- Email: [email protected]
Plantar Fascitis: Physical therapy perspective
Plantar fascitis
REFERENCES Calliet R 1981 Foot and Ankle Pain. FA Davis Company, Philadelphia Chaitow L 1996 Muscle Energy Techniques. Churchill Livingstone, Edinburgh Clemente C 1984 Anatomy: A Regional Atlas of the Human Body. Urban and Schwarzenberg, Baltimore-Munich Dowd I 1996 Taking Root to Fly. Contact Collaborations, Inc., New York
Kapandji IA 1974 Physiology of the Joints Volume 2. Churchill Livingstone, New York Lewit K 1992 Manipulation in rehabilitation of the motor system. Butterworth, London Rolf I 1977 Rolfing. Healing Arts Press, Rochester Travell, Simons 1983 Myofascial Pain and Dysfunction: The Trigger Point Manual,
Volume 1 and Volume 2. Williams and Wilkins, Baltimore Warfel J 1981 Extremities. Lea & Febiger, Philadelphia Warwick and Williams 1974 Gray’s Anatomy. WB Saunders Company, Philadelphia. PA Witt P 1999 Institute of Structural and Integrative Somatics class lecture.
Physical therapy perspective Janet Potts
Introduction Traditionally, in physical therapy, plantar fascitis is treated at the site of the symptoms with use of ultrasound, ice, exercise, soft tissue mobilization, etc. Practitioners have also focused attention on foot mechanics, especially subtalar joint pronation, and its involvement in plantar fascitis as well as other symptoms. Again, the treatment area focused on with this approach is at the foot with orthotic fabrication and use. This author wishes to present an approach, which, rather than focusing on a symptomatic model of care, introduces the possibility that attention to distant influences might offer alternative therapeutic choices.
Janet Potts PT 4218 Idldale Drive Fort Collins, CO 80526, USA
The questions she wishes to ask include: . Could plantar fascitis result from a pelvic soft tissue and/or joint imbalance? . Furthermore, in the example of our case study client, could cranial restrictions influence a pelvic imbalance and contribute to symptoms of plantar fascitis? The focus of this article is threefold. The first aspect considers cranial influences on the pelvis and therefore on gait. The second section considers a theoretical model of how a pelvic imbalance, could result in plantar fascitis. Lastly, clinical findings, treatment approaches, and the outcome of the care of the case study patient will be presented as it relates to this approach.
Functional anatomy of the cranium, core link and sacrum
Correspondence to: J. Potts Tel.: +1 970 229 1617 Received August 2000 Revised September 2000 Accepted October 2000 ........................................... Journal of Bodywork and Movement Therapies (2001) 5(1), 45^49 # 2001 Harcourt Publishers Ltd doi: 10.1054/jbmt.2000.0205, available online at http://www.idealibrary.com on
The meninges of the brain and spinal cord are the dura mater, arachnoid and pia mater. Intracranially, the dura mater is fused to the periosteum on the inner surface of the skull with the strongest attachments along the venous
sinuses and at the base of the skull and circumferentially at the foramen magnum. The dura mater has sheet like projections that subdivide the cranial cavity and are the falx cerebri, the tentorium cerebelli, the falx cerebelli, and the diaphragm sellae (Fig. 1). Extracranially, the dura attaches to the posterior vertebral bodies of C1, C2 and sometimes C3. It then continues as a free sack until its firm attachment at the second segment of the sacrum anteriorly. It is here where the three membranes blend and extend through the sacral hiatus and anchor at the tailbone (Hollinshead 1974). According to craniosacral concepts theorized in a biomechanical model, each of the cranial bones has a characteristic motion that is considered normal physiologic motion. During the flexion phase of cranial motion, the midline bones of the cranium (sphenoid, occiput, ethmoid, and vomer) are said to rotate anteriorly or posteriorly about a transverse axis into flexion. Simultaneously, the paired peripheral bones (frontal, parietal, temporals, maxillae, palatines, zygomae) are said to rotate externally around their varied, specific axes (Fig. 2).
