2014 malaysia the inverted pendulum approach the spring mass approach the integrated spring mass approach to treating plantar fasciitis

The Inverted Pendulum Approach,
The Spring-Mass Approach
AND
The Integrated Spring Mass Approach
To Treating Plantar Fasciitis.
by Dr. James Stoxen DC
President, Team Doctors
Lecture presented August 30th
2014
www.teamdoctorsblog.com 1

Plantar Fasciitis
Plantar Fasciitis is the most common
cause of heel pain in adults. (1)
Plantar Fasciitis
Top 10 most common
conditions of the lower body (2)
1. Patellofemoral Pain Syndrome
2. Iliotibial Band Friction
Syndrome
3. Plantar Fasciitis
4. Meniscal Injuries Of The Knee
5. Tibial Stress Syndrome
6. Patellar Tendonitis
7. Achilles Tendonitis
8. Gluteus Medius Injuries
9. Stress Fracture Tibia
10. Spinal Injuries
2014

Plantar Fasciitis AKA
• Plantar fasciitis is often called “heel spurs,” although
this terminology is somewhat of a misnomer because
15 to 25 percent of the general population without
symptoms have heel spurs and many symptomatic
individuals do not. (3)
• The other names for plantar fasciitis are plantar
fascitis, plantar fasciosis, fasciitis plantaris, plantar
fascial fibromatosis, plantar heel pain syndrome,
policeman's heel, heel spur syndrome, painful heel
syndrome, and inferior calcaneal exostoses.
Lecture presented August 30th 2014 www.teamdoctorsblog.com 3

Relationship to Heel Spurs
Around 50 percent of
patients with plantar
fasciitis have heel spurs,
but they are most often an
incidental finding and do
not correlate well with the
patient's symptoms. (4)
2014

What is Plantar Fasciitis?
• It is by definition, a painful inflammation of
the plantar fascia.
• It is an abnormality or injury at the site of
attachment of a ligament or tendon to bone)
of the origin of the plantar fascia at the medial
tubercle of the calcaneus due to excess
traction often characterized by pain on the
first step in the morning (5) or when they
stand up after prolonged sitting. (6)
2014

Incidence
• Plantar fasciitis is the most common cause of
heel pain with ten percent of the population
will pull up with plantar fasciitis in their
lifetime. (7).
• The condition accounts for eleven to fifteen
percent of all foot symptoms, affecting two
million people in the United States alone. (8)
Lecture presented August 30th 2014 www.teamdoctorsblog.com 6

What are the symptoms of
plantar fasciitis?
• The tenderness you would feel is usually noted on the medial
calcaneal tuberosity (see image) and along the plantar fascia. The
classic sign or plantar fasciitis is pain on first few steps in the
morning. The pain usually decreases after you walk it off, but can
return throughout the day the longer you are on your feet.
• Most feel the symptoms of pain when standing on feet too long.
The pain can come on worse at the end of the day. Its more
common and more severe in those who are overweight, obese or
weakness in specific muscles of the foot.
• The pain often increases with stretching of the plantar fascia, which
is achieved by lifting your foot (dorsiflexion) and toes up. (4)
2014

Causal Connection to Heel Spurs
• Fuller stated that fascial stretching caused pain either to the plantar
fascia itself or at the attachment to the bone. High tension in the
fascia could also cause a periosteal lifting at its insertion on the
calcaneus, and bone healing could cause growth of a spur that
might be seen at the calcaneus. (9)
• Plantar fasciitis is generally believed to be due to repetitive partial
tearing at this enthesis with associated chronic inflammation. (10)
• These results support the belief that pain occurs not from the bone
spur but from the excessive tension applied to the plantar fascia (11)
2014

Doesn’t Plantar Fasciitis
Only Effect Athletes? No!
• Plantar fasciitis is usually seen as an overuse injury in athletes, runners in
particular (accounting for nearly 10% of running injuries), but is also seen in non
athletes too. (12)
• Most non-athletes have it in the subclinical state, which means that there is
inflammation of the fascia but not enough to cause pain you can feel unless you
press into the fascia called deep tissue palpation.
• If non-athletes have this form of non painful inflammation of the fascia and walk a
few blocks barefoot or run with or without shoes they will feel the pain in their
fascia as the inflammation rises to a point where the nerves and brain together
sense the higher concentration of inflammation.
• I check the plantar fascia and the health of the feet for all conditions because I feel
the status of the foundation of our body or the bodies spring suspension system
2014

