Also, he says that adhesions form at the trigger point sites of the muscles anywhere in the body and that the trigger points contribute to retraction/cramping of the muscle. That's why he wants to do massage of the calf and hip/leg muscles wherever there are trigger points. He doesn't want to touch the feet for fear of generating pain there, although massage is sometimes indicated on the feet of P.F. patients if they can tolerate it without it aggravating the condition.
Hopefully I've explained the doctor's info correctly. It's hard to summarize in a paragraoh.
I think the night splint would complement the massage/stretching of the calf muscles.
Ellen J.

Re: pf/calf connection

Ellen J. on 10/14/02 at 21:01 (097497)

Hi John,.
Others will be able to explain better, but when you stretch the calves, you also end up stretching the fascia in the bottom of the foot. The doctor described it as 'The windlass effect' (sp?) which I won't attempt to describe since I don't sail.
Tight calf muscles can, in turn, pull on the fascia and stress it. The trick is to gently stretch the calf muscles without overdoing it and ripping the fascia which is in the process of healing. Also, we are discussing (in one of the threads below), the Trigger Point therapy and I posted a link about that. To very generally describe it, tight knots (trigger points) in the calves or other muscles send pain to distant areas of the body. Trigger points in the calves apparently create sensitive areas in the feet. Since I'm not very familiar with that subject either, I won't attempt to elaborate.
From what I have read, there are benefits to both strengthening and stretching and again, the trick is to do both without further irritation of the fascia in the feet. I'm not a doctor or P.T. however, so take my thoughts with a grain of salt.
Ellen

Re: pf/calf connection

Julie on 10/15/02 at 01:53 (097509)

John

The gastrocnemius and soleus muscles run into the achilles tendon, which runs into the plantar fascia: they are a continuum. If the gastro/soleus/achilles complex is tight, there is a constant pull on the plantar fascia, which - combined with other factors such as overweight, ageing, poor footgear, and too much impact exercise such as running or aerobics without sufficient stretching - may lead to the fascia pulling away from the calcaneus resulting in a case of classic PF.

There are other causes of PF, but a tight calf/achilles complex is certainly one of them, and lengthening that complex is one of the aims towards which treatment is directed. The challenge is how to stretch the calves without further injuring the fascia, and without irritating the achilles. My view on this, as a yoga teacher, former PF sufferer, and long-time reader of these message boards, is that weight-bearing exercise, such as the frequently-recommended wall stretch, almost always does more harm than good.

The night splint, which applies a gentle, consistent stretch to the calves is considered by the doctors here to be the most effective means of lengthening the complex and increasing the angle of dorsiflexion. The simple yoga exercises for the feet that I've posted here several times, will help to stretch the complex without irritating the inflamed tissues, strengthen the entire musculature of the foot, and increase blood flow to the area.

I don't think 'strengthening' the calf muscles is an aim in treating PF. Strengthening muscle fibres, unless you're awfully careful and very clued up anatomy-wise, will usually shorten them. But strengthening the muscles of the feet is certainly in order.

I hope this is helpful.

Re: Windlass effect

Julie on 10/15/02 at 02:12 (097511)

Ellen, the 'windlass effect' happens when the toes are pulled back towards the body, as in the towel-around-the-ball-of-the-foot exercise, or when the Strassberg Sock is worn.

Re: pf/calf connection

Ellen J. on 10/15/02 at 08:54 (097519)

Hi Julie,
Thanks for the correction on the windlass effect. Also, here's what my doctor described about the calf-fascia connection: He said that a tight calf muscle is retracted and pulls the heel bone back. Because the plantar fascia is attached to that same bone and the bone gets slightly displaced due to the pulling by the calf muscle, it stresses the fascia. Hopefully I understood his description. Does that sound right?
This is all interesting to me because I have a very tight calf and can't seem to get it to loosen yet. Am stretching and soon to do trigger point therapy.
Ellen J.

Re: pf/calf connection

Julie on 10/15/02 at 09:28 (097523)

Yes.

Ellen, I can't remember: have you tried the night splint in your struggle with your tight calf?

Good luck with the trigger point therapy.

Re: pf/calf connection

A Manoli MD on 10/15/02 at 14:25 (097548)

John,

you are correct.

