Hi fabulous PTs on the board!

[Sheesh]

I have a question, and was hoping one of our fabulous physical therapists on the board might have some ideas/suggestions...

I've been in PT for almost 8 weeks for treatment for plantar fascitis, achilles tendonitis, and overall tight calf muscles in general. The plantar fascitis seems to be gone, but now I am experiencing pain in the flexor hallus longus (???) - the tendon that flexes my big toe. My PT says she doesn't have many more ideas for how to address this issue and will soon be sending me back to the podiatrist. I figured it was worth a shot asking here whether anyone has ideas... We've done lots of massage and stretching, but that doesn't seem to solve the problem. The tendon is really tight and "stringy" according to my PT. Any ideas on how to make this pain go away?

Thanks for your help!
Sheesh

[Wahine]

I'll put in my two cents but Knott is really the footsie person and I'm sure she'll have suggestions.

You mentioned calf tightness and I think that this is likely the key for you.

Check out www.thestick.com, they have a great myofascial release tool that allows you to do deep tissue massage to your own calves or have a partner do it. You could also go for a deep tissue massage. It hurts like h e double l but it works for me. It's important to drink a lot of fluids after the massage and make sure you stretch a lot in the days following.

Also check out this thread:

http://forums.teamestrogen.com/showthread.php?t=15318&highlight=plantar+fasciitis

It's specific to PF but a lot of the treatments for PF are the same for flexor hallucis longus tendonitis. You might get some new ideas.

Hope that helps.

[han-grrl]

Some options to think/look at

1) sometimes a new specialist is helpful, they see with a different set of eyes that maybe the PT had missed
2) shoes, custom orthotics might solve some things, you can stretch and stretch but if you are in poor footwear and/or on bad floors (like working on a concrete floor with little shock absorption) you canl remain with chronic pain issues...
3) technique you use for your sport, like running, if you have issues with gait then that can lead to chronic issues as well...

good luck!
han

[Sheesh]

Thanks, ladies! I appreciate the quick responses.

I have been keeping up on the plantar fascitis threads, and many of the exercises mentioned are what I've been doing for 8 weeks. I've gained some flexion in my foot (they initially didn't even make a 90 degree angle, even when pushed!), but still not enough...

We thought it might be my flip flops (I know, flip flops are bad, but they are Chacos!), so I switched to other shoes (even tennis shoes) and the pain seems to actually get worse. I couldn't get an appointment for this week, but I go in twice more next week so maybe I'll get a referral back to the podiatrist and hopefully she'll have more suggestions.

If you have more ideas, please keep 'em coming! THANKS!

[Wahine]

Sheesh, does your big toe move the same amount as the other side. When you bend it backward it should bend to almost 90 degrees. If it's stiff this may be a problem.

Knott really likes these chakos:

http://www.chacousa.com/products/ProductOptions.cfm?cID=3&pID=25&gID=2

I just bought a pair this weekend to help with a toe issue. I got the slip on kind tho. They're hard to get used to but really cool and I think they'll do the trick.

[KnottedYet]

Chacos are good! (I have 3 pair)

I have no issues with flip-flops if they have decent footbeds (like Chacos). In fact, they can strengthen your feet since you have to have active and lively feet to keep them on.

Are you wearing any nice NEUTRAL over-the-counter footbeds in all your regular shoes, like Superfeet or Spectrum Stabilizers or Shock Doctors?

Grumpy PF/FHL are like canaries in a coalmine. If something is out of whack, they start chirping. It might not even be something out of whack in the foot; it could be ankle or knee or hip or even weak core muscles!

Sounds like something is putting huge stress on the critters that hold your arch up. So why stretch those critters? Well, your body tightens them up trying to hold them together against the stress, but tight structures cause their own problems. How about reducing the stress first? Then your streches will not be in vain (your bod won't tighten up again as quickly).

If you have a spare $35 or $40 lying around, and if you don't have orthotics or good footbeds already, how about going to a *good* shoestore and just trying a pair of Superfeet "Green" or "Berry" footbeds. If those feel icky, try the Blue or any other color the store has. (I'm voting for green, but don't listen to ME, listen to your FEET!) You have 60 days to try out the Superfeet, and you can still return them to either the store or Superfeet Co. even if you trim them or post them. (If you have trouble returning within 60 days, contact me. I have a Superfeet rep who will handle the issue.)

Ask your PT if she can post your Superfeet if you need posting. Has she given you any intrinsic foot muscle exercises? Extrinsic foot muscle exercises? Balance/proprioceptive exercises? Posture exercises? (both foot and body) Hip external rotator exercises?

