I'm Brett DeGoyer. I'm a primary care sports medicine specialist and neuromusculoskeletal medicine specialist practicing for Samaritan HealthCare in Moses Lake, Washington. In this case, we're discussing plantar fasciitis, a very common problem not just in athletes but in the general population as well. The pain is experienced typically along the base of the calcaneus but can also radiate all the way up towards the metatarsals, towards the toes. In this, we need to keep in mind there are many structures that can be contributing to the symptoms that are going on, not just the plantar fascia. The plantar fascia has several bands, so also be aware that pain can be medial or it can be out lateral. The other pain generators can be the deeper structures, the deeper muscles, like the flexor hallucis. But you also need to keep in mind in treating for the plantar fascia that there are connections all the way around the calcaneus that connect in with the Achilles and then all the way up into the calf muscles. So when we're doing treatment with osteopathic manipulation, we have to take all of those factors into consideration. By and large, the treatment will focus on the plantar fascia. One of the ways we do this is to use counter strain. Counter strain is a type of treatment where you find the point on the area of the body that is most painful, typically at the enthesis or in the middle of a muscle belly or at the myotendinous junction. We monitor at that spot. And then simplistically, we try to fold around that spot and hold for 90 seconds or so. In this case with the plantar fascia, I'm going to monitor right at the base of the calcaneus. I'm going to plantar flex the foot, plantar flex the toes, and add in a little bit of compression, at least in this position. As I add in just a little bit of compression, that should relax the plantar fascia, take a lot of the pain away. And you ask the patient for some feedback. If there was a 10 out of 10 pain when we started, where is it now? And if they respond that it's less than a 3 out of 10, then you should maintain that position. If it's larger than that, say they're still at a 6, then you try to induce a little bit greater motion, add in a little bit more compression, or a little bit of side bending or torsion, until we can get that pain to reduce to 3 out of 10 or lower. Again, hold for 90 seconds, maybe a little bit longer. Once that's been completed, then you return to the normal position. And then retest to see how much pain is left, if at all. So that's one way to do it in the supine position. So alternatively, instead of treating in the supine position, we can put the patient in a prone position or face down, belly down. Go ahead and turn. And then we can balance the foot against the knee, monitor that spot right at the base of the calcaneus. Only now, I can use my knee as leverage to induce the plantar flexion and compression. Additionally, I can add pressure through the calcaneus, directed directly dorsal, to achieve that wrapping around position. Shortening the fibers of the plantar fascia, and then allowing the nervous system input to settle down. 90 seconds, once that's completed, back to a neutral position, retest the point.

3rd Edition, CASE 17

3rd Edition

Foot

plantar fasciitis

sports medicine

counter strain

Achilles

pain relief