arch supports, plantar fasciitis

The extent to which stretching and strengthening exercises successfully address plantar fasciitis continues to be a matter of debate among practitioners. Variables known to be associated with the condition include obesity, reduced ankle dorsiflexion, and work-related weight-bearing.

A 2008 study in Skeletal Radiology, however, added atrophy of the abductor digiti minimi muscle to the list, although it remains unclear whether the atrophy was the cause of fasciitis or its result. Similarly, a 2003 study from the University of North Carolina found that subjects with fasciitis had weaker toe flexors than did controls, but the cause and effect was unclear.

An author of that study, Michael Gross, PT, PhD, a professor of physical therapy, explained the dilemma.

“If someone already has fasciitis, and they’re guarding so that they don’t push off forcefully, that could lead to weakness of the toe flexors,” he said. “On the other hand, if they have a preexisting weakness, that could contribute to the onset of fasciitis.”

And although no controlled trials demonstrate the efficacy of exercises, Gross believes a case can be made for stretching of both the plantar fascia and the Achilles tendon for some patients.

“Heel raises will strengthen the extrinsic muscles of the foot,” he said. “The intrinsic muscles may benefit from toe grasping, which you can do by putting your foot on a weighted towel, then repeatedly curling your toes to drag the weight and the towel toward you.”

Walt Reynolds, CSCS, CPT, a personal trainer in Lansing, MI, who has written on the Web about exercises for fasciitis, still uses them occasionally with patients but has moved toward a more holistic approach.

“I work with a lot of runners, and the issues they face are largely form-related,” he said. “As a result, I now approach training on the ’5S’ model—speed, strength, stamina, suppleness, and skill.”
Reynolds said athletes with fasciitis may experience pain in the affected foot, but the root of the problem often lies elsewhere.

“Stretches may deal with the fasciitis to a point, but they won’t address the problem that actually drives it,” he said.

When Reynolds does suggest stretching, he favors a rotational hamstring stretch, a tri-plane Achilles stretch, and a rotational plantar fascia stretch. (Detailed descriptions can be found at www.sportsinjurybulletin.com/archive/plantar-fasciitis-exercise.html.)

“When you add a rotational component, you get a more functional stretch,” Reynolds said. “Most people consider the ankle joint as working primarily in the sagittal plane, but all motion is ultimately in all three planes, and transverse-plane motion may be the most significant.”

Strengthening can simply be a matter of gait. Researchers from the German Sport University in Cologne reported at the 2005 International Society of Biomechanics conference that runners who warmed up for a few minutes with minimalist footwear increased the strength of their metatarsophalangeal joints and the cross-sectional area of their flexor hallucis, flexor digitorum, abductor hallucis, and quadratus plantae muscles.

“My theory is that we have conditioned our feet to be lazy by the overuse of arch supports,” said Irene Davis, PT, PhD, former director of the Running Research Laboratory at the University of Delaware and now with the department of physical medicine and rehabilitation at Harvard Medical School.

Although Davis recommends the usual exercises—toe grasping and heel raises (she finds the latter particularly effective if done on stairs, so that the subject begins with the heels lower than the forefoot)—she considers walking at least as important.

“One of the best exercises is to use your foot in a functional way,” she said. “If people place greater demands on their feet in a slow, progressive way, I think we can reduce the incidence of plantar fasciitis.”

yes stretching is extremely important, utilizing appropriate orthotics is also important, buying arch supports at the store when not fitted for your foot is a waste of money.

If arch supports/orthotics are working correctly they will help strengthen your foot, but if you buy poorly fit orthotics then you are wasting your time and hurting your fee.

Bruce Werber DPM, FACFAS

10900 N. Scottsdale Rd Suite 604

Scottsdale, AZ 85254

480-948-2111

www.inmotionfootandankle.com

ESWT High Energy Shockwave Therapy

It is now available for low cost at InMotion foot and ankle specialists

The EPOS Extra Corporeal Shockwave device is available for those with heel pain, achilles pain, neuroma pain that has not responded to injections, cortisone, orthotics, platelet rich plasma, physical therapy, night splints and rest.

Want to wake up pain free, try this revolutionary therapy that has been shown to be highly effective in treating heel pain, and achilles tendon pain.