There are a bazillion cool things that can be done with footsies. PM me if you need some more info!

Knot-has-a-thing-for-feet-but-thats-ok

Edit: don't let anyone talk you into the custom heat-molded Superfeet or Your Soles. You don't want to play that game. Neutral over-the-counter footbeds is the way to go first. If anything is being custom molded to your feet, please let it be done by a Licensed Orthotist. (which I am NOT, but I have one I send my patients to)

[VeloVT]

I am NOT a PT, and don't know much about PF other than basically what it is, so this may or may not be useful, but I thought I might share my experience in case it offers something you haven't tried yet (maybe one of the PT ladies could comment on whether or not it might be useful).

I got peroneal tendinitis while in the later stages of marathon training this spring (thus no marathon for me... grrrr... next year...). It's often an overuse injury like PF, though in my case it was an acute injury from a misplaced footfall. Initially it was quite painful (I couldn't walk for more than 100 yards or so without starting to limp).

My PT prescribed iontophoresis (they tape a pad with contacts soaked in steroid solution to your foot, and then hook it up to a battery pack and run current through it for 20 minutes or so. I guess the solution has a different polarity than the current, which causes it to be pushed deeper into the tissue than would otherwise be the case with a topical application). We did about 12 sessions. I would say the first 3-4 actually helped -- they took the worst of the acute inflammation away and made it possible for me to walk normally (it was really helpful for me to wear super stable shoes to walk in everyday while I was trying to heal -- I wore the Brooks Trail Runners that are uncomfortably stable for me to run in, but they really helped keep my foot from hurting as I went about my daily activities). Anyway, the rest of the ionto sessions really did nothing -- my condition just plateaued to where I could walk and go about my business well (though a full day on my feet would be an issue), but I couldn't run more than two miles without a flare-up.

They did a full eval at this point, to see if orthotics would help. I was told that I have a structural deformity that prevents my heels/rearfoot from moving much at all during my gait cycle, and since I have fairly high, rigid arches, my forefeet are basically left to do all the compensation for this. She said my gait looks remarkably normal given this, but it puts alot of stress on the supporting muscles in my foot since they are always working and doing more than they were "designed" to do. PT was on the fence about whether orthotics were necessary/would be helpful...

So we had to come up with some other course of treatment. It had been almost two months since my injury and I still couldn't run. The woman who evaluated me (a different doctor at my University rehab clinic than the woman who was treating me regularly) suggested -- and I hope I have the name right here -- postural release work, since she theorized that the constant tension in my foot/lower leg might be responsible for my slow healing. Basically, the PT would do a little massage along the affected tendon/muscles, find trigger spots, and then position my foot/leg in such a way as to neutralize the tension (I'm SURE someone can do a better job explaining this). Anyway, although it hurt, it was MIRACULOUS for me. After two sessions I was able to run 6 miles with minimal pain. After two more sessions I was back to running as much as I could (in my out-of-shape state, at that point!) with no pain. I wish we'd started it earlier instead of wasting time & money on ionto... So, I know you mentioned that you'd done massage, but I wondered, if you have not tried this particular technique, if it might be of value...

Sorry this is so long. I hope your condition gets better soon. Painful feet are a real drag.

[KnottedYet]

Postural Release, Active Release, Trigger Point, Strain/Counterstrain, and more! All groovy.

Ionto with dex is niftyy, generally at first.... like you experienced. It's nice for calming down symptoms but doesn't do much for the cause. But it sure can help with symptoms so you can root out the cause without too much misery.

Another cool thing with ionto which I've only had one podiatrist order: acetic acid. When PF was being aggravated by a heel spur, he'd order inoto with acetic acid to help the body dissolve the spur. (we'd also be putting them in good insoles, posting as needed, exercising, teaching them massage techniques, stretches, etc.)

Feet are so cool!

[Sheesh]

My podiatrist had ordered iontopheresis, but the PT though it wasn't really necessary since it's more for inflammation, and my feet aren't really inflamed, just tight. The PT also said that most HMOs won't cover it and it's an expensive treatment, so we skipped it.

While my PT was doing RAGBRAI, I had appts with another PT who had me do some nerve stuff (the sheet says Slump Tibial Nerve Mobilization, and flexing my foot different directions to work on the nerves on the sides of the ankles). That was new, but I can't say whether I saw any benefits...

I do not have footbeds in my shoes. I can't wear tennis shoes to work, so I need to build up a new shoe collection (I wore high heels a lot, so now I have to find cute, comfy, flat shoes that will take a footbed). Any suggestions for comfy but cute dress shoes?

Knot - My PT hasn't given me any exercises other than stretches. Do you have some to suggest?

THANKS for sharing your wealth of knowledge!

[KnottedYet]

Knot - My PT hasn't given me any exercises other than stretches. Do you have some to suggest?

:eek: :eek: :eek: :eek: :eek: :eek: :eek: :eek: :eek: :eek:

Yes! Oh, my goodness! And footbeds that fit in high heels, too! And shoes! Oh, my!

Do you want me to PM, or post for everyone to read?

[snapdragen]

Share with the group! :D

[Zen]

I do not have footbeds in my shoes. I can't wear tennis shoes to work, so I need to build up a new shoe collection (I wore high heels a lot, so now I have to find cute, comfy, flat shoes that will take a footbed). Any suggestions for comfy but cute dress shoes?

THANKS for sharing your wealth of knowledge!

Skechers?

I'm starting to think my knee/back problem might be helped by looking at my feet...(must bookmark this thread) I haven't walked pain free for a long time and have just about given up on PT.

[Sheesh]

Knot - I'm okay with you posting for everyone to read. Who knows, maybe someone else will benefit, too. :) Also, today is "move in day" for our freshmen students, so I'm wearing tennis shoes and I've taken the green superfeet out of my hiking boots and put them in my tennis shoes. I'll let you know how the day goes!

Zen - That's how I ended up at the podiatrist. I have had lower back pain forever, and my new chiropractor sent me to get lots of x-rays and did some deep tissue massage and realized that I have major shin splints. Once the x-rays came back, she said the problem was my feet and that I needed to get that corrected and it would ultimately help me back... no relief yet, but I'm still hoping.

[Wahine]

Zen - That's how I ended up at the podiatrist. I have had lower back pain forever, and my new chiropractor sent me to get lots of x-rays and did some deep tissue massage and realized that I have major shin splints. Once the x-rays came back, she said the problem was my feet and that I needed to get that corrected and it would ultimately help me back... no relief yet, but I'm still hoping.


This is a which came first, the chicken or the egg question. The whole lower quadrant including your low back worked together as a unit and one can affect another. I just wanted to pipe in to say that this makes doing some core stabilization exercises even more applicable for you as well as addressing your feet.

[emily_in_nc]

I've been reading this thread with interest as I've developed a pain after I run (treadmill or trails). The pain is in my right toe, down low at the base, in the joint I guess, more on top of the foot than underneath the toe. None at all in my left foot. I don't feel it while running, but only when walking around afterwards.

My shoes are good New Balance 754 running shoes (not very old). I do not have any kind of insert other than what came in the shoes. I have rigid, underpronating feet so went for the "cushioning" type of shoe as opposed to the stability type. I went up a half-size from my street shoes after a bout of black toenail in my left big toe last year from wearing too-small running shoes just a couple of times. These shoes seem plenty long and have an ample toe box. My feet are medium width.

Any ideas of what this pain could be? It usually lasts for a day or two after a run, then goes away, only to return after the next run. Would Superfeet possibly help, or is a trip to a PT or podiatrist in my future?

Thanks!
Emily

[VeloVT]

Emily,
Does your toe get swollen? One of my (older) running buddies was having big-toe pain and swelling after runs and it turned out to be -- eek! -- arthritis. PT gave him a carbon sole, which created as many problems as it solved. My "buddy" (luv that word!) went out and bought a copy of Chi Running and has been trying to apply those principles, it seems like with pretty good success.

[emily_in_nc]

Emily,
Does your toe get swollen? One of my (older) running buddies was having big-toe pain and swelling after runs and it turned out to be -- eek! -- arthritis. PT gave him a carbon sole, which created as many problems as it solved. My "buddy" (luv that word!) went out and bought a copy of Chi Running and has been trying to apply those principles, it seems like with pretty good success.

Nope, no swelling, redness, etc. Just a funny pain in the base of the toe when I walk after running. It was pretty bad yesterday after my run, but is nearly gone today. My mom has gout, but that is very different from what I'm experiencing (i.e., her toe hurts all the time when she's having an episode, not just when walking), and her attacks have nothing to do with exercising (b/c she doesn't!) but more with diet. It's possible mine is osteoarthritis, I guess, as it also runs in my family, and I'm not getting any younger (I'm 46). I think rheumatoid arthritis is usually in symmetrical joints, so my left toe would also be bothering me, which it isn't.