This paper was presented at a recent American Orthopaedic Foot & Ankle Society Meeting:

The Effects of Duration and Frequency of Achilles Tendon Stretching on Dorsiflexion and Outcome in Painful Heel Syndrome: A Randomized, Blinded, Control Study
David Porter, M.D., Ph.D.; Erin Barrill, P.T., A.T.C.; Kathy Oneacre, A.T.C.; Benjamin D. May, M.S.

The American Orthop¾dic Foot and Ankle Society recommends at least six months of nonsurgical treatment before considering surgical intervention for painful heel syndrome. Achilles tendon stretching exercises are consistently reported to be one of the more effective nonsurgical modalities for treatment of painful heel syndrome. However, the optimal duration and frequency of the exercises has not been reported. The purpose of this study was to evaluate and compare the effectiveness of sustained and intermittent Achilles tendon stretching for the relief of pain associated with painful heel syndrome. This prospective, randomized, blinded study was performed from May 1997 to July 2000. A total of 94 people (122 affected feet) fit the inclusion criterion and agreed initially to participate in a treatment study group. To achieve our purpose, study participants were randomized into two stretching groups. One group performed sustained Achilles tendon stretches (three minutes, three times daily), the other performed intermittent stretches (five sets, 20 seconds each, two times daily). Participants were evaluated once a month for a period of four months subsequent to diagnosis. At each monthly visit, participants completed subjective questionnaires about their pain. Also, a physical therapist measured each participantÕs Achilles tendon flexibility. The study determined that both sustained and intermittent Achilles tendon stretching exercises increase Achilles tendon flexibility. This increase in flexibility correlated with a decrease in pain. There was no significant difference in outcome between the sustained and intermittent stretching groups. The data suggest that both sustained and intermittent Achilles tendon stretching exercises were effective nonsurgical treatments for painful heel syndrome.

i believe it may have been published recently, as well.

i fact, in cases of very refractory plantar fasciitis, at our clinic we will release the gastrocnemius muscle, when all conservative/other surgical measures fail. even in these very difficult cases, we have had 90% relief of pain.

am2

Re: pf/calf connection

Pauline on 10/15/02 at 15:02 (097550)

Dr. Manoli,
Is your practice including ESWT as part of the conservative treatment given before you attempt any surgical measures for plantar fasciitis? If so, what machine do you use? If not, are you considering incorporating it into your treatment for P.F. as a standard form of treatment.

I'd appreciate hearing your opinion on ESWT.

Re: pf/calf connection

Ellen J. on 10/15/02 at 15:43 (097553)

Hi Julie,
I have to admit I'm guilty of not trying the night splint because it looks so bulky and uncomfortable. I think I may try the strassburg sock, however, as it looks like something I could live with for awhile.
If the trigger point therapy works (when the doctor finally does it), I'll let people know. I have no idea if it will be a good thing or a bad thing, but it's worth a try. Thanks for wishing me luck on it!
Ellen J.

Re: pf/calf connection

John I on 10/15/02 at 15:56 (097556)

Thanks Dr. Manoli. In doing a bit of research on lower leg anatomy I found out that the posterior tibial tendon actually attaches to a small muscle in calf (which one?) and then to the underside of the foot, thereby supporting the arch and allowing the foot to turn inward. Could the PTT actually have a stronger direct impact on pf than the AT itself? This would make some degree of sense. I am still trying to figure out how the calf/pf connection actually works from a biomechanical standpoint. Of course it is never enough for me to know that something works and leave it at that. Am skeptical of a direct causal relationship between the Achilles and pf, but certainly do accept that stretching the Achillies is helpful for some reason. Am I correct that the the AT does not actually insert into the pf directly?

Re: pf/calf connection

pala on 10/15/02 at 18:18 (097562)

i have post tib dysfunction caused by tight calf weak ankles and flat feet. according to docs,

Re: pf/calf connection--where do hamstring stretches fit in?

Mike D on 10/15/02 at 23:40 (097592)

Where do stretches of the hamstrings fit into this? I found that achilles tendon stretches with calf stretches were very helpful, but when I added hamstring stretches, things really began to improve for me.

Re: pf/calf connection

Julie on 10/16/02 at 03:37 (097599)

Ellen have a look at the night splint that Scott sells on the website. It's said to be softer and much more comfortable than other brands, and there have been many good reports of it.

