After seeing what the normal plantar fascia should look like here is my patient Kate with her plantar fascia torn at the attachment into the heel. If you try to follow the black line from the arch where the fascia looks normal towards the heel (to the right), you can see that there is disruption of the black line. The thin black line attaching into the heel is replaced with grayish thick scar tissue. The scar tissue and plantar heel swelling extends downward through the fat layer (where it does not belong) to the plantar skin (at the bottom of your foot. Just looking at this MRI image and you can tell Kate is in alot of pain.
Kate never felt the tear, and just thought she had very bad plantar fasciitis. You can only really treat this one way initially, 3 monthes in a removable cast to limit the bend at the toes. After the casting, and only when you are comfortable walking, you can begin to wean out of the cast into some form of supportive orthotic devices to support the arch. Most patients need alot of physical therapy with deep tissue work to break down the scar tissue which always over does it. While you are in the cast, you can do pain free activities (biking, ellyptical as it calms down, some swimming, etc), icing, stretching (pain free), and foot strengthening (crucial, but must be pain free).
Here are a copy of links that tie into to this article.
http://www.drblakeshealingsole.com/2010/04/tips-to-avoid-castimmobilization.html
Removable Boot with EvenUphttp://www.drblakeshealingsole.com/2010/08/injury-rehabilitation-magical-80-rule.html
Hello...
ReplyDeleteI have a question...
Which kind of cast do you use?
How many hours a day do you indicate it?
Do you remove it to make therapeutic exercises?
How many time do you indicate the cast?
In your opinion : Can we you ultrasound as a diagnostic tool? Has it good yield?
Thanks,
Gerardo Amilivia, MD im PM&R from Uruguay (south america)
Great effort from you to make this interesting and excellent blog...Go ahead!
Dear Dr Amilivia, Thank you for your kind words. They definitely help me. I have found the removable casts as shown in the blog to be just fine, however, within two weeks of casting and icing 3 times a day, the patient should be relatively assymptomatic (pain scale 1 to 2). If they still have significant symptoms, level 4 or more on the pain scale after 2 weeks, you should consider complete immobilization for a month, then back to the removable cast. Overall, the casting, to create a painfree environment is done for 3 months, although the 4th month can be a weaning out of the cast month.
ReplyDeleteFor this injury, I like the cast full time, unless sleeping, icing, showering.
Yes, the cast is removed to do pain free only exercises. This is an explosion area in medicince (the restrengthening of injured body parts),which is started at the time of the injury almost, but must be painfree in the injured area.
I do not have experience with ultrasound, but it sounds very useful in diagnosis. Probably depends on the skill of the technician.
Thank you for your questions. It is good to have a friend in Uruguay. Rich Blake
Thanks for the answers
ReplyDeleteOne more question:
In the case of a patient who work in a company that requires formal dress, how do you juggling the use of the cast ?
Do you use it all day? (including job activities)
best wishes
Gerardo Amilivia from Uruguay
Dear Dr Amilivia, The goal of the cast is to avoid toe bend which constantly pulls on the plantar fascia. And the cast has so much extra space that added padding to soften the heel if needed can be placed. This being said the goal of treatment for plantar fascial tears is 3 months of pain free existence. If that can be created, and guaranteed, in another type of shoe, like a stiff soled dress shoe, I say go for it. But the cast is complete immobilization and alot of people feel so much more secure and anxiety free. If the patient does very little walking during a work day, I am sure they could have a good chance that they could definitely go part of each work day without the boot. They have to be very honest, as soon as pain develops, put the cast/boot back on. I hope this helps. Rich
ReplyDeletethank you very illustrative to me
ReplyDeletevery informative. gr8 job. i do have a question, however, if the only method of diagnosis available is x-ray, would this be enough to form a diagnosis? what other methods of diagnosis do u suggest or clinical measures to take?
ReplyDeletelizzy, medical student
Lizzy, Thanks for the question. I will post on the blog tonight October 7th, 2011. Rich Blake
ReplyDelete