Call now for evaluation and treatment

InMotion Foot and Ankle Specialists
Dr. Bruce Werber DPM, FACFAS

www. inMotionFootandAnkle.com

480-948-2111

Platelet Rich Plasma, treating heel pain, tendon injuries

Athletes’ Own Blood Could Nurse Them to Health

Dr. Werber has been a leader in the field of platelet rich plasma, initialing utilizing this technology 7 years ago for diabetic wounds / ulcers and over the last few years utilizing it for the treatment of heel pain, and tendon injuries.

As published in Podiatry Today (November 2008) recently, I discussed that most fascial and tendon injuries are rarely inflammatory and that they are a result of incomplete and poor healing of the tissue and we need to use methods to reinitiate the inflammatory process and angiogensis ( revasculaize) the injured tissue to get it to heal correctly.

Platelet rich plasma is one method, another method is ExtraCorporeal Shockwave therapy and the last is Radio Frequency coblation.

Visit my website www.inmotionfootandankle.com
or email inmotionfootandankle@gmail.com
Dr. Bruce Werber

The article in the New York Times by Alan Schwartz tells the story below :
"By ALAN SCHWARZ"

Pittsburgh Steelers’ biggest stars, Hines Ward and Troy Polamalu, used their own blood in an innovative injury treatment before winning the Super Bowl. At least one major league pitcher, about 20 professional soccer players and perhaps hundreds of recreational athletes have also undergone the procedure, commonly called platelet-rich plasma therapy.

Related

Doping Implications of Platelet-Rich Plasma Therapy Remain Unclear (February 17, 2009)

Experts in sports medicine say that if the technique’s early promise is fulfilled, it could eventually improve the treatment of stubborn injuries like tennis elbow and knee tendinitis for athletes of all types.

The method, which is strikingly straightforward and easy to perform, centers on injecting portions of a patient’s blood directly into the injured area, which catalyzes the body’s instincts to repair muscle, bone and other tissue. Most enticing, many doctors said, is that the technique appears to help regenerate ligament and tendon fibers, which could shorten rehabilitation time and possibly obviate surgery.

Research into the effects of platelet-rich plasma therapy has accelerated in recent months, with most doctors cautioning that more rigorous studies are necessary before the therapy can emerge as scientifically proven. But many researchers suspect that the procedure could become an increasingly attractive course of treatment for reasons medical and financial.

“It’s a better option for problems that don’t have a great solution — it’s nonsurgical and uses the body’s own cells to help it heal,” said Dr. Allan Mishra, an assistant professor of orthopedics at Stanford University Medical Center and one of the primary researchers in the field. “I think it’s fair to say that platelet-rich plasma has the potential to revolutionize not just sports medicine but all of orthopedics. It needs a lot more study, but we are obligated to pursue this.”

Dr. Neal ElAttrache, the Los Angeles Dodgers’ team physician, used platelet-rich plasma therapy in July on a partially torn ulnar collateral ligament in the throwing elbow of pitcher Takashi Saito. Surgery would have ended Mr. Saito’s season and shelved him for about 10 to 14 months; he instead returned to pitch in the September pennant race without pain.

Dr. ElAttrache said he could not be certain that the procedure caused the pitcher’s recovery — about 25 percent of such cases heal on their own, he said — but it was another encouraging sign for the nascent technique, which doctors in the field said could help not just injuries to professional athletes but the tendinitis and similar ailments found in the general population.

“For the last several decades, we’ve been working on the mechanical effects of healing — the strongest suture constructs, can we put strong anchors in?” Dr. ElAttrache said. “But we’ve never been able to modulate the biology of healing. This is addressing that issue. It deserves a lot more study before we can say that it works with proper definitiveness. The word I would use is promising.”

Platelet-rich plasma is derived by placing a small amount of the patient’s blood in a filtration system or centrifuge that rotates at high speed, separating red blood cells from the platelets that release proteins and other particles involved in the body’s self-healing process, doctors said. A teaspoon or two of the remaining substance is then injected into the damaged area. The high concentration of platelets — from 3 to 10 times that of normal blood — often catalyzes the growth of new soft-tissue or bone cells. Because the substance is injected where blood would rarely go otherwise, it can deliver the healing instincts of platelets without triggering the clotting response for which platelets are typically known.