What Causes Plantar Fasciitis?
• Plantar fasciitis is one of the more common soft-tissue
disorders of the foot, yet little is known about its
etiology.
• The fascia foot pain is caused by stress and strain in the
area, that leads to the release of inflammation and
when the inflammation gets high enough you feel pain.
• Although the pathology of plantar fasciitis is
understood the development or causes of plantar
fasciitis is less agreed upon.
2014

What Causes Plantar Fasciitis?
• Also, although plantar fasciitis
is a prevalent problem, little
scientific evidence exists
concerning the most
appropriate treatment
approach or intervention. (12)
• Why?
• Because doctors cannot agree
on the cause of plantar fasciitis
it makes it difficult for
physicians to diagnose and
treat this common injury.
• I explain why in this
presentation
2014

Three Schools Of Bio-Mechanics
• Inverted Pendulum Model – and The Lever
Series Model (1685)
• The Spring- Mass Model (1989/1990)
• The Integrated Spring-Mass Model (2012)
2014

Plantar Fasciitis
Examination, Treatment and Prevention
Inverted Pendulum/Lever Series Approach
vs
Integrated Spring-Mass Approach
How do they differ?
2014

What is the plantar fascia?
• The plantar fascia, also known as the plantar aponeurosis is a broad, flat, fibrous,
tendon-like structure, which consists of non-contractile irregularly ordered collagen
fibers with minimal elastic properties. (13)
What does that mean?
• What that means is that it is like gristle on a steak.
• It means it doesn’t stretch much.
• It means it does not contract like a muscle.
What roll does it play?
• The plantar aponeurosis plays an important role in transmitting Achilles tendon
pull forces to the forefoot when you are about to push off when you walk. (46)
2014

• Many “lever model only” thinkers believe we ambulate
with levers in linkages.
• That is why they are validated when they note the
symptom of pain in the fascia when we have tension on the
Achilles tendon through the gastroc/soleus muscle
contraction. (14)
• Unfortunately, “Pendulum-Lever model only” thinkers cant
provide much of an explanation for how the mechanism
breaks down to cause the stress on the plantar fascia.
• They have few theories
2014

This is what the lever model thinkers
say causes plantar fasciitis
• Increasing tension on the Achilles
tendon is coupled with an
increasing strain on the plantar
fascia. Overstretching of the
Achilles tendon resulting from
intense muscle contraction and
passive stretching of tight Achilles
tendon are plausible mechanical
factors for overstraining of the
plantar fascia. (15)
• What is causing the
overstretching or strain on the
Achilles and fascia is the key
question to solving this riddle
2014

• the human lever model says that the primary
reason for why the fascia has stress is because
of a tight fascia due to a tight Achilles.
• I have never found the Achilles tight in one of
the patients I have examined with plantar
fascia in my life.
2014

Why Tight Achilles is
Not a Cause of Plantar Fasciitis
1. The Achilles is not a contractile element
1. The plantar fascia has no contractile
elements.
2. There is no research that shows increased
electrical activity in the Achilles muscle group
coincides with plantar fasciitis (no proof)
2014

Lever Series says
Tight Achilles is the Cause?
• For example: the human lever
model says that the primary
reason for why the fascia has
stress is because of a tight
fascia due to a tight Achilles.
• I have never found the Achilles
tight in one of the patients I
have examined with plantar
fascia in my life.
• No biomechanical explanation
why Achilles Tendon Muscle
group is Tight or in Spasm in
the Scientific Literature.
2014

Achilles Spring
The gastrocnemius and soleus do not push the body forward when walking or running – They spring it
forward
• An average of 38 J of energy was recovered from the elastic recoil of the tendon, which contributes
16% of the total average mechanical work of the hop (254 J). (16)
• In conclusion, the properties of the elastic Achilles tendon can contribute significantly to the total
mechanical work of the body during one-legged hopping; however, individual variation in the
properties of the tendon vary the energy storing capacity of this structure. (16)
• The results indicated that the AT does indeed act like an energy storing spring by contributing a
considerable amount of energy to the total mechanical work performed. (16)
• The results of this study demonstrated the energy storing capabilities of the AT, whereby the
tendon stretches in proportion to the force applied during the downward motion of the body and
then recoils to release most of the energy stored (74%) during the upward movement. This
provides a substantial amount of the total mechanical energy of the hop (16%). (16)
2014

If Spasms or Tight Achilles then..
• If the cause of plantar fasciitis is spasms or tightness in the Achilles
Tendon Group then how does this relate to the normal cause which
is standing on the feet too long?
• If the cause of plantar fasciitis is spasms or tightness in the Achilles
Tendon Group then you should find trigger points or muscle spasms
in the area.
• If tension in the Achilles then the plantar fascia would still pull only
harder and the windlass mechanism would still work because the
fascia is connective tissue and not muscle.
• It doesn’t make sense!
2014