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Potts
The extension phase of cranial motion is said to result in the opposite motions as the cranial bones return to their neutral/start position. In addition, during the flexion phase there is thought to be a cephalad pull of the spinal dura due to the attachment of the membranes around the foramen magnum being elevated. The motion at the sacrum, which is thought to result, involves the apex moving anteriorly and the base moving posteriorly. The motion of the sacrum occurs around a transverse axis at the level of S2 — the location of the dural attachment. This motion, called respiratory motion of the sacrum, is an involuntary motion and differs from the voluntary biomechanical motion of the sacrum. It should be understood however, that this respiratory motion of the sacrum often corresponds with pulmonary respiration synchronistically; yet, the two are distinct, separate entities (Magoun 1976; Fig. 3). As a result of the dural attachments and the dural membrane connections there is thought to be a direct duplicating motion of the occiput and sacrococcygeal complex. Sutherland, the father of cranial osteopathy, described this connection as ‘the core link between the pelvic bowl and the cranial bowl’ (Magoun 1976). One can now conceptualize how abnormal, asymmetrical tensions placed on the meningeal membranes by sacralcoccygeal dysfunctional motion could be transmitted to the other bones to which these membranes attach (cranium and/or upper cervicals). This situation could theoretically result in abnormal cranial motion. Conversely, abnormal, asymmetrical intracranial tensions or motion restrictions could theoretically be transmitted to the sacrum. For example, clinical findings by this author show a high correlation between left torsions of
Fig. 1 Dural membranes. As published in Cranial Manipulation, L. Chaitow, Churchill Livingstone.
the sphenoid and left sacral torsions and that right spheno-frontal restrictions correlate highly with upward shears of the right ilium. Moreover, treatment of the intracranial restrictions seems to be able to promote direct correction of sacral and illial lesion. Restricted motion at either end of the core link seems to be able to prevent permanent correction of a lesion at the other end of the link. It has been said that the cranial mechanism is the most cogent manifestation of life itself (Magoun 1976). By definition, it has the power to compel or constrain (MerriamWebster 1979). The physiological functions of the body are said to be controlled within its environment (fourth ventricle). Therefore restrictions of motion or cessation of the entire pumping mechanism are thought to be able to result in many, varied and distant manifestations.
The e¡ect of a concentrically shortened iliopsoas on foot mechanics/plantar fascitis: A theoretical model Plantar fascitis correlates highly with prolonged or excessive
Fig. 2 Proposed motion of the cranium with flexion phase of motion.
pronation of the foot. If the foot has not returned to a supinated position at push-off, then the foot is forced to push off, not in a rigid bony lever, but through increased tension in the plantar fascia. Foot pronation may be due to local problems or from more proximal dysfunctions. A common finding seen by this author, in plantar fascitis, is a decreased push-off in the gait cycle and a concentrically contracted, hypertonic iliopsoas. In considering the effect of muscle imbalance on gait, we must recognize the functional environment of the body, i.e. closed chain ‘functional’ kinetics versus
46
J O U R NA L O F B O DY WO R K A N D M OV E ME N T TH E R AP IE S JANUARY 20 01
Plantar fascitis
Fig. 3 The core link. As published in Palpation Skills, L. Chaitow, Churchill Livingstone.
open chain kinetics. Muscle function during closed chain kinetics involves an eccentric stabilizing, decelerating, or accelerating muscle contraction. Therefore, muscle function, including that of the iliopoas, during the weightbearing portion of the gait cycle primarily involves eccentric stabilizing, decelerating, or accelerating muscle contraction. (This is often the opposite of the classic, concentric action definition of the muscle). EMG studies by Basmajian have shown that during ambulation, the iliacus muscle acts continuously and peaks at two points in the gait cycle. One peak is during the swing phase and the other is at midstance. The psoas peaks at these times, as well as, a third peak at 50% of the cycle during push-off (Basmajain 1985). Other research has shown that accelerating muscle contraction is most important during the swing phase when the iliopsoas and quadriceps femoris bring the limb forward. This momentum progression is then controlled and stabilized by most muscles during weightbearing and is of a decelerating nature on the limb and stabilizing type at the joints (Dykyj 1988). For example, the findings of Simon et al. describe the role of the posterior calf muscles in normal gait as ‘restraining the body’s own forward momentum and not used to propel it further’ (Simon 1978). Therefore, the role of the iliopsoas during the swing phase is acceleration of motion and the
probable role during the weightbearing phase is of stabilization/deceleration. In accordance with the nature of closed-kinetic chain muscle function this weightbearing contraction would normally be eccentric. Research by Janda has shown that muscle dysfunction is not a random occurrence but that muscles respond in characteristic patterns. Postural-tonic muscles respond to dysfunction by facilitation, hypertonicity and shortening. Dynamic-phasic muscles respond to dysfunction by inhibition, hypotonicity and inhibitory weakness (Janda 1983). Therefore, the iliopsoas responds to dysfunction by becoming short and hypertonic. This author proposes that a dysfunctional, concentrically shortened iliopsoas reduces push-off in the gait cycle because it is acting concentrically during a closed chain weightbearing activity. When a concentrically shortened iliopsoas’ influence is unilateral or asymmetrical a rotational movement dysfunction is produced in the pelvis and lumbar spine. For example, a hypertonic right iliacus will produce a left torsion of the sacrum (anterior prominence of the sacrum on the right/posterior prominence on the left) due to its anterior attachments to the sacrum. (This finding also corresponds to the action of a hypertonic left piriformis). A hypertonic right psoas assists in producing a left lumbar
rotation (transverse processes prominent on the left). As discussed above, sphenoid torsions seem to correlate with sacral torsions, and spheno-frontal restrictions seem to correlate with illial dysfunctions. Could sacral torsions and illial dysfunctions therefore be shown to influence gait mechanics? Further study of this dysfunctional gait pattern as it relates to concentric versus eccentric function of the iliopsoas; how iliopsoas dysfunction relates to pelvic obliquity, and how pelvic obliquity relates to dysfunctional gait patterns might demonstrate a clear link between these factors and the development of plantar fascitis. Consideration has so far been given to the influence of an iliopsoas muscle imbalance on the push-off phase to the gait cycle. Discussion has also shown the possibility of a dysfunctional iliopsoas contributing to pelvic obliquity and functional roto-scoliosis. The possibility has been discussed that specific cranial restrictions could contribute to this pattern of dysfunction. What follows is a presentation of the findings, treatment and outcome for the case-study patient, as it relates to this approach.