Re: pf/calf connection--where do hamstring stretches fit in?

Ellen J. on 10/16/02 at 07:59 (097604)

I too am interested in this, as I am finding a connection between hamstrings and the feet. Hopefully someone can answer this one. The tighter my hamstrings are, the worse my feet get.
Ellen

Re: Re:night splint vs Strassburg sock

Ellen J. on 10/16/02 at 08:01 (097605)

Hi Julie,
I had just looked at that a couple of weeks ago and it does look much better than the old version. How does the Strassburg Sock compare? Have you heard anything about that?
Ellen

Re: To John, calf tightness/pf pain

A Manoli MD on 10/16/02 at 09:44 (097615)

it was once common belief that the achilles insertion and the plantar fascia were a continuous sheet, but somebody in the foot society presented a paper a couple of years ago which showed that, actually, they were discontinuous, with a bit of the calcaneus sticking out between the achilles insertion and the pf origin.

it probably doesn't really matter that this is the case, as the achlles still has a tremendous effect on the pf origin, anyway. imagine a real tight achilles pushing the metatarsal heads into the ground. the fascia, muscles, and tendons on the bottom of the foot are all under stretch, as the are the 'string of the bow, resisting the arch flattening.'

also, if the toes dorsiflex a bit, the windlass mechanism also comes into effect, pulling on the pf and understructures, as well. if you passively dorsiflex your great toe, notice that the arch increases. this is the windlass effect.

both of these increase the tension in the pf. maybe this strain is the cause of the pain that is felt. zingas has shown that the pf tissue at the origin actually changes into fibrocartilage with time. we've shown that the post tibial tendon does the same in post tib insufficiency, which is also driven by a tight achilles (primarily the gastroc portion). as the ankle can only dorsiflex by everting through the subtalar joint, strain is put in the pt tendon, and spring lig, causing failure, and metaplasia into fibrocartilage.

yes, the hamstrings are often tight when the gastroc is tight. both atavistic traits.

enough.....eh?

am2

Re: To John, calf tightness/pf pain

John In Santa Cruz on 10/16/02 at 10:08 (097617)

Thanks alot Doc. That was just the explanation I was looking for. Appreciate the freebie anatomy lesson.

John

Re: Re:night splint vs Strassburg sock

Julie on 10/16/02 at 11:05 (097624)

Hi Ellen

I would think the night splint would be better. I'm not sure about the effectiveness of engaging the windlass effect (which is what the Strassberg Sock does). But I really don't know, and this is an unfounded opinion which I've raked up only because you've asked me! I've thought about it - but I haven't used either.

Dr Wander was talking about the SS a few weeks ago, but I don't recall any reports of it from users in the past couple of years. Have you done a search? Perhaps there are some contributions from the more distant past. There have been lots of favourable reports on the N'Ice Stretch night splint.

Re: pf/calf connection--where do hamstring stretches fit in?

Julie on 10/16/02 at 11:09 (097625)

All these structures are related: calves, hamstrings, lower back. Tightness anywhere along that continuum will effect all the other bits of the continuum. The aim - right through the body - is nicely stretched, lengthened muscles that allow free, optimum movement. So yes, stretching the hamstrings will help PF. I suppose the reason the focus here is on the gastro/soleus/achilles complex is that tightness there is the main PF culprit.

Re: Achilles and plantar fascia

Julie on 10/16/02 at 11:24 (097626)

This question, John, has been occupying me all day - and your reply, Dr Manoli, is really interesting.

When I saw the question this morning I would have said that yes, the tendon and the fascia were continuous, but as it happened I was just going out to revisit the Bodyworlds exhibition this morning, so I reserved judgement and made a point of investigating it there.

(Bodyworlds, in case you're not familiar with it in the States, is an exhibition of human bodies preserved by a process called plastination, devised by a German professor of anatomy. One can view bones, joints, muscles, ligaments, tendons, nerves, organs. It sounds ghoulish, but it's both highly educational and astonishingly beautiful, and if it comes to the States I hope some of you can see it.)