Thanks!
Emily

[Sheesh]

I wore my green superfeet all day yesterday (on my feet and running around for 12 hours!) and they made an amazing difference! But, by the end of the day, I had some pain in my arch near my heel. Maybe too much arch support? Or will I get used to it over time? Should I try the berry superfeet instead?

I'll wear the green superfeet again today and see how my feet feel at the end of the day. Ultimately, though, if inserts are the way to go, I need suggestions for inserts that I can wear in dressier shoes.

Thanks for the help, ladies!

[KnottedYet]

they will make your feet tired, because your feet are working in a different position now.

Pressure/pain in the arch near the heel is exactly where you will feel it if you have been overpronating and now you're being corrected by the insole. The ramp up to the arch in the insole acts like a kickstand at the sustentaculum tali of the calcaneus, and keeps your foot from collapsing.

Foot exercises will strengthen you and allow your own muscles to hold you up instead of needing a kickstand.

If the insoles get irritating, take them out and give your feet a break. 12 hours on your feet on the first day is pretty hefty.

[Sheesh]

When I went to put my shoes on, the pressure on the arch near the heel was too much. I ended up wearing my Chacos for most of the day. Towards the end of the day, I put my tennis shoes back on and I was good to go.

Knot - Do you have suggestions for foot exercises? I see my physical therapist again on Tuesday so I'll give her an update on the superfeet, but I'm not confident that she'll do much more than massage... Thanks again for your help!

[pll]

I suffered with PF in 2002-03 and found Birkenstock 3/4 insoles (http://www.birkenstockusa.com/search_product/insoles/) in my loafers. I still use them. However, I spent several months back then using running shoes (with Powerstep (http://www.powersteps.com/) insoles) and Birkenstock sandals, nightsplints, taping, the works... Among the exercises I was prescribed, I remember most the toe rises.

And a "footlog (http://www.roadrunnersports.com/rrs/products/FOL001/)" is great. You can get a good "massage" at home for as long as you need.

[KnottedYet]

Tell your PT you'd like some intrinsic foot muscle exercises (those are for the little muscles that are in the foot itself) and some extrinsic foot muscle exercises (muscles that are in your lower leg, but have tendons going into the foot.)

Ask her to teach you closed-chain lower extremity (including pelvis in there) posture exercises. (closed-chain will work balance and proprioception, too, so you get more bang for your buck!)

I wouldn't ask her to post your Superfeet until you have broken them in/strengthened your feet to the point that you can wear them all the time. If she hasn't been trained in posting, don't worry. She probably knows someone who can do it. At the very least she can check your foot/ankle posture and functional positions when you wear the Superfeet and she should be able to tell you if you even need to have them posted.

[sundial]

This is a really interesting thread and I'm fascinated with the treatment options.

My problem with shoe inserts is.......I don't know which side to put one in. I lack joint space in my right knee, so I'm 4-5 mm shorter there, but my left side is shorter than my right according to a fitting I had recently at a bike shop.

Since I wear mtb shoes with Frog pedals, I'm not able to shim the right cleat. If I wear a shoe insert, do I wear it in both shoes, the left, or the right? :confused:

[goodjude]

I have suffered with this same problem and it really just takes lots of good shoes that are more or less orthotic, stretching the calf muscles with a yoga strap pulling the toes towards you as best you can. I also would wear a special boot at night that helped to keep the toes straight and the foot flexed. Good luck. I can't wear flip-flops at all and I live in Florida. If I wear them for only one day the next day the PF starts right back up. Be patient, it does take some time to recover from. Also do not walk on the floors in your house barefoot, make sure you have good support, no bare feet! Sorry ( most comfortable):

[KnottedYet]

This is a really interesting thread and I'm fascinated with the treatment options.

My problem with shoe inserts is.......I don't know which side to put one in. I lack joint space in my right knee, so I'm 4-5 mm shorter there, but my left side is shorter than my right according to a fitting I had recently at a bike shop.

Since I wear mtb shoes with Frog pedals, I'm not able to shim the right cleat. If I wear a shoe insert, do I wear it in both shoes, the left, or the right? :confused:

Insoles you wear one in each shoe. They come in pairs, and you should wear the entire pair even if your foot problems are only one sided. You can post/ship/lift one side to deal with asymmetry.

BTW: everyone is lopsided. You only need to shim the length difference if it is very large (like 1/2 inch or more) and/or if it is causing you pain.