Case study ¢ndings, treatment and outcome The most significant, clinical findings at the time of the physical therapy initial evaluation of the case study patient (Pamela) were as follows: Subjective The patient’s primary complaint was frontal headaches occurring every weak lasting for 1–5 days (pain scale of 6–10/10) beginning 3 years earlier. Her secondary complaint was of daily foot pain on the left greater than on the right (pain scale of 0–5/10) occurring with more weightbearing that began while
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Potts
running cross country 6 months earlier. She also reported bilateral anterior thigh pain that only occurs with an increased activity level (and reached a pain level of 10/10) when she was running on the crosscountry team. (It is interesting to note that anterior thigh pain is a referred pain pattern of the iliopsoas according to Simons and Travell 1992). Gait . Shuffling gait with minimal pushoff. . Hard heel strike on the right with circumduction of the right foot. Structural . Valgus rearfoot position. . equal leg lengths. . Pelvic obliquity (right upward shear of ilium; left sacral torsion and sidebending). . Functional rotoscoliosis (L5–T6 concave right; T5–T3 concave left) with multiple segmental motion restrictions. Mobility . Gross active and passive range of motion was within normal limits including passive dorsiflexion. Strength . Plantar flexion was slightly weak on the right side. . Bilateral hip adductor weakness with substitution including dropping of contralateral shoulder. Soft tissue . Left greater than right psoas hypertonicity.
. Swelling on the posterior medial arches of both feet.
Cranial dysfunction (de¢ned by direction of ease of motion) . Spheno-basilar junction: left torsion, superior vertical strain, and right lateral strain. . Left temporal and parietal external rotation. . Right temporal and parietal internal rotation. . Bilateral spheno-frontal restrictions. Treatment From the evaluation, it was determined that primary motion restrictions were present in Pamela’s cranium and treatment was initiated there. Her gait pattern was observed after each stage of treatment. Pamela’s gait pattern, following treatment of her cranium, demonstrated a more integrated, less disruptive gait with less ‘soupiness’. This improvement was notable but not dramatic. However, it was impressive to find that all of the segmental functional scoliosis components had normalized except for the upward iliac shear. This finding was then treated by releasing of her left and right illiopsoas muscle hypertonicity (Box 1) until her iliac crests were of equal heights. The sacrum was in neutral after treatment of the cranium. It was felt that the illiopsoas hypertonicity imbalance was influencing the structural inequality rather than the sacroiliac joint itself. After treatment of Pamela’s illiopsoas her gait was observed again and found to be of a more dramatically improved nature. There was more equal weight shifting on a more upright vertical axis with markedly improved equilibrium and fluidity.
Pamela’s second visit was approximately 10 days later and included re-assessment of the original findings. The functional rotoscoliosis had maintained correction and the cranial restrictions were at a minimum. A core-strengthening program was then initiated with Pilatesbased exercises that emphasized eccentric control of the psoas, oblique and transverse abdominal muscles, hip adductors, and the deep external hip rotators. The Pilatesbased exercises neuro-muscularly reprogram these muscles and effectively ‘lift’ the trunk off the feet, decompressing the arch of the foot. On the third visit Pamela was reporting relief from her headaches. Objective findings were as on the second visit. Pilates-based footwork exercises were initiated and her gait was re-assessed afterward. There was a dramatic decrease in the ‘shuffling’ gait pattern and Pamela commented ‘my knees are moving, lifting’. Pamela’s fourth visit revealed that her improved gait pattern observed after her last visit had been maintained. She reported that this
Box 1
The patient lies supine with knees bent and feet flat on the table. The therapist palpates to find the psoas in the lower abdominal area superior and medial to the ASIS (resisting hip flexion may be used to confirm the location). Having made digital contact via an oblique pressure (towards the spine) the patient is asked to rock the pelvis backward into a posterior pelvic tilt and forward into an anterior pelvic tilt, but not to the extremes of the motion. This motion is performed gently, until a release is noted by the palpating fingers. Usually there is a significant decrease in tenderness to palpation with this technique.
