His feet have hurt for 10 years!

[cheater hater]

Could use fresh eyes on this patient, who I've seen 4 times in 3 weeks for foot pain when walking:

67-year-old man, retired, general good health and good humor. Hx of plantar and dorsal surface foot pain, R>L, x10 years. Pain worst after resting - feet feel "stiff," better after a little movement. Every step hurts, R>L. R knee surgery 15 yrs ago, L knee 6 yrs ago (both scoped, he doesn't remember exact problem, descrip of pain sounds like meniscus tear/repair). Scheduled for BL knee repeats this year, similar pain to before. L knee pain incr. w/activity; R knee P incr. w/fatigue (worst at night, wakes w/pain when one sleep position held too long and hard to get back to sleep). No hx of back pain, headaches, serious falls, or MVA. Was a runner for 15 years; stopped about 10 years ago. Walks 2-3 miles/day now. No use of pain relievers at this time. Self-referred.

reviews his toes feel "stiff" at all times, x10 years. Cannot actively plantarflex small toes BL at all - plantar flexion of BL big toes v. v. limited at MTP joints R>L. Passive plantarflex of toes at MTP joints produces mod. pain in MTP joints and sensation of "about to cramp" in med. arch. Gentle squeeze to toe tips produces pain. Has not been evaluated for arthritis in feet/toes (recommended).

Let's see, what else . . . high medial arches BL, w/pronounced visible "bump" at medial/intermediate cuneiform bones BL. Lots of tenderness and almost impenetrable stiffness/adhesion along BL tibs anterior and peroneals (esp. belly of brevis), right markedly more "brittle"-feeling than left. BL ankle ROM v. limited in all ranges, esp. pronation. Hx of youthful R ankle sprain (lat side). Gait looks as though his torso is pitched slightly forward and using rect.abd. to lift ant. pelvis upward w/each step; limited arm swing; normal gait speed. Stands comfortably straight - gait pitch/pelvis lift may be due to the fact that all 8 of his small toes are essentially unavailable due to rigidity?

I've seen him for 4 sessions and he's coming in for at least a fifth. His chief concern when he began tx was the foot/heel pain. Now he is experiencing relief of pain and even periods of respite, and his chief concern is the toe stiffness, which he feels as "super tightness" on distal dorsal surface of feet BL. Since I'm not sure what is chicken and what is egg here (which problem came first, the pelvis or the knees or the toes or the arches?), we are treating globally, but with lots of work on feet and lower legs to free up this really amazingly adhered, crispy soft tissue. Passive stretching of feet produces breathe-through-it pain, and has been assigned as homework (I don't think he's doing it).

Please tell me your thoughts on eval and/or treatment! What am I missing? Where can I shift our focus for quicker, more lasting results? What have you done for people in similar situations? I feel like tx is going well but I want to give him the very best.

 

[faerie]

His feet have hurt for 10 years!

For Plantar Fasciitis I will not only do very specific deep tissue work on lower leg and foot (myofascial release, trigger points, slow stripping),
I will do quite a bit of stretching.
If you have Mattes's Active Isolated Stretching there are several good stretches there - including those for toes.
For stiff toes I spend a lot of time and work individually...then follow up into foot and leg...if you work at it you can regain some movement.

I give client "homework" of stretches and some self-massage work on foot with a rubber ball (my chiro recommends a golf ball, one client would freeze a water bottle and do an ice massage)

Even though you do not have this diagnosis for client (plantar fasciitis), your description is consistent with clients I have treated with this condition. If this sounds like a possibility do a search here - I am sure you will find much more thorough discussion.

Arthritis...meh...you must have missed my post on my least favorite diagnosis of arthritis .
Even if he did have that dx - what difference would it make in your treatment as a massage therapist?
If there is no acute joint inflammation you are good to treat.
At his age I would imagine there is some osteo arthritis somewhere and if he had rheumatoid arth. he would have already been diagnosed.

 

[Stealth Redhead]

His feet have hurt for 10 years!

You've probably already checked this out, but here are a few thoughts on areas to work:
TFL and medial quads- could be pulling all the way through to the foot if they are tight.
Abdominals- as a runner/walker these mm could also be pulling up on the mm all the way down to the feet.
ITB and the vastus lateralus- common for TRps here to refer into the knee
The whole fascial sheath just below the knee. You can try this on yourself and feel how it affects the foot. Gently wrap your hands around your leg just below/distal to the knee and let the fascia slowly melt in a distal direction.

Sounds like a very interesting case. I'd be curious to hear updates. Good luck.

 

[Susie T]

His feet have hurt for 10 years!

My first priority would be hip flexors, hamstrings, soleus, and gastrocnemius, with second priority his dorsal interossei and plantar lumbricals, third priority everything else. His background is indicative of hypertonic hip flexors, which would tend to lead to inhibited glutes and compensatory hamstring tightness. With the glutes inhibited, his calves would be overactive during running, and knee problems would aggravate them further. His chronicly tight tibialis anterior and inhibited plantar flexors also support the possibility of chronicly tight calves.

With his posterior chain chronically tight/sore, his gait would tend to become forward-leaning. This would place a major load on soleus. With the plantar flexors inhibited, soleus would have to pick up THAT slack too. Anterior ankle muscles would become very fibrotic to compensate, limiting pronation, resulting in limited ankle ROM in all directions. Limited ankle ROM would tend to inhibit movement on both ends of the metatarsals, leading to sensory motor amnesia (in this case, his small toes). All of that together would tend to restrict peripheral circulation, leading to greater sensitivity to palpation and tendency to cramp.

His glutes are probably underdeveloped/atrophied and sore when palpated. Releasing the hip flexors would make it easier to work the glutes, hip rotators, and hamstrings. The calves and feet may need a good deal of fascial work and gentle stretching. Stretching methods that engage the nervous system with movement (Active Isolated Stretching, PNF, MET, CRAC) can be very useful both for lengthening stubborn tissues and for neuromuscular re-education. AIS in particular would probably be the gentlest, most enjoyable method for him to practice. Passive stretching induces greater ischemia during sustained holds and may aggravate his situation, which would explain why it hurts and he doesn't like to practice that method.

For self-stretching homework, I'd have him spend some time doing a few (ACTIVE) simple hip/glute stretches, and a few (ACTIVE) calf/ankle stretches. All stretches should be done in positions where the tissues being stretched are NOT under load (i.e. no calf stretches standing and leaning against a wall). Unweighted pain-free ROM improvement will facilitate improved circulation and recovery of the target tissues. As he becomes comfortable (and consistent!) with his hip/glute and calf/ankle stretches, he will be better able to handle hamstring and hip flexor stretches.

My recommendation for this gentleman would be 1-2 sessions per week for 4-8 weeks. The more he practices his active stretches and works on remaining generally physically active, the faster he'll overcome the pain and recover normal function. You are in a position to educate this gentleman about his personal responsibility for recovery and ongoing maintenance, and he needs to hear it even if he doesn't really want to.

Hope those thoughts help you help him!

 

[laracroft79]

His feet have hurt for 10 years!

I love you guys.

 

[devan_dev1]

His feet have hurt for 10 years!

bumpity bump - I'm seeing him again tomorrow

 

[Fred D]

His feet have hurt for 10 years!

The above suggestions sound pretty good, and very thorough.. but wondered if he would also consider soaking his feet nightly in hot water with Epsom salt and arnica oil added? I literally am soaking my feet in this even as I type this. It is a huge help for Plantar Fasciitis and arthritis...not to mention general foot strain..

I totally agree with the hip flexor work and addressing the upper legs along with the feet and calves..

Cant wait to hear how it goes at his next session..!

 

[b3k@]

His feet have hurt for 10 years!

Last session went well. The adhered tissues in the entirety of BL lower legs were MUCH freer and softer than before, a major milestone. R heel pain is gone, plantarflexion of small toes more possible. (He doesn't like to hold plantarflexion b/c he fears his medial arch will cramp, but that tendency is subsiding.)

I don't know that I would call plantar fasciitis on this one.

Got another coming in but will post more later - and thanks to all.

 

[Shelly]

His feet have hurt for 10 years!

Last session went well. The adhered tissues in the entirety of BL lower legs were MUCH freer and softer than before, a major milestone. R heel pain is gone, plantarflexion of small toes more possible. (He doesn't like to hold plantarflexion b/c he fears his medial arch will cramp, but that tendency is subsiding.)

I don't know that I would call plantar fasciitis on this one.

Got another coming in but will post more later - and thanks to all.

Can't wait to see a more detailed review! Sounds like you did great!