As I have been doing Locum work over the last 6 years I have noticed one very obvious failing in a few Practices.

The standard of the new Graduates has been extremely high.

Note taking fluctuates from Practice to Practice. Most are very good, much better than mine! Others go down to my level!

All Physios are very good at mobilising joints.

But often the muscles controlling those joints are overlooked.

Two examples I have come across in more than one Practice.

1. Wrist joints. 

All the joints were very well mobilised, yet pain in the joint remained.

I know it is very easy for me to look at what has been done and then just try other things. But surely this is what the Physios should have been doing themselves.

So when I see a joint that has obviously been mobilised many times and pain and tenderness remains I routinely palpate up the forearm and usually find tight muscles.

After a few minutes massage the pain and tenderness goes.

A Miracle?

No. Just commonsense!

But the Patients think I am a wonderworker and I get a buzz.

 

2. Plantafasciitis.

The classic sign of plantar fasciitis is that the worst pain occurs with the first few steps in the morning, but not every patient will have this symptom. Patients often notice pain at the beginning of activity that lessens or resolves as they warm up. The pain may also occur with prolonged standing and is sometimes accompanied by stiffness. In more severe cases, the pain will also worsen toward the end of the day.

On examination, the patient usually has a point of maximal tenderness at the anteromedial region of the calcaneus. The patient may also have pain along the proximal plantar fascia. The pain may be exacerbated by passive dorsiflexion of the toes or by having the patient stand on the tips of the toes.

 

How do you treat Plantafasciitis?

With a rolling pin or can of baked beans? Deep massage to the fascia? 

Stretches to the Fascia and/or Calf muscles? 

Ice? Ultrasonics?

Taping for support? Night splints? Orthotics? 

Rest?

 

This is very intriguing and I have noticed this many times.

What I do as a routine now is palpate around the fascia and heel area.

Get the Patient to confirm pain and tenderness.

Then I massage the Flexor Digitorum Longus. Do this for a few minutes and the re-palpate the once tender areas!

90% of those I have treated in the last 4 years have noticed a partial reduction or complete reduction in tenderness.

That includes tenderness around the anteromedial region of the calcaneus!

It is not enough to massage and stretch the Calf muscles!

Yes I do get Patients to do their own massage and stretches at home!

Early morning pain is diminished and walking on hard surfaces during the day is less painful.

Remember, both of the above are after other treatments have been tried.

But looking at the muscles early in the treatment cycle is recommended!

 

Questions

1. How can just massage to muscles in the lower leg, whose tendons do not attach to the heel, result in a lowering of tenderness in the heel?

Does the fascia around the tendons attach to the heal?

Notes from Grays

Laciniate Ligament (ligamentum laciniatum; internal annular ligament).—The laciniate ligament is a strong fibrous band, extending from the tibial malleolus above to the margin of the calcaneus below, converting a series of bony grooves in this situation into canals for the passage of the tendons of the Flexor muscles and the posterior tibial vessels and tibial nerve into the sole of the foot. It is continuous by its upper border with the deep fascia of the leg, and by its lower border with the plantar aponeurosis and the fibers of origin of the Abductor hallucis muscle. Enumerated from the medial side, the four canals which it forms transmit the tendon of the Tibialis posterior; the tendon of the Flexor digitorum longus; the posterior tibial vessels and tibial nerve, which run through a broad space beneath the ligament; and lastly, in a canal formed partly by the talus, the tendon of the Flexor hallucis longus.

2. Does the tension in the FDL tendons affect the Plantafascia?

 

 

I am sure some learned Physio will help us with these questions.

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