Regional Interdependence Utilizing Dynamic Hip

Control and Strengthening as a Treatment for

Plantar Fasciitis

Capstone Presentation: December 2016

Author: Zac Lynch

East Tennessee State University

Outline

Introduction and overview of the case report

Current best evidence

Case description

Examination

Differential diagnosis and impression

Intervention

Outcome

Discussion and review

References

Introduction1,2

Plantar fasciitis

Sedentary vs active injuries

Long distance runner with signs and symptoms of right-sided

plantar fasciitis

Proximal impairment, distal pain

Current Evidence – Martin, et al.2

• Joint and soft tissue

mobilization

• Passive fascia stretching

• Gastrocnemius and soleus

stretching

• Anti-excessive pronation

therapeutic taping

• Medial arch support for heel

strike maintenance

• Night splints

• Phonophoresis

• Shoe rotation

• Strengthening and movement

correction

Current Evidence – Young, et al.3

Posterior talocrural joint mobilization

Subtalar joint distraction mobilization and manipulation

Triceps surae stretching

Plantar fascia stretching

Self AP mobilization at home

Current Evidence4,5,6

Rathleff, et al.

High-load progressive

strength training

performed every second

day. Consisted of

unilateral heel raises with

a towel inserted under the

toes.

Cole, et al.

One article stated that custom-made splints help promote maintenance of range of motion.

Chien-Tsung Tsai, et al.

Kinesiotaping in comparison to standardized stretching and strengthening of the ankle and foot.

Current Evidence – Urovitz, et al.7

Systematic review reported that home based exercises

focused on stretching the calf muscles, plantar fascia, flexor

hallicus longus, and Achilles tendon proved to be a superior

treatment option for short and long term effects of plantar

fasciitis

This review compared exercises to control group therapy,

exercises with a custom orthoses, foot insoles and exercise

therapy, calcaneal taping, iontophoresis

Limitations to “Current Evidence”

Pathoanatomic pendulum

Lack of movement based, performance based evaluations such as

FMS, MDT systems

Interventions focused on the painful region

CPG briefly mention treating the hip for biomechanical deviations

Passive treatments

Poor injury prevention education, lack of prophylaxis

Case Description

Examination

NPRS

4/10 currently and consistently

6/10 exacerbation during running

Subjective

Jumping, running increased symptoms

Ice massage, anti-inflammatory OTC medication briefly eased symptoms

Painful areas and body chart

Goals

Return to running without pain

Examination

Vital Signs

Blood Pressure (mmHg)

130/82

Heart Rate (BPM)

59

Body Mass Index

25.33

Oxygen Saturation (%)

98

Examination

Palpation

Increased muscle tone at distal right Triceps Surae

Tenderness medial slip and origin of right plantar fascia

Posterior Tibialis at level of Medial Mallelous

Achilles Tendon – midportion and insertion

Range of Motion

Examination

Strength

Examination

Neurological and Edema Assessment

Special Tests

Examination

Observational Gait

Analysis

Functional Strength

and Motor Control

Testing

Clinical Diagnosis and Plan of Care

Two separate anatomical areas that are impaired due to regional interdependence

Hip

Foot

Plan of Care

LTG 4-6 weeks at 2 times/wk

Dec p!, graded exposure, inc strength

Regain and restore normal function

Intervention8,9

Passive Modalities

Phonophoresis – Medial slip of plantar fascia at the origin

US gel + Dexamethasone Phosphate (0.4%) with a setting of 3.3 MHz, 1.0W/cm, 50% pulsed at 5 minutes

Applied prior to exercise in order to allow medication to promote anti-inflammatory effects during therapeutic movements

Cryotherapy to right ankle and foot

15 minutes application for short term pain relief

Applied after treatment in order to avoid a decrease in nerve conduction velocity prior to movement

Intervention10-12

Manual Therapy

Joint Mobilization

Talocrural

Mobilization with Movement

CKC dorsiflexion technique with strap

Passive Range of Motion

Knee extension and ankle dorsiflexion

Intervention13-15

Strengthening

Eccentric strengthening for hip external rotation

Manually resisted side-lying hip external rotation

Hip abduction strengthening for distal mechanical correction

Concentric and eccentric lower extremity exercise in order to provide stability and motor control during dynamic movements

Intervention2,16

Stretching

Gastrocnemius

Soleus

Hamstrings

Exe

rcis

e D

osa

ge

Exercise Dosage

Outcomes

D/C after 8 treatment sessions

Improvement in strength and ROM to that of contralateral LE

Improvement in proper mechanics during gait analysis and running

Decrease in resting high muscle tone

The patient ran a half marathon two days prior to discharge. Reported no pain, stiffness, or restriction before/during/after the race

Discussion2,17-21

CPGs interventions suggested:

Manual therapy of the lower extremity, being joint mobilization/soft tissue mobilization

Stretching of plantar fascia, gastrocnemius, soleus

Anti-pronation taping of the ankle and foot

Orthoses to support medial longitudinal arch of the foot

Night splints to prevent morning stiffness

Low-level laser therapy

Phonophoresis

Rocker-bottom shoe fabrication with implementation of a foot orthosis

Rotation of shoes during the work week

Education about weight loss

Strengthening and movement correction of muscles correlated to weight bearing forces and pronation control

Discussion2,17-21

As we utilized many of the interventions recommended in the current CPG for plantar fasciitis, we also utilized a treatment philosophy called REGIONAL INTERDEPENDENCE in order to facilitate improvement of plantar fasciitis signs and symptoms, and also underlying pathology

Our approach encompassed strengthening and the promotion of motor control exercises of the right side hip in order to control movement in the sagittal and frontal plane and correct abnormal movement at the knee and the foot

Discussion2,17-21

Regional Interdependence - a theoretical model structured on

improvements of sport specific movements rather than just

treating the presenting complaint, pain

Impairments of right hip external rotation and abduction motor

control lead to the patient compensating with knee valgus

positioning during the weight acceptance phase, and forceful

pronation of the right foot during weight acceptance through

the mid-foot and heel-off portions of the gait cycle

Discussion2,17-21

This case report suggests that the regional interdependence

model is appropriate for treating anatomical areas related to,

but not in the same region as the chief complaint

Limitations2

Lack of use of patient reported outcome measures

Suggestions from CPG:

Foot Function Index

Foot Health Status Questionnaire

Foot and Ankle Ability Measure

Lower Extremity Functional Scale

Conclusion

Regional interdependence was utilized in order to identify and manage contributions of weakness and motor control issues in the proximal hip that led to plantar fasciitis signs and symptoms

Improvement in pain and performance of the patient’s recreational activities

D/C with no pain, improved display of dynamic movements and high intensity running

Further research is warranted to clarify the regional interdependence correlation to ipsilateral hip impairment and distal foot plantar fasciitis

References

1. Thompson JV, Saini SS, Reb CW, et a.. Diagnosis and Management of Plantar Fasciitis. J Am Osteopath Assoc2014;114(12):900-901. doi: 10.7556/jaoa.2014.177.

2. Martin RL, Davenport TE, Reischl SF, et al. Heel pain-plantar fasciitis: revision 2014. J Orthop Sports Phys Ther. 2014;44(11):A1-33.

3. Young B, Walker MJ, Strunce J et al. A combined treatment approach emphasizing impairment-based manual physical therapy for plantar heal pain: a case series. JOSPT. 2004;34:725-733.

4. Rathleff MS, Mølgaard CM, Fredberg U, et al. High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial.

5. Cole C, Seto C, Gazewood J. Plantar fasciitis: evidence-based review of diagnosis and therapy. Am FamPhysician. 2005 Dec 1;72(11):2237-42.

6. Chien-Tsung Tsai et al., Effects of Short-Term Treatment with kinesiotaping for Plantar fasciitis, Journal of Musculoskeletal Pain, March 2010, Vol. 18, No. 1, Pages 71-80.

7. Urovitz EP, Birk-Urovitz A, Birk-Urovitz E. Endoscopic plantar fasciotomy in the treatment of chronic heel pain. Can J Surg. 2008 Aug;51(4):281-3

References

8. Landrum EL, Kelln CB, Parente WR, et al. Immediate Effects of Anterior-to-Posterior Talocrural Joint Mobilization after Prolonged Ankle Immobilization: A Preliminary Study. J Man Manip Ther. 2008;16(2):100-5

9. Deshpande MM, Patil CB. Heel pain and phonophoresis. J Indian Med Assoc. 2010;108(6):365.

10. Jerrold S. Petrofsky, Michael S. Laymon, Faris Alshammari, et al. Evidence Based use of Heat, Cold and NSAIDS for Plantar Fasciitis. Clinical Research on Foot & Ankle. 2014.

11. Landrum EL, Kelln CB, Parente WR, et al. Immediate Effects of Anterior-to-Posterior Talocrural Joint Mobilization after Prolonged Ankle Immobilization: A Preliminary

11. Vicenzino B, Branjerdporn M, Teys P, et al. Initial changes in posterior talar glide and dorsiflexion of the ankle after mobilization with movement in individuals with recurrent ankle sprain. J Orthop Sports Phys Ther. 2006;36(7):464-71.

12. Landrum EL, Kelln CB, Parente WR, et al. Immediate Effects of Anterior-to-Posterior Talocrural Joint Mobilization after Prolonged Ankle Immobilization: A Preliminary Study. J Man Manip Ther. 2008;16(2):100-5.

13. Nakagawa TH, Muniz TB, Baldon Rde M, et al. The effect of additional strengthening of hip abductor and lateral rotator muscles in patellofemoral pain syndrome: a randomized controlled pilot study. Clin Rehabil. 2008;22(12):1051-60.

References

14. Woitzik E, Jacobs C, Wong JJ, et al. The effectiveness of exercise on recovery and clinical outcomes of soft tissue injuries of the leg, ankle, and foot: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Man Ther. 2015;20(5):633-45.

15. Andreasen J, Mølgaard CM, Christensen M, et al. Exercise therapy and custom-made insoles are effective in patients with excessive pronation and chronic foot pain-a randomized controlled trial. Foot (Edinb). 2013;23(1):22-8.

16. Radford JA, Landorf KB, Buchbinder R, et al. Effectiveness of calf muscle stretching for the short-term treatment of plantar heel pain: a randomised trial. BMC Musculoskelet Disord. 2007;8:36.

17. Sueki DG, Cleland JA, Wainner RS. A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications. J Man Manip Ther. 2013;21(2):90-102.

18. Cashman GE. The effect of weak hip abductors or external rotators on knee valgus kinematics in healthy subjects: a systematic review. J Sport Rehabil. 2012;21(3):273-84.

19. Bolgla LA, Malone TR. Plantar fasciitis and the windlass mechanism: a biomechanical link to clinical practice. J Athl Train. 2004;39(1):77-82.

20. Bialosky JE, Bishop MD, George SZ. Regional interdependence: a musculoskeletal examination model whose time has come. J Orthop Sports Phys Ther. 2008;38(3):159-60.

21. Mcdevitt A, Young J, Mintken P, et al. Regional interdependence and manual therapy directed at the thoracic spine. J Man Manip Ther. 2015;23(3):139-46.