#fascitis

Botox..For plantar fasciitis? Really?

We found this article (1) in one of our favorite journals, Lower Extremity Review , and were a little surprised. Let us get this straight: you are going to take one of the the most poisonous biological neurotoxins known (1) and inject it into your calf and foot?

The article in LER is well written and the results (thankfully) were inconclusive regarding its usage. They do cite 3 studies (with two by the same lead author) where it has been effective (2-4). Yes, it is better than saline (5) (but not as good as extracorporeal shock wave therapy (6)), and better than placebo (7-10) but considerably more risky.

So the premise is “if the muscle is dysfunctional, then let’s just take it out of the equation”. But this really doesn’t fix the problem, it just covers up the symptom. And what about the other potential side effects since botulinum toxin acts not only at the neuromuscular junction, blocking the release of acetylcholine, but also at the autonomic ganglia, postganglionic parasympathetic nerve endings, as well as the post ganglionic sympathetics that use acetylcholine (capillaries of skin, piloerector muscles and sweat glands) (11)?.

In our experience, most cases of plantar fasciitis are secondary to lack of forefoot rocker, lack of ankle rocker, lack of hip extension or in some cases, direct trauma. Wouldn’t it make more sense to strengthen the anterior compartment to reciprocally inhibit the posterior compartment, increasing ankle dorsiflexion and hip extension? We find, oftentimes, treating only the area of chief complaint and not what is "driving the bus" can offer temporary, symptomatic relief but not long standing pathmechanics or pathoanatomy.

Just like the road to enlightenment, there are no shortcuts in treating plantar fasciitis and if you are not going to treat the cause, then be prepared to reap what you sow.

Dr Ivo Waerlop, one of The Gait Guys

#botox #plantarfascitis #badideas #gaitproblem #thegaitguys

1. https://lermagazine.com/article/botox-injection-not-just-for-celebrities-furrows-and-wrinkles

2. Elizondo-Rodriguez J, Araujo-Lopez Y, Moreno-Gonzalez JA, Cardenas-Estrada E, Mendoza-Lemus O, Acosta-Olivo C. A comparison of botulinum toxin A and intralesional steroids for the treatment of plantar fasciitis: A randomized, double-blinded study. Foot Ankle Int. 2013;34(1):8-14.

3. Díaz-Llopis IV, Rodríquez-Ruíz CM, Mulet-Perry S, Mondéjar-Gómez FJ., Climent-Barberá JM., Cholbi-Llobel F. Randomized controlled study of the efficacy of the injection of botulinum toxin type A versus corticosteroids in chronic plantar fasciitis: results at one and six months. Clin Rehabil. 2012;26(7):594-606.

4. Díaz-Llopis IV, Gómez-Gallego D, Mondéjar-Gómez FJ, López-García A, Climent-Barberá JM, Rodríguez-Ruiz CM. (2013). Botulinum toxin type A in chronic plantar fasciitis: clinical effects one year after injection. Clin Rehabil. 2013;27(8):681-685.

5. Ahmad J, Ahmad SH, Jones K. Treatment of Plantar Fasciitis With Botulinum Toxin. Foot Ankle Int. 2017 Jan;38(1):1-7. doi: 10.1177/1071100716666364. Epub 2016 Oct 1.1.

6. Roca B, Mendoza MA, Roca M. Comparison of extracorporeal shock wave therapy with botulinum toxin type A in the treatment of plantar fasciitis. Disabil Rehabil. 2016 Oct;38(21):2114-21. doi: 10.3109/09638288.2015.1114036. Epub 2016 Mar 1

7. Babcock MS, Foster L, Pasquina P, Jabbari B. Treatment of pain attributed by plantar fasciitis with botulinum toxin A: a short-term randomized, placebo-controlled, double blinded study. Am J Phys Med Rehabil. 2005;84(9):649-654.

8. Samant PD, Kale SY, Ahmed S, Asif A, Fefar M, Singh SD. Randomized controlled study comparing clinical outcomes after injection botulinum toxin type A versus corticosteroids in chronic plantar fasciitis. Int J Res Orthop. 2018;4(4):672-675.

9. Huang YC, Wei SH, Wang HK, Lieu FK. Ultrasonographic guided botulinum toxin type A treatment for plantar fasciitis: an outcome-based investigation for treating pain and gait changes. J Rehabil Med. 2010;42(2):136-140.

10. Ahmad J, Ahmad SH, Jones K. Treatment of plantar fasciitis with botulinum toxin. Foot Ankle Int. 2017;38(1):1-7.

“What do you mean my plantar fasciitis is due to my hip?”

I recently saw a 60 YO male patient with right-sided plantar fasciitis of approximately 1-1/2 months duration. It began insidiously with pain located at the medial calcaneal facet on the right hand side. He had localized tenderness in this area with some spread distally towards the metatarsal heads. He has ankle dorsiflexion was relatively symmetrical with mild impairment on the right compared to left but only approximately 2 degrees. He had hip extension is 0 degrees on the affected side and 10 degrees on the affected side. Sacroiliac pathomechanics were present as well with the loss of flexion and extension. He had a slight leg length discrepancy, short on the symptomatic side.

So what is going on?

Moving forward in the sagittal plane requires a few things:

Adequate hip extension

Adequate ankle dorsiflexion

Adequate hallux dorsiflexion with an intact Windlass mechanism

He has a diminished step length going from right to left. Because of the lack of hip extension, the motion needs to occur somewhere. His ankle dorsiflexion is almost sufficient but less sufficient on the right (symptomatic) side than it is on the left. He has adequate hallux dorsiflexion but lacks adequate hip extension. Like the song goes, begin "Two of of three ain’t bad". However in this case, it is bad. He has an intact windlass mechanism. In fact, a little too intact. This is causing a tug at the medial calcaneal facet, creating an insertional tendinitis that we know as "plantar fasciitis".

So we did we do?

Manipulated the right sacroiliac joint

Gave him lift she/spread/reach exercises

Gave him shuffle walk exercises

Worked on hip flexor lengthening

Treated the plantar fascial insertion locally with acupuncture and laser therapy

Dr Ivo Waerlop, one of The Gait Guys

#GlobalNews: “¿Talones dolorosos? Podría ser fascitis plantar, y así es como tratarla – National “

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Es una afección del pie que comienza con dolor en el talón, y los expertos dicen que es bastante común.

Jamie Mandlsohn, un podólogo de la Clínica de Toronto Foot, describió la afección en cuestión, fascitis plantar, como la inflamación de la maceta fascia, una banda de tejido que se extiende desde el talón hasta el hueso del pie medio.

“Imagine su pie como un amortiguador”,…