Anyway. I got down on the floor to examine closely the calves, heels and arches of every one of the bodies, and it certainly looked to me as though the tendon passes uninterruptedly into the fascia. If there was a bit of the calcaneus sticking out between the achilles origin and the PF insertion, I couldn't see it!

I'm not arguing with you, Dr M, or with the paper you cited, and as you say, it really makes no difference: the effect of one on the other is there whether continuous or discontinuous. But now I don't know what to think.

Back to the anatomy textbooks.

Re: pf/calf connection

john h on 10/16/02 at 12:10 (097627)

Dr. Manoli: Your data is actually the first medical data/paper I have seen on achilles stretching. Appreciate your input. Some years ago I had a severe case of achilles tendonitis with a large knot on the tendon. I could barely walk. Two weeks of physical thearapy wich included vigorous stretchng using both an incline board and the runners stretch were instrumental in curing this problem Also the thearapist used very very vigorous massage of the tendon which was super painful. It all worked but of course I was not dealing with PF at the time.

Re: pf/calf connection

john h on 10/16/02 at 12:13 (097628)

Ellen: You really need to give the night splint a try. Not one of those bulky uncomfortable ones but one like Scott sells or used to sell. It is easy to sleep in, very adjustable, and can be very effective. I have about worn mine out and may have to buy another one from Scott.

Re: Re:night splint vs Strassburg sock

john h on 10/16/02 at 12:19 (097630)

Ellen: I used the straussberg sock for about a month and did not like it compared to a conventional night splint. It would come loose at night and seemed to concentrate on bending my great toe.

Re: pf/calf connection

Ellen J. on 10/16/02 at 12:36 (097634)

Thanks, I'll give it a try and I sure hope it works. After having this for 3 yrs. I would love to become as active as I was before this problem set in.
Sounds like you have been wearing yours for awhile and I'm glad you are finding it beneficial.
Ellen

Re: Re:night splint vs Strassburg sock

Ellen J. on 10/16/02 at 12:42 (097636)

Sounds like the night splint is the way to go. I was just reading somewhere that massaging the calves has also been very beneficial to some people so I'm doing that too. The massage is in addition to a night splint--not in place of it. The big question in my mind these days is whether simple stretching over a long period of time, will in and of itself remove adhesions, or whether massage is necessary to break them up.
Well, thanks for all the input on the night splint. Time for me to bite the bullet on this, I guess.
Ellen

Re: question for Dr. Manoli

elliott on 10/16/02 at 12:51 (097640)

Any reason this study didn't have a control group that didn't stretch at all? Just as with ESWT, this may be important, since many having PF, especially those in the earlier stages (as I gather those in this study were), get better doing nothing.

Thanks.

[]

Re: To John, calf tightness/pf pain

Mike W on 10/16/02 at 13:37 (097643)

Hello Dr. Manoli,

Do you know which achilles tendon stretches were performed in the study?

Regards,

Mike W

Re: Re:night splint vs Strassburg sock

Julie on 10/16/02 at 16:03 (097651)

Ellen, if you have adhesions (do you? what from?) I think massage is called for. I seriously doubt whether stretching will do the job.

After my mastectomy some years ago my PT made very clear that vigorous massage along the line of the scar was necessary to avoid adhesions. That was in addition to some quite aggressive stretching to undo all the muscle spasms and regain my lost movement. Both worked.

Different part of the anatomy of course, but an adhesion is an adhesion.

Re: Re:adhesions/massage

Ellen J. on 10/16/02 at 16:25 (097656)

Hi Julie,
It sounds like the massage and stretching really helped you. What a thing to go through for you, and I've had a few of my friends who went through the same thing. All are doing well, even years afterward.
Anyway, the doctor said that after years of chronic inflammation in the fascia, that adhesions would probably be in the area. I don't know if that's true or not. Also, he says that adhesions form at the trigger point sites of the muscles anywhere in the body and that the trigger points contribute to retraction/cramping of the muscle. That's why he wants to do massage of the calf and hip/leg muscles wherever there are trigger points. He doesn't want to touch the feet for fear of generating pain there, although massage is sometimes indicated on the feet of P.F. patients if they can tolerate it without it aggravating the condition.
Hopefully I've explained the doctor's info correctly. It's hard to summarize in a paragraoh.
I think the night splint would complement the massage/stretching of the calf muscles.
Ellen J.