Primary Cause
• Standing on your
feet too long
2014

The Effect Of Flip-flops On Dorsiflexion
and Tibialis Anterior Electromyography.
• The study also showed that female subjects had a
more vertical attack angle in flip-flops when
compared to athletic sneakers
• Specifically, as the non-support leg swings through,
the tibialis anterior (TA) demonstrated an increase
in muscle activity, yet less dorsiflexion (DF) was
noted compared to barefoot walking.
• This finding was counterintuitive, as the TA is a
primary dorsiflexor, and more activity should have
been realized with an increase in dorsiflexion.
• the counterintuitive finding of increased dorsiflexor
muscular activity and less observed dorsiflexion
angle leads the author to conclude that the
increased activity of the TA in the presence of less
dorsiflexion could be the result of the flip-flop
wearer’s attempt to “grip” the flip-flop using the
plantar surface of the foot.
• Reciprocal inhibition, Internal Compressive Forces -
Bang and Twist Plantar Fasciitis and Shin Splints
2014

More Evidence of Spring vs Push
• This study we investigated in vivo length changes in the
fascicles and tendon of the human gastrocnemius
medialis (GM) muscle during walking.
Two important features emerged:
• the muscle contracted near-isometrically in the stance
phase, with the fascicles operating at ca. 50 mm; and
• the tendon stretched by ca. 7 mm during single support,
and recoiled in push-off. (17)
The spring-like behavior of the tendon indicates storage and
release of elastic-strain energy
2014

Basis of Lever Model Treatment
• There is an indirect relationship whereby if the toes
are dorsiflexed, the plantar fascia tightens via the
windlass mechanism. If a tensile force is then
generated in the Achilles tendon it will increase
tensile strain in the plantar fascia. Clinically, this
relationship has been used as a basis for treatment
for plantar fasciitis, with stretches and night stretch
splinting being applied to the gastrocnemius/soleus
muscle unit. (18)
2014

Cause: Preloading by Dorsiflexors
• The results show that the PA experienced
tension significantly above rest during early
stance phase in all subjects (P<0.01), thus
providing support for the PA-preloading
hypothesis. (19)
• In contrast to their finding, however, in this
study the PA appeared to be pre-loaded at
heel-strike. (19)
• The simultaneous action of the ankle
dorsiflexors and toe extensors, which prevent
foot-slap and dorsiflex the toes at the MTPJ,
and the plantarflexion moment applied to
the calcaneus by the vertical ground reaction
forces could account for some pre-stretching
of the PA. (19)
• A MTPJ dorsiflexion angle of about 30 deg.
was measured for the three subjects thus
confirming the action of the toe dorsiflexors
at and prior to heel-strike. (19)
2014

SPRING LOADING
2014

Toe Off
2014

Arch Load Various Force Landings
2014

Windlass Effect
2014

Windlass Effect
• During dorsiflexion of the toes, as
occurs in late stance, the PA is
stretched as it wraps around the
MH. This is the so-called windlass
mechanism which, in the late
phase of stance, is responsible for
raising the arch of the foot.
• and contributing to stiffening of
the foot by pulling on the heel,
causing inversion at the subtalar
joint and `locking' the midtarsal
joint
2014

What Suspends The Load Of The Arch
Off The Plantar Fascia?
• Throughout the literature
you see contradictions.
• For instance one paper says
that the plantar fascia
prevents foot collapse by
virtue of its anatomical
orientation and tensile
strength.
• One biomechanical model
estimated it carries as much
as 14% of the total load of
the foot. (20)
• What holds up the rest?
2014

Metatarsal Cunieform Joint
Joint Play Examination
2014

How would Spring-mass Model
thinkers, diagnose plantar fasciitis?
Advanced Video Gait
Evaluation Study at all force
increments
1. Double leg
2. Single leg
3. Walking
4. Fast Walking
5. Jogging
6. Running
7. Plyometrics
2014

Response to Traditional
Lever Based Treatment Approaches
• (44%) respondents
favored initiation of
plantar fascia-specific
stretching (PFSS)
• (24%) supervised physical
therapy
• (20%) night splinting
• (6%) steroid injection –
(4%) custom orthotics
• (2%) cast or boot
immobilization (21)
2014

Taping
• Taping provides only
transient support, with
studies showing that as
little as 24 minutes of
activity can decrease
the effectiveness of
taping significantly. (22)
2014