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Plantar fascitis
change in her gait felt more second nature to her and that she was no longer having foot pain. Treatments were continued with emphasis on improving her core and adductor strength. After six total treatments Pamela had walked 1/4 mile and ran 100 yards without return of her symptoms. Her headaches and daily foot pain had not returned. It is interesting to note that during the course of her treatment she had one significant exacerbation that was a result of emotional stress. Her shuffling gait pattern returned as well as significant cranial restrictions. To her credit, Pamela was able to rebound after one cranial treatment and her own processing that this author believes was a result of the ‘tools’ she had been given by and work she had done with the body-mind therapist. Outcome Pamela’s headaches and foot pain was relieved after four treatment sessions with a sedentary activity level. Her symptoms have not
returned with the progressive return to a running, walking and swimming program. At the time of this writing, one month since her last visit, Pamela is able to run one mile without exacerbation of her symptoms.
consider the whole body as well as holistic influences including the structural, biochemical, and mental/ emotional factors, so that we can effectively enhance the self-corrective nature of that individual’s body.
Conclusion
REFERENCES
Foot or ankle dysfunction may obviously precipitate disturbances in the knee, hip, pelvis, low back. Conversely, low back, hip, knee, even cranial dysfunction can be shown to have the potential to precipitate disturbances in the gait. From a clinical standpoint, either structural/kinematic possibility could be an etiological factor. In addition, there exist a variety of complimentary treatment approaches of a particular condition such as plantar fascitis, that produce similar, beneficial, results. The structural and kinematic relationships that occur during gait are complex and each client presents with their individual set of symptoms and dysfunctions. It is our job as clinicians to openly
Basmajian JV, DeLuca CJ 1985 Muscles Alive. Their Functions Revealed by Electromyography. Williams and Wilkins, Baltimore Dykyj D 1988 Anatomy of Motion. Clinical Podiatric Medicine and Surgery. July 5 477–490 (Abstract) Hollinshead WH 1974 Textbook of Anatomy. Harper and Row, Hagerstown Janda V 1983 Muscle Function Testing. Butterworths, London Magoun HI 1976 Osteopathy in the Cranial Field. Sutherland Cranial Teaching Foundation. Fort Worth, Texas. Webster’s New Collegiate Dictionary 1979 G&C Merriam Company, Springfield Simon SR, Mann RA, Hagy JL, Larsen LJ 1978 Role of the Posterior Calf Muscles in Normal Gait. Journal of Bone and Joint Surgery; 60 465–472 (Abstract) Simons DG, Travell JG 1992 Myofascial Pain and Dysfunction. The Trigger Point Manual. Volume 2. Williams and Wilkins, Baltimore
A chiropractic perspective Terry Hambrick This article contains parallel threads of clinical information based both Terry Hambrick DC 116 West Havard Street Suite 2, Fort Collins, CO 80525, USA Correspondence to: T. Hambrick Tel: +1 970 282 1173; Fax: +1970 2821175 E-mail: [email protected] Received August 2000 Revised September 2000 Accepted October 2000 ........................................... Journal of Bodywork and Movement Therapies (2001) 5(1), 49^55 # 2001 Harcourt Publishers Ltd doi: 10.1054/jbmt.2000.0203, available online at http://www.idealibrary.com on
on the general collective impressions of the practitioners and the actual impressions gleaned from evaluating and treating (or recommending treatment for) the same patient who has served as a model for the project. Fascia, both superficial and deep, originates from mesenchymal tissue and differentiates into forms suited to their location and function in the body. The fascia on the plantar surface of the foot would be considered a deep fascial sheet of fibrous tissue that aids in supporting the longitudinal arch. On the calcaneus, the plantar fascia attaches to the anterior margin of the medial and lateral processes
and it (the fascia) extends into a band that attaches at the base of the metatarsals (Hamilton 1976). It is of value in assessing the plantar fascia to consider the muscles that originate on the calcaneus and assist in supporting the longitudinal arch. The abductor hallucis, flexor digitorum brevis and the abductor digitus minimus all have such attachments and provide support, with the abductor digitus minimus supporting the lateral portion of the arch while the other two form part of the medial arch (Hamilton 1976). Often, shortening of the gastrocnemius and soleus is viewed
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REFERENCES Calliet R 1981 Foot and Ankle Pain. FA Davis Company, Philadelphia Chaitow L 1996 Muscle Energy Techniques. Churchill Livingstone, Edinburgh Clemente C 1984 Anatomy: A Regional Atlas of the Human Body. Urban and Schwarzenberg, Baltimore-Munich Dowd I 1996 Taking Root to Fly. Contact Collaborations, Inc., New York
Kapandji IA 1974 Physiology of the Joints Volume 2. Churchill Livingstone, New York Lewit K 1992 Manipulation in rehabilitation of the motor system. Butterworth, London Rolf I 1977 Rolfing. Healing Arts Press, Rochester Travell, Simons 1983 Myofascial Pain and Dysfunction: The Trigger Point Manual,
Volume 1 and Volume 2. Williams and Wilkins, Baltimore Warfel J 1981 Extremities. Lea & Febiger, Philadelphia Warwick and Williams 1974 Gray’s Anatomy. WB Saunders Company, Philadelphia. PA Witt P 1999 Institute of Structural and Integrative Somatics class lecture.
Physical therapy perspective Janet Potts
Introduction Traditionally, in physical therapy, plantar fascitis is treated at the site of the symptoms with use of ultrasound, ice, exercise, soft tissue mobilization, etc. Practitioners have also focused attention on foot mechanics, especially subtalar joint pronation, and its involvement in plantar fascitis as well as other symptoms. Again, the treatment area focused on with this approach is at the foot with orthotic fabrication and use. This author wishes to present an approach, which, rather than focusing on a symptomatic model of care, introduces the possibility that attention to distant influences might offer alternative therapeutic choices.
Janet Potts PT 4218 Idldale Drive Fort Collins, CO 80526, USA
The questions she wishes to ask include: . Could plantar fascitis result from a pelvic soft tissue and/or joint imbalance? . Furthermore, in the example of our case study client, could cranial restrictions influence a pelvic imbalance and contribute to symptoms of plantar fascitis? The focus of this article is threefold. The first aspect considers cranial influences on the pelvis and therefore on gait. The second section considers a theoretical model of how a pelvic imbalance, could result in plantar fascitis. Lastly, clinical findings, treatment approaches, and the outcome of the care of the case study patient will be presented as it relates to this approach.
Functional anatomy of the cranium, core link and sacrum
Correspondence to: J. Potts Tel.: +1 970 229 1617 Received August 2000 Revised September 2000 Accepted October 2000 ........................................... Journal of Bodywork and Movement Therapies (2001) 5(1), 45^49 # 2001 Harcourt Publishers Ltd doi: 10.1054/jbmt.2000.0205, available online at http://www.idealibrary.com on
The meninges of the brain and spinal cord are the dura mater, arachnoid and pia mater. Intracranially, the dura mater is fused to the periosteum on the inner surface of the skull with the strongest attachments along the venous
sinuses and at the base of the skull and circumferentially at the foramen magnum. The dura mater has sheet like projections that subdivide the cranial cavity and are the falx cerebri, the tentorium cerebelli, the falx cerebelli, and the diaphragm sellae (Fig. 1). Extracranially, the dura attaches to the posterior vertebral bodies of C1, C2 and sometimes C3. It then continues as a free sack until its firm attachment at the second segment of the sacrum anteriorly. It is here where the three membranes blend and extend through the sacral hiatus and anchor at the tailbone (Hollinshead 1974). According to craniosacral concepts theorized in a biomechanical model, each of the cranial bones has a characteristic motion that is considered normal physiologic motion. During the flexion phase of cranial motion, the midline bones of the cranium (sphenoid, occiput, ethmoid, and vomer) are said to rotate anteriorly or posteriorly about a transverse axis into flexion. Simultaneously, the paired peripheral bones (frontal, parietal, temporals, maxillae, palatines, zygomae) are said to rotate externally around their varied, specific axes (Fig. 2).
45
J O U R NA L O F B O DY WO R K A N D M OV E ME N T TH E R AP IE S JANUARY 20 01
Potts
The extension phase of cranial motion is said to result in the opposite motions as the cranial bones return to their neutral/start position. In addition, during the flexion phase there is thought to be a cephalad pull of the spinal dura due to the attachment of the membranes around the foramen magnum being elevated. The motion at the sacrum, which is thought to result, involves the apex moving anteriorly and the base moving posteriorly. The motion of the sacrum occurs around a transverse axis at the level of S2 — the location of the dural attachment. This motion, called respiratory motion of the sacrum, is an involuntary motion and differs from the voluntary biomechanical motion of the sacrum. It should be understood however, that this respiratory motion of the sacrum often corresponds with pulmonary respiration synchronistically; yet, the two are distinct, separate entities (Magoun 1976; Fig. 3). As a result of the dural attachments and the dural membrane connections there is thought to be a direct duplicating motion of the occiput and sacrococcygeal complex. Sutherland, the father of cranial osteopathy, described this connection as ‘the core link between the pelvic bowl and the cranial bowl’ (Magoun 1976). One can now conceptualize how abnormal, asymmetrical tensions placed on the meningeal membranes by sacralcoccygeal dysfunctional motion could be transmitted to the other bones to which these membranes attach (cranium and/or upper cervicals). This situation could theoretically result in abnormal cranial motion. Conversely, abnormal, asymmetrical intracranial tensions or motion restrictions could theoretically be transmitted to the sacrum. For example, clinical findings by this author show a high correlation between left torsions of
Fig. 1 Dural membranes. As published in Cranial Manipulation, L. Chaitow, Churchill Livingstone.
the sphenoid and left sacral torsions and that right spheno-frontal restrictions correlate highly with upward shears of the right ilium. Moreover, treatment of the intracranial restrictions seems to be able to promote direct correction of sacral and illial lesion. Restricted motion at either end of the core link seems to be able to prevent permanent correction of a lesion at the other end of the link. It has been said that the cranial mechanism is the most cogent manifestation of life itself (Magoun 1976). By definition, it has the power to compel or constrain (MerriamWebster 1979). The physiological functions of the body are said to be controlled within its environment (fourth ventricle). Therefore restrictions of motion or cessation of the entire pumping mechanism are thought to be able to result in many, varied and distant manifestations.
The e¡ect of a concentrically shortened iliopsoas on foot mechanics/plantar fascitis: A theoretical model Plantar fascitis correlates highly with prolonged or excessive
Fig. 2 Proposed motion of the cranium with flexion phase of motion.
pronation of the foot. If the foot has not returned to a supinated position at push-off, then the foot is forced to push off, not in a rigid bony lever, but through increased tension in the plantar fascia. Foot pronation may be due to local problems or from more proximal dysfunctions. A common finding seen by this author, in plantar fascitis, is a decreased push-off in the gait cycle and a concentrically contracted, hypertonic iliopsoas. In considering the effect of muscle imbalance on gait, we must recognize the functional environment of the body, i.e. closed chain ‘functional’ kinetics versus
46
J O U R NA L O F B O DY WO R K A N D M OV E ME N T TH E R AP IE S JANUARY 20 01
Plantar fascitis
Fig. 3 The core link. As published in Palpation Skills, L. Chaitow, Churchill Livingstone.
open chain kinetics. Muscle function during closed chain kinetics involves an eccentric stabilizing, decelerating, or accelerating muscle contraction. Therefore, muscle function, including that of the iliopoas, during the weightbearing portion of the gait cycle primarily involves eccentric stabilizing, decelerating, or accelerating muscle contraction. (This is often the opposite of the classic, concentric action definition of the muscle). EMG studies by Basmajian have shown that during ambulation, the iliacus muscle acts continuously and peaks at two points in the gait cycle. One peak is during the swing phase and the other is at midstance. The psoas peaks at these times, as well as, a third peak at 50% of the cycle during push-off (Basmajain 1985). Other research has shown that accelerating muscle contraction is most important during the swing phase when the iliopsoas and quadriceps femoris bring the limb forward. This momentum progression is then controlled and stabilized by most muscles during weightbearing and is of a decelerating nature on the limb and stabilizing type at the joints (Dykyj 1988). For example, the findings of Simon et al. describe the role of the posterior calf muscles in normal gait as ‘restraining the body’s own forward momentum and not used to propel it further’ (Simon 1978). Therefore, the role of the iliopsoas during the swing phase is acceleration of motion and the
probable role during the weightbearing phase is of stabilization/deceleration. In accordance with the nature of closed-kinetic chain muscle function this weightbearing contraction would normally be eccentric. Research by Janda has shown that muscle dysfunction is not a random occurrence but that muscles respond in characteristic patterns. Postural-tonic muscles respond to dysfunction by facilitation, hypertonicity and shortening. Dynamic-phasic muscles respond to dysfunction by inhibition, hypotonicity and inhibitory weakness (Janda 1983). Therefore, the iliopsoas responds to dysfunction by becoming short and hypertonic. This author proposes that a dysfunctional, concentrically shortened iliopsoas reduces push-off in the gait cycle because it is acting concentrically during a closed chain weightbearing activity. When a concentrically shortened iliopsoas’ influence is unilateral or asymmetrical a rotational movement dysfunction is produced in the pelvis and lumbar spine. For example, a hypertonic right iliacus will produce a left torsion of the sacrum (anterior prominence of the sacrum on the right/posterior prominence on the left) due to its anterior attachments to the sacrum. (This finding also corresponds to the action of a hypertonic left piriformis). A hypertonic right psoas assists in producing a left lumbar
rotation (transverse processes prominent on the left). As discussed above, sphenoid torsions seem to correlate with sacral torsions, and spheno-frontal restrictions seem to correlate with illial dysfunctions. Could sacral torsions and illial dysfunctions therefore be shown to influence gait mechanics? Further study of this dysfunctional gait pattern as it relates to concentric versus eccentric function of the iliopsoas; how iliopsoas dysfunction relates to pelvic obliquity, and how pelvic obliquity relates to dysfunctional gait patterns might demonstrate a clear link between these factors and the development of plantar fascitis. Consideration has so far been given to the influence of an iliopsoas muscle imbalance on the push-off phase to the gait cycle. Discussion has also shown the possibility of a dysfunctional iliopsoas contributing to pelvic obliquity and functional roto-scoliosis. The possibility has been discussed that specific cranial restrictions could contribute to this pattern of dysfunction. What follows is a presentation of the findings, treatment and outcome for the case-study patient, as it relates to this approach.
Case study ¢ndings, treatment and outcome The most significant, clinical findings at the time of the physical therapy initial evaluation of the case study patient (Pamela) were as follows: Subjective The patient’s primary complaint was frontal headaches occurring every weak lasting for 1–5 days (pain scale of 6–10/10) beginning 3 years earlier. Her secondary complaint was of daily foot pain on the left greater than on the right (pain scale of 0–5/10) occurring with more weightbearing that began while
47
J O U R NA L O F B O DY WO R K A N D M OV E ME N T TH E R AP IE S JANUARY 20 01
Potts
running cross country 6 months earlier. She also reported bilateral anterior thigh pain that only occurs with an increased activity level (and reached a pain level of 10/10) when she was running on the crosscountry team. (It is interesting to note that anterior thigh pain is a referred pain pattern of the iliopsoas according to Simons and Travell 1992). Gait . Shuffling gait with minimal pushoff. . Hard heel strike on the right with circumduction of the right foot. Structural . Valgus rearfoot position. . equal leg lengths. . Pelvic obliquity (right upward shear of ilium; left sacral torsion and sidebending). . Functional rotoscoliosis (L5–T6 concave right; T5–T3 concave left) with multiple segmental motion restrictions. Mobility . Gross active and passive range of motion was within normal limits including passive dorsiflexion. Strength . Plantar flexion was slightly weak on the right side. . Bilateral hip adductor weakness with substitution including dropping of contralateral shoulder. Soft tissue . Left greater than right psoas hypertonicity.
. Swelling on the posterior medial arches of both feet.
Cranial dysfunction (de¢ned by direction of ease of motion) . Spheno-basilar junction: left torsion, superior vertical strain, and right lateral strain. . Left temporal and parietal external rotation. . Right temporal and parietal internal rotation. . Bilateral spheno-frontal restrictions. Treatment From the evaluation, it was determined that primary motion restrictions were present in Pamela’s cranium and treatment was initiated there. Her gait pattern was observed after each stage of treatment. Pamela’s gait pattern, following treatment of her cranium, demonstrated a more integrated, less disruptive gait with less ‘soupiness’. This improvement was notable but not dramatic. However, it was impressive to find that all of the segmental functional scoliosis components had normalized except for the upward iliac shear. This finding was then treated by releasing of her left and right illiopsoas muscle hypertonicity (Box 1) until her iliac crests were of equal heights. The sacrum was in neutral after treatment of the cranium. It was felt that the illiopsoas hypertonicity imbalance was influencing the structural inequality rather than the sacroiliac joint itself. After treatment of Pamela’s illiopsoas her gait was observed again and found to be of a more dramatically improved nature. There was more equal weight shifting on a more upright vertical axis with markedly improved equilibrium and fluidity.
Pamela’s second visit was approximately 10 days later and included re-assessment of the original findings. The functional rotoscoliosis had maintained correction and the cranial restrictions were at a minimum. A core-strengthening program was then initiated with Pilatesbased exercises that emphasized eccentric control of the psoas, oblique and transverse abdominal muscles, hip adductors, and the deep external hip rotators. The Pilatesbased exercises neuro-muscularly reprogram these muscles and effectively ‘lift’ the trunk off the feet, decompressing the arch of the foot. On the third visit Pamela was reporting relief from her headaches. Objective findings were as on the second visit. Pilates-based footwork exercises were initiated and her gait was re-assessed afterward. There was a dramatic decrease in the ‘shuffling’ gait pattern and Pamela commented ‘my knees are moving, lifting’. Pamela’s fourth visit revealed that her improved gait pattern observed after her last visit had been maintained. She reported that this
Box 1
The patient lies supine with knees bent and feet flat on the table. The therapist palpates to find the psoas in the lower abdominal area superior and medial to the ASIS (resisting hip flexion may be used to confirm the location). Having made digital contact via an oblique pressure (towards the spine) the patient is asked to rock the pelvis backward into a posterior pelvic tilt and forward into an anterior pelvic tilt, but not to the extremes of the motion. This motion is performed gently, until a release is noted by the palpating fingers. Usually there is a significant decrease in tenderness to palpation with this technique.
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change in her gait felt more second nature to her and that she was no longer having foot pain. Treatments were continued with emphasis on improving her core and adductor strength. After six total treatments Pamela had walked 1/4 mile and ran 100 yards without return of her symptoms. Her headaches and daily foot pain had not returned. It is interesting to note that during the course of her treatment she had one significant exacerbation that was a result of emotional stress. Her shuffling gait pattern returned as well as significant cranial restrictions. To her credit, Pamela was able to rebound after one cranial treatment and her own processing that this author believes was a result of the ‘tools’ she had been given by and work she had done with the body-mind therapist. Outcome Pamela’s headaches and foot pain was relieved after four treatment sessions with a sedentary activity level. Her symptoms have not
returned with the progressive return to a running, walking and swimming program. At the time of this writing, one month since her last visit, Pamela is able to run one mile without exacerbation of her symptoms.
consider the whole body as well as holistic influences including the structural, biochemical, and mental/ emotional factors, so that we can effectively enhance the self-corrective nature of that individual’s body.
Conclusion
REFERENCES
Foot or ankle dysfunction may obviously precipitate disturbances in the knee, hip, pelvis, low back. Conversely, low back, hip, knee, even cranial dysfunction can be shown to have the potential to precipitate disturbances in the gait. From a clinical standpoint, either structural/kinematic possibility could be an etiological factor. In addition, there exist a variety of complimentary treatment approaches of a particular condition such as plantar fascitis, that produce similar, beneficial, results. The structural and kinematic relationships that occur during gait are complex and each client presents with their individual set of symptoms and dysfunctions. It is our job as clinicians to openly
Basmajian JV, DeLuca CJ 1985 Muscles Alive. Their Functions Revealed by Electromyography. Williams and Wilkins, Baltimore Dykyj D 1988 Anatomy of Motion. Clinical Podiatric Medicine and Surgery. July 5 477–490 (Abstract) Hollinshead WH 1974 Textbook of Anatomy. Harper and Row, Hagerstown Janda V 1983 Muscle Function Testing. Butterworths, London Magoun HI 1976 Osteopathy in the Cranial Field. Sutherland Cranial Teaching Foundation. Fort Worth, Texas. Webster’s New Collegiate Dictionary 1979 G&C Merriam Company, Springfield Simon SR, Mann RA, Hagy JL, Larsen LJ 1978 Role of the Posterior Calf Muscles in Normal Gait. Journal of Bone and Joint Surgery; 60 465–472 (Abstract) Simons DG, Travell JG 1992 Myofascial Pain and Dysfunction. The Trigger Point Manual. Volume 2. Williams and Wilkins, Baltimore
A chiropractic perspective Terry Hambrick This article contains parallel threads of clinical information based both Terry Hambrick DC 116 West Havard Street Suite 2, Fort Collins, CO 80525, USA Correspondence to: T. Hambrick Tel: +1 970 282 1173; Fax: +1970 2821175 E-mail: [email protected] Received August 2000 Revised September 2000 Accepted October 2000 ........................................... Journal of Bodywork and Movement Therapies (2001) 5(1), 49^55 # 2001 Harcourt Publishers Ltd doi: 10.1054/jbmt.2000.0203, available online at http://www.idealibrary.com on
on the general collective impressions of the practitioners and the actual impressions gleaned from evaluating and treating (or recommending treatment for) the same patient who has served as a model for the project. Fascia, both superficial and deep, originates from mesenchymal tissue and differentiates into forms suited to their location and function in the body. The fascia on the plantar surface of the foot would be considered a deep fascial sheet of fibrous tissue that aids in supporting the longitudinal arch. On the calcaneus, the plantar fascia attaches to the anterior margin of the medial and lateral processes
and it (the fascia) extends into a band that attaches at the base of the metatarsals (Hamilton 1976). It is of value in assessing the plantar fascia to consider the muscles that originate on the calcaneus and assist in supporting the longitudinal arch. The abductor hallucis, flexor digitorum brevis and the abductor digitus minimus all have such attachments and provide support, with the abductor digitus minimus supporting the lateral portion of the arch while the other two form part of the medial arch (Hamilton 1976). Often, shortening of the gastrocnemius and soleus is viewed
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