“This could be a method to stimulate wound healing in areas that are not well-vascularized, like ligaments and tendons,” said Dr. Gerjo van Osch, a researcher in the department of orthopedics at Erasmus University Medical Center in the Netherlands. “I call it a growth-factor cocktail — that’s how I explain it.”

Dr. van Osch and several other experts said they had used the procedure as a first option before surgery for reasons beyond its early results. There is little chance for rejection or allergic reaction because the substance is autologous, meaning it comes from the patient’s own body; the injection carries far less chance for infection than an incision and leaves no scar, and it takes only about 20 minutes, with a considerably shorter recovery time than after surgery.

Because of those apparent benefits, the consensus among doctors is that the procedure is worth pursuing. However, several doctors emphasized that platelet-rich plasma therapy as it stands now appeared ineffective in about 20 to 40 percent of cases, depending on the injury. But they added that because the procedure costs about $2,000 — compared with $10,000 to $15,000 for surgery — they expected that with more refinement, insurance companies would eventually not only authorize the use of PRP therapy but even require it as a first course of treatment.

Dr. Mishra said that he was particularly encouraged by PRP therapy’s effectiveness on chronic elbow tendinitis, or tennis elbow. For a 2006 study published by The American Journal of Sports Medicine, he used the treatment on 15 of 20 patients who were considering surgery; the five others received only anesthetic. Two months later, the patients receiving PRP therapy noted a 60 percent improvement in pain measurements, compared with 16 percent for the control group.

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Related

Doping Implications of Platelet-Rich Plasma Therapy Remain Unclear (February 17, 2009)

Dr. van Osch is performing a double-blind, randomized study on 54 patients with Achilles’ tendon injuries, while doctors in the United States, India, Sweden and elsewhere are performing formal trials on PRP therapy’s performance with rotator-cuff shoulder strains, partial knee-ligament tears and bone fractures. Studies also are examining PRP therapy’s possible use in conjunction with surgery, which a group in Spain used on Achilles’ tendon ruptures and found recovery time reduced.

“The guy who plays softball on weekends, the woman who runs a 5k race every now and then, they suffer very common injuries,” said Samir Mehta, the chief of the orthopaedic trauma service at the Hospital of the University of Pennsylvania who has performed PRP therapy on nine patients. “It’s for those people that we hope that this therapy’s uses can be more apparent.”

The possibilities of platelet-rich plasma are certainly apparent to the Steelers. Mr. Polamalu, an All-Pro safety, had the procedure for a strained calf after a playoff game and, although the injury was not considered particularly serious, he returned healthy enough the next Sunday against the Baltimore Ravens to return an interception 40 yards for a touchdown.

The technique played its most glaring role with Mr. Ward, a receiver who left that Baltimore game in the first quarter with a sprain of the medial collateral ligament in his right knee. The next day, he was injected with a form of PRP therapy called autologous conditioned plasma, which features different proportions of platelets and other cells. Along with strenuous rehabilitation and hyperbaric oxygen therapy, Ward recovered enough to make two catches in the Super Bowl, in which the Steelers beat the Arizona Cardinals.

“I was next in line, the next guinea pig,” Mr. Ward said, referring to Mr. Polamalu’s experience with platelet-rich plasma. “I think it really helped me. The injury that I had was a severe injury, maybe a four- or six-week injury. In order for me to go out there and play in two weeks, I don’t think anyone with a grade-2 M.C.L. sprain gets back that fast.”

Professional sports teams have great financial incentive to pursue decreasing athletes’ rehabilitation even one week. Last year, Major League Baseball’s 30 teams had 519 players spend 28,602 days on the disabled list — representing $455 million in total salary sitting idle — according to data compiled by Baseball Prospectus.

“Let’s say a soccer player is out six weeks — if you can cut a week or two off, that equates to two, three, four games,” said Dr. Michael Gerhardt, the team physician for Major League Soccer’s Chivas USA and Los Angeles Galaxy clubs. He said that he had administered PRP therapy to about 20 players with medial collateral ligament injuries and had found an average decrease in recovery time of 25-30 percent.

But most doctors said that if platelet-rich plasma was scientifically proven to be safe and effective, its largest effects would be on the amateur, weekend-warrior athletes for whom sports was recreation and healthy lifestyle. Stanford’s Dr. Mishra said: “It’s not just the professional athlete who needs to get back to their game. Everyone wants to get back to what they do for play or for work.”