ORTHOTICS?
• By placing a support under the arch it could
inhibit full depth of loading of the arch in its
descent. You have a shoe which causes a
compressive force on the arch and fascia
from the top and the arch support occupying
space at the bottom. If the arch must raise
up to accommodate the windlass effect there
is a possibility that the windlass effect could
be sabotaged or reduced. This could place
more stress on the plantar fascia.
• A binding device can possibly restrict the
mobility of the loading and rolling. If there is
restrictiuon of movement there is reduction
in maximum muscle contraction and
relaxation. This could inhibit the adaptation
strengthening of the intrinsic and spring
suspension system muscles.
2014

Adjustments and stretching vs
orthotics
• As mentioned previously, the study by Dimou, Brantingham
and Wood of chiropractic adjustments/manipulation of the
foot and ankle along with a daily stretching regimen). (23)
• The custom orthotics group reported significant
improvements in almost all outcome measures, but these
improvements were not statistically different or superior to
those obtained in the chiropractic and stretching group.
(23)
• Dimou et al reported a significant difference for pain
between the manipulation treatment group and the CFO
treatment group, with the chiropractic group being
superior. (23)
2014

Night splints
• Night splints usually are designed to
keep a person's ankle in a neutral
position overnight.
• Most individuals naturally sleep with
the feet plantar-flexed, a position
that causes the plantar fascia to be in
a foreshortened position
• A night dorsiflexion splint allows
passive stretching of the calf and the
plantar fascia during sleep
• Disadvantages of night splints include
mild discomfort, which may interfere
with the patient's or a bed partner's
ability to sleep. (24)
• How can fascia stretch when it is not
a muscle?
2014

Cortisone injections
• All of the patients found the corticosteroid
injection painful. The post-injection pain was
said to have continued for a mean duration
of 5 and 7 days respectively (25) (26)
• This pain in the injection site can lead to an
abnormal gait. Walking with a stiff painful
foot causing a limp can alter foot
biomechanics or your pattern of walk and
make your plantar fasciitis worse.
• Lee and Ahmad’s study reported the
corticosteroid group to show a significant
reduction in pain on the visual analog scale
at both 6 weeks and 3 months in comparison
to the autologous blood group.
• However, this change was not significant at 6
months. (26)
•
2014

CORTISONE INJECTION
• The risk factors for the use of CSI include plantar
fascial rupture, hypoglycemia in diabetic patients,
skin and fat-pad atrophy, and sepsis. These findings
suggest that treatment regimens such as serial
corticosteroid injections into the plantar fascia
should be reevaluated in the absence of
inflammation and in light of their potential to induce
plantar fascial rupture. (27)
2014

CORTISONE INJECTIONS
Georgia Baptist Medical Center, Atlanta,
1992 to 1995
• The authors injected 122 of the
765 patients, resulting in 12 of
the 44 plantar fascia ruptures.
Subjective and objective
evaluations were conducted
through chart and radiographic
review.
• Thirty patients (68%) reported a
sudden onset of tearing at the
heel, and 14 (32%) had a gradual
onset of symptoms.
• At an average 27-month follow-
up, 50% had good/excellent
scores and 50% had fair/poor
scores (28)
2014

BOTOX
• Reserve for chronic injuries, after intensive use of other approaches for at least 2 months has failed
• Use when rehabilitation is inhibited by symptoms
• Informed consent should be obtained from the patient, who must be willing to follow postinjection
guidelines
• The practitioner should have full knowledge of the local anatomy
• Select the finest needle that will reach the lesion
• The practitioner's hands and the patient's skin should be cleansed and a no touch technique used
• Use short or medium acting corticosteroid preparations in most cases, with local anaesthetic
• Injection should be peritendinous; avoid injection into tendon substance
• Minimum interval between injections should be 6 weeks
• Use a maximum of three injections at one site
• Soluble preparations may be useful in those patients who have had hypersensitivity/local reaction to
previous injection
• Details of the injection should be carefully recorded
• Do not repeat if two injections do not provide at least 4 weeks' relief (29)
2014

10 months no relief – Surgery or
ECSWT
• What was the surgeon's preferred treatment after 10
months of non-responsive to treatments. (30)
•
• 62 (74%) respondents chose surgery or ECSWT
(extracorporeal shock wave therapy) as their next step
(30)
• 46 (55%) Some form of surgery with the most popular
operative interventions were gastrocnemius recession
(alone or in combination with another procedure) and
open partial plantar fascia release with nerve
decompression. (30)
2014

HOW DOES THE FOOT ABSORB
IMPACTS
• The Arch Leaf Spring - There have been
studies on the arch with all muscles removed
leaving just the bones and ligaments. These
were extracted from cadavers. What the
study showed was that the arch complex
itself has the ability to spring back forces
without the aid of the muscles.
• The Spring Suspension System Muscles - I
coined these muscles as the spring
suspension system muscles, the landing
muscles or the pronation-supination cuff
muscles. I identified this new medical
terminology myself in order to better explain
the function of this area.
• The Windlass Mechanism - The plantar
fascia does not stretch much during push off,
so the arch of the foot must bend up to
accommodate the forces generated at push
off. This is like a spring from a bouncing ball.
2014

FORCES ON THE BODY
• Standing (50% of
bodyweight on each
foot)
• Walking (1.25 x
bodyweight on the foot at
landing)
• Running (3x bodyweight
on the foot at landing)
• Plyometrics (3-5x+
bodyweight on the foot at
landing)
2014

Spring Suspension Muscles
• Also if there is too
much stress on the
plantar fascia isn’t it
from the structures that
hold up the arch 86%
that are weak that we
need to address? (20)
2014

Spring Suspension System Muscles
(Your Landing Gear)
• Tibialis Posterior AKA Posterior tibial tendon
dysfunction is the most common cause of
acquired flatfoot deformity in adults. he arch
is further supported by the plantar
aponeurosis, by the small muscles in the sole
of the foot, by the tendons of the Tibialis
anterior and posterior and Peronæus longus,
and by the ligaments of all the articulations
involved. Henry Gray (1821–1865). Anatomy
of the Human Body. 1918. rewrite
•
• The Peronæus longus also everts the sole of
the foot, and from the oblique direction of
the tendon across the sole of the foot is an
important agent in the maintenance of the
arch. Henry Gray (1825–1861). Anatomy of
the Human Body. 1918.
2014

What do I find (that other doctors don’t) when examining a
patient with plantar fasciitis.
• Over Pronation – Im Not The
Only One
• Weakness and tense painful
spasms In The Tibiailis
Posterior – Im Not The Only
One
• Locking Of The Metatarsal
Cuneiform Joint
• Thordarson et al found that
the posterior tibialis muscle
provided the most significant
dynamic arch support during
the stance phase of gait. The
posterior tibialis eccentrically
lengthens to control pronation
and reduce the tension
applied to the plantar fascia
during weight acceptance.
Excessive pronation can cause
posterior tibialis weakness and
plantar fascia elongation. (21)
2014

Endurance of Suspension System
• The most frequent training error seen with plantar
fasciitis is a rapid increase in volume (miles or time
run) or intensity (pace and/or decreased recovery).
(22)
• A final training error seen in athletics is with a
rapid return to some preconceived fitness level.
Remembering what one did "last season" while
forgetting the necessity of preparatory work is part
of the recipe for injury. (22)
2014

Footwear designed as a Guide…
not as a Support
• A change in shoes was
cited by 14 percent of
patients with plantar
fasciitis as the treatment
that worked best for
them. (23)
• Motion-control and
stability shoes also have a
firm heel counter and a
firm midsole to control
the amount of pronation.
(23)
2014

Deep Tissue
• This study provides evidence that the addition of
TrP manual therapies to a self-stretching protocol
resulted in superior short-term outcomes as
compared to a self-stretching program alone in
the treatment of patients with plantar heel pain.
(24) (25)
2014

Arch and Ankle Release
2014

The biggest mistake made in
stretching is:
• People don’t stretch the foot
• When they stretch the foot they don’t stretch
the foot in 3 dimensions
• They don’t stretch the foot in the right direction
• They don’t stretch individual bones of the foot
(metarsal cuneiform joints).
• They don’t stretch during walking or running
• They don’t stretch enough
2014

Metatarsal Cunieform Joint
Arch Release
2014

Toe, Foot and Ankle Stretch
2014

Spring Suspension System Release
2014

Manual Therapy
• Manual therapy
consisted of
either grade III or
grade IV joint
mobilization
and/or high-
velocity, low-
amplitude
manipulation to
the affected
joints in the foot
and ankle, and
home-based
exercise.
2014

LEVER EXERCISE
RESISTANCE EXERCISE
2014

Training errors can be responsible for
up to 60% of injuries. (26)
2014

Double Leg Drills
2014

Single Leg Drills
2014

Thank you!
2014

2014 malaysia the inverted pendulum approach the spring mass approach the integrated spring mass approach to treating plantar fasciitis

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