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Transcript of Josh Renzi
for Treatment of the
Finding the etiology.
Clinical Reasoning applied to Plantar Fasciitis
Patient is a 22 year old female who has been running for several years without incident.
4 months ago she developed left posterior-lateral knee pain associated with running up hills.
MRI and X-rays were negative.
Rest helped minimally. Upon return to running she began to experience superior and central patellar pain after 10 min, worse on hills. Pain with squatting and occasionally when descending stairs.
Two months prior to her initial knee pain she had increased her running program from 3-6 miles 3-4 days per week to 5 days per week in preparation for a 10 K race.
The answer can usually be found in the form of a local biomechanical or neurological dysfunction, OR a dysfunction away from the painful area.
Josh Renzi, PT, MPT, COMT
Thoughts so far?
When a runner has an injury you must consider contributing factors such as training schedule, running surface, and shoe wear.
BUT, as the treating clinician, you must also ask a very important question.
Why are they unilaterally symptomatic?
The runner uses both legs, so why has one side become symptomatic.
You must look for etiologies.
Knee PROM is full although slightly painful at end range flexion.
Knee flexion 5/5, knee extension 5-/5 with pain at the quad tendon.
Tender at the patellar cartilage at the superior pole medially and laterally, at the distal quad tendon, but non-tender at the patellar tendon or joint line.
Negative special tests of the knee, except increased valgus-varus mobility on the left.
Full standing squat is reported to be painful at the distal quad tendon.
Are your ready to treat?
If so, what are the treatments you would utilize?
Lumbar AROM is full and pain-free, negative quadrants. Sensation and reflexes normal.
Hip strength is 5-/5 ext and abd, Ankle DF 4+/5, PF 5/5 (slight delayed contraction), eversion 5/5.
Hip PROM is full and pain-free, with the exception of slightly limited left hip extension and IR.
Left SIJ is hypomobile into posterior rotation (anterior rotated innominate).
Dorsal hypomobilities at the naviculo-talar and the naviculo-cuneiform joints.
Plantar hypomobilities of the 1st and 2nd mets.
Distal tib-fib joint is hypermobile anter-laterally, proximal tib-fib joint is hypermobile postero-medially and painful upon overpressure.
Slightly limited talar swing test (reduced lateral rotation of the talus in the talo-crural joint i.e. anterior talus / reduced DF)
Foot biomechanical exam
After dorsal manipulations of the navicular and cuneiform, her squat was less painful.
After hip manipulation and SIJ mobe her pain improved as well.
Local frictions at the patellar cartilage also improved her ability to squat with less pain.
Now we are ready to treat
No. I haven’t watched her run or assessed her balance, gait or motor control. She may eventually need a shoe insert due to the severity of her foot stiffness.
Am I done?
Remote etiologies causing pain and dysfunction in the lower quadrant are typically involved through one of the following ways.
biomechanical dysfunctions anywhere in the chain, i.e. anterior talus
radiculopathies, i.e. weakened PF’s or tibialis posterior
pain inhibition, reflex inhibition i.e. prior ankle sprain
combinations of the above
These dysfunctions may be the joints from which pain is arising, or they may be away from the symptomatic tissue.
Hypomobilites of the SIJ, hip, distal tib-fib, subtalar, tarsal or metatarsal joints,
i.e. tibialis anterior tendonopathy due to a hypomobility of the medial cuneiform.
Treat the culprit with local mobilization or manipulation in order to alleviate the stress on the painful tissue.
Requires a detailed biomechanical exam or at least careful testing for quality of ROM at end ranges (end feel).
Biomechanical dysfunction in the foot that causes tension on the plantar fascia
Plantar fascia is not “tight”
Inverted or everted subtalar joint
Medially rotated talus (do NOT stretch the gastroc)
Dorsi- or plantarflexed navicular
Dorsi- or plantarflexed 1st metatarsal
Incompetent foot intrinsic muscles
What could have caused the foot intrisics to become incompetent?
Same logic for
IT Band syndrome
L4, Tibialis anterior
L5, Peroneals or tibialis posterior
S1, Foot intrisics
The biomechanical treatment must be followed by NMR such as lower extremity PNF patterns, foot intrinsic exercises (NOT toe flexor exercise), balance exercises, NMES, Kinesiotape, etc.
Putting it all together
The goal is to reduce stress on the injured tissue by identifying and correcting the etiologies that are logical contributing factors.
This requires a very good understanding of the anatomy of the entire chain.
Manual therapy for the foot, ankle and hip reduced her lateral knee pain to the point that she returned to running 4 miles, but...
She began to experience mid belly hamstring tightness during and slightly after running.
SIJ and L5 mobes eliminated the hamstring "strain" and she returned to running 5-6 miles without pain.
Am I done?
Spine and Sports Rehabilitaions Center
Talo-crural joint - talar swing test
Talo-calcaneal joints- anterior STJ medial glide for inversion and lateral glide for eversion, posterior STJ medial glide for eversion and lateral glide for inversion
Talo-navicular joint- dorsal and plantar glides
Naviculo-cuneiform joints- dorsal and plantar glides
Calcaneo-cuboid joint- dorsal and plantar glides
Naviculo-cuboid joint- dorsal and lateral glides
Cuneo-metatarsal joints- dorsal and plantar glides
Hip quadrant testing
Scour test for Flexion IR and Adduction
Extension in prone
IR in prone
Sacroiliac Joint Exam
Prone spring test for Flexion (nutation) and Extension (counter nutation)
Lumbar spine biomechanical exam
Passive intervertebral motion testing
No. Treatment must include NMR, such as PNF, glute strengthening, hip flexor stretching, discussion of running progression, modified running technique
If she returns to PT with a recurrence, what are my treatment options?
What if she did not progress as I had expected?
Are these muscles incompetent or weak due to radiculopathy?
Segmental (Somatic) dysfunction? (delay response to muscle strength testing).
Incompetent due to pain inhibition?
May need to be treated locally and/or proximally
A good clinician will have a good understanding of muscle innervations in order to problem solve the underlying etiology.
Not all dysfunctions are fixable.
Must account for the "specimen".
Age, co-morbidities, poor plasma.
Desire to participate in an activity that they may not be suited for.
The damage may have been done.
If you can not progress a patient in an appropriate manner, seek help. It's not about you!
Where to go from here...
Change the shoes?
Change running mechanics?
Change in training program?
Examine and Scan
1.Meadows, James. Orthopedic Differential Diagnosis In Physical Therapy. McGraw Hill. 1999
2.Greenman, Philip. Principles of Manual Medicine. Lippincott Williams & Wilkins. 1996
3.Meadows, James. "Maryland Manual Therapy Certification." Physical Therapy First. Baltimore, MD. 2011
4. Hollinshead, Henry. Textbook of Anatomy. Harper and Row. 1985