Appendix An Acupuncturist s Guide to the Treatment and Assessment of Plantar Fasciitis and Excessive Foot Pronation

Transcription

1 Appendix An Acupuncturist s Guide to the Treatment and Assessment of Plantar Fasciitis and Excessive Foot Pronation By Matt Callison, M.S., L.A.c I

2 An Acupuncturist s Guide to the Treatment and Assessment of Plantar Fasciitis and Excessive Foot Pronation The feet play a very important role in dynamic posture and balance, although a change in the foot mechanics can predispose the foot and body to injury. The foot, being shaped like a half dome, has two primary arches that provide shock-absorbing features during weight-bearing activities. A collapse of one or both of these arches puts overwhelming stress on the soft tissue and joint components of the foot with the end result being pain somewhere along the musculoskeletal chain. In this article, we will examine excessive foot pronation, its role with plantar fasciitis and how acupuncture can effectively treat this syndrome. In addition, we will discuss rehabilitative exercises and the indications for arch support use. First, a brief functional anatomy overview of the foot is needed in order to continue. The foot and ankle consist of 26 bones articulating with 30 synovial joints, supported by over 100 ligaments and 30 muscles. 1 The distal tibia and fibula meet the talus bone to form the talocrural joint, commonly known as the ankle joint. The talus bone sits between the medial and lateral malleolus in the mortise cavity, aligned directly below the tibia. With no muscle attachment to it, the talus bone acts as a pivot for the ankle joint, in which the gastrocnemius and soleus moves the joint into plantar-flexion while the tibialis anterior and toe extensors perform dorsi-flexion. Distal from the ankle joint, the inferior surface of the talus articulates with the calcaneus (heel bone), making up the subtalar joint. On the medial side of the foot, the head of the talus articulates with the navicular bone; this joint can be palpated at SP 5 (Shangqiu) as the foot moves in-and-out of inversion. On the lateral side of the foot, approximately halfway between UB 62 (Shenmai) and UB 63 (Jinmen), the calcaneus articulates with the cuboid. These combined joints (the subtalar, talonavicular and calcaneocuboid) have the primary function of absorbing the rotation of the lower extremity by producing movements of supination (inversion, plantarflexion and adduction) and pronation (eversion, dorsiflexion and abduction). 3,6 The key muscles responsible for these movements are the gastrocnemius/soleus group (triceps surae) and the anterior and posterior tibialis muscles. When these lower extremity muscles fail to adequately control the subtalar motion, hypermobility can exist. When left untreated, they may lead to the development of many foot and ankle problems. 2 The bones of the foot are arranged structurally to form three arches. The two main shock-absorbing arches are the medial longitudinal arch, which runs the medial length of the foot, and the anterior transverse arch that runs across the width of the distal forefoot. The third arch, the lateral longitudinal arch, runs the length of the lateral side and is more functional during weight-bearing positions. II

3 The medial longitudinal arch, traversed by the spleen and kidney channels, extends from the calcaneus through the first three metatarsals. It is the longest and highest arch, and is the most dynamic as a shock absorber during static support and movement. The navicular bone is the keystone of the medial arch and is found at the arch s high point, just above K2 (Rangu). This point can be very tender when the navicular bone drops inferiorly, as in foot hyperpronation (Fig. 4). The tendon of the tibialis posterior inserts on the navicular bone and is important in maintaining the integrity of this arch, whereas weakness of this muscle can lead to a pronated position of the foot. 2 Fig. 1 Medial longitudinal and anterior transverse arches. The major ligamentous support with the greatest contribution for the medial arch is due to the plantar aponeurosis. 11 The plantar aponeurosis, or plantar fascia, is a fibrous band that runs distally from the plantar medial aspect of the calcaneus to the metetarsalphalangeal joints. Fig. 2 Plantar aponeurosis III

4 The anterior transverse arch, or metatarsal arch, extends approximately from UB 65 (Shugu) crossing with K 1(Yongquan) to meet SP 3 (Taibai). This arch also provides shock absorption as it depresses and spreads during weight bearing. The lateral longitudinal arch extends from the calcaneus through the last two metatarsals. It is shorter and lower than the medial arch with its keystone bone being the cuboid, located just above UB 63 (Jinmen). The Over-Pronating Foot K2 (Rangu) A B Fig 3 Non-weight bearing position: (A) and (B) K2 (Rangu) A B Fig. 4 Weight-bearing position. (A) Collapse of medial arch. (B) Tension on tendons and ligaments. Foot pronation is often referred to as something that is dysfunctional or abnormal. On the contrary, foot pronation is part of normal foot motion during gait. Pronation acts as a shock absorbing mechanism for the forces applied on to the foot, especially when the foot comes into full contact with the ground. It is when the medial longitudinal arch begins to, or has, fallen, that the foot hyperpronates. The patient may have the appearance of a normal arch when they lie or sit down, but when standing up, bearing weight on the foot, the medial arch falls, creating excessive pronation (Fig. 3 and 4). Excessive pronation IV

5 stretches the soft tissue that supports the arch; as a result, the muscles must work harder to control the hyperpronation from this stretched position. This puts overwhelming stress on the soft tissue and joint components of the foot with the end result being pain somewhere along the musculoskeletal chain such as that found with plantar fasciitis, morton s neuroma, shin splints, knee problems and more. Many people have overly pronated feet without any musculoskeletal complaints; although, in a clinical study of 50 people with musculoskeletal pain, 84% of the patients had excessive foot pronation. 4 Signs of excessive foot pronation: Helbing s Sign, a medial bowing of the Achilles tendon. 5 Fig. 5 Positive Helbing s sign of right foot. Foot flare when standing or during gait. Internal knee rotation, the center of the patella angles inwards. Fig. 6 The feet may flare outwards causing the patella bone to angle inwards with excessive pronation. The Wet Foot Test. Have the patient wet their feet and walk on a smooth, dry surface to view the body s weight distribution created by the footprint. Fig. 7 Wet Foot Test: (A) Normal weight distribution. (B) Excessive weight distribution. V

6 A protruding medial malleolus and a low medial arch. This can be measured with the following techniques: 1) From a standing position, a measurement can be taken between K2 (Rangu) and the floor for each foot comparing them for fallen arches. If there is a difference between the feet greater than 3-4 mm, then there is a moderate-to-high risk of injury. 2) A measurement taken on one foot at a time, from a non-weight bearing position and compared with a weight bearing position, is significant in assessing the medial arch. If there is a difference in the arch from weight bearing to non-weight bearing greater than 5-7 mm then there is a moderate-to-high risk of injury. The measurement is taken from K2 (Rangu) to the floor in both positions. The patient can place the body weight on the back leg for the non-weight bearing measurement. K2 (Rangu) K2 (Rangu) A B Fig. 8 Measuring K2 (Rangu) located at the bottom of the navicular bone