Plantar fasciitis or intrinsic foot muscle strain , how do you differentiate ?

[Gerrard Farrell]

Re: Plantar fasciitis or intrinsic foot muscle strain , how do you differentiate ?

In the first post I outlined a test which I feel could be used for differentiating between heel pain caused by plantar fasciitis , and muscle related pain such as tendonitis /tendinopathy . I was not sure if the test was original or not but I now think it may well be since , according to a recent article in The Journal of the American Podiatric Medical Association , tendinopathy is not a recognized cause of heel pain in the scientific literature . I would appear to have "invented" a test for differentiating between plantar faciitis and something else which does not "officially " exist !

An abstract of the article is included below but here is a particularly striking part of that abstract -

"The close anatomic proximity and mechanical function of these muscles relative to the plantar fascia suggests potential for proximal plantar intrinsic tendinopathy as a result of repetitive loading during gait and other weightbearing activities. To date, this diagnosis has not been proposed in the scientific literature."

If the abstract is anything to go by (I do not have access to the full text ) ,the article is most welcome even if overdue .



Here is a recap of that tendinopathy /tendinitis Vs plantar fasciitis /fasciopathy test -

"The test ? Dead easy . You would need a simple board for the foot with a raised ,ramp section at one end for the toes and a non elastic leather strap to hold the foot in place . Before taking those first few steps the patient would place their foot on the board ,located on the floor , with the toes inclined on the ramp . The leather strap would go round the board and the foot , and be fastened to hold the foot to the board . The patient now presses the toes against the ramp section so that the ball of the foot tends to lift off the board but is held in place by the rigid leather strap . The fascia is being unloaded here , whilst the intrinsics are contracting . Pain means a muscular pain source ."


Article Citation:
Sean Christie, Gary Styn Jr, Gregory Ford, and Karl Terryberry (2019) Proximal Plantar Intrinsic Tendinopathy: Anatomical and Biomechanical Considerations in Plantar Heel Pain. Journal of the American Podiatric Medical Association: September 2019, Vol. 109, No. 5, pp. 412-415.

https://doi.org/10.7547/17-198

SPECIAL COMMUNICATION
Proximal Plantar Intrinsic Tendinopathy: Anatomical and Biomechanical Considerations in Plantar Heel Pain



Sean Christie, PT, DPT*†Gary Styn Jr, MD*Gregory Ford, PT, DPT, PhD, OCS*Karl Terryberry, PhD*

*Department of Physical Therapy, Daemen College, Buffalo, NY.
†North Hills Orthopedic and Sports Physical Therapy, Pittsburgh, PA.
Corresponding author: Sean Christie, PT, DPT, 5551 Copper Dr, Apt 205, Erie, PA 16509. (E-mail: sean.christie@daemen.edu)



Plantar heel pain is often managed through podiatric and physical therapy interventions. Numerous differential diagnoses may be implicated in patients presenting with plantar heel pain; however, symptoms are often attributed to plantar fasciitis. Abductor hallucis, flexor digitorum brevis, and quadratus plantae share proximal anatomic attachment sites and mechanical function with the plantar fascia. Although these plantar intrinsic muscles each perform isolated digital actions based on fiber orientation and attachment sites, they function collectively to resist depression of the lateral and medial longitudinal arches of the foot. Overuse injury is the primary contributing factor in tendinopathy. The close anatomic proximity and mechanical function of these muscles relative to the plantar fascia suggests potential for proximal plantar intrinsic tendinopathy as a result of repetitive loading during gait and other weightbearing activities. To date, this diagnosis has not been proposed in the scientific literature. Future studies should seek to confirm or refute the existence of proximal plantar intrinsic tendinopathic changes in patients with acute and chronic plantar heel pain through diagnostic imaging studies, analysis of lactate concentration in pathologic versus nonpathologic tendons, and response to specific podiatric and physical therapy interventions germane to tendinopathy of these muscles.


Copyright ©2019 by the American Podiatric Medical Association

[Gerrard Farrell]

Pain from intrinsic muscle strain and from plantar fasciitis . How do you differentiate between the two and is there a difference in the treatment prescribed ?

In some instances it might be quite easy to differentiate between muscle pain and pain from the fascia .

My understanding is that foot pain is often at its worst for the first few steps after getting out of bed in the morning , so that may be the best time to have the test ( carried out by the patient themselves but only after diagnosis and instruction by a suitably qualified individual ) .

The test ? Dead easy . You would need a simple board for the foot with a raised ,ramp section at one end for the toes and a non elastic leather strap to hold the foot in place . Before taking those first few steps the patient would place their foot on the board ,located on the floor , with the toes inclined on the ramp . The leather strap would go round the board and the foot , and be fastened to hold the foot to the board . The patient now presses the toes against the ramp section so that the ball of the foot tends to lift off the board but is held in place by the rigid leather strap . The fascia is being unloaded here , whilst the intrinsics are contracting . Pain means a muscular pain source .

Once again you would carry this out only after expert instruction but in essence its pretty simple once you know how .

Further to the above , it will be understood that if a patient has marked pain with the first few steps in the morning , but the technique outlined does not produce pain when the intrinsics are contracting ,then it is likely to be a fascia based problem .

Toe curling type exercises are unlikely to be of any use in the test since they principally concern the extrinsics .

How often is intrinsic muscle damage or insertional tendonitis mistaken for plantar fasciitis ? Given the number of muscles in the foot and the job they perform during the latter part of stance , I would imagine the misdiagnosis happens frequently .



Asked in the first sentence of this post , " is there a difference in the treatment prescribed ? "

Well , a muscle strain might initially be treated with rest and ice , but progressive strengthening exercises would normally also be involved , as soon as symptoms began to resolve . Physiotherapists would normally routinely recommend targeted, strengthening exercises for skeletal muscle strains but this might not happen with injuries attributed to plantar fascia problems .

Therefore with the foot , I can see considerable value in being able to differentiate between muscle and "fascia related " problems .

Any thoughts


( Much of the above is from material written by me on Podiatry Arena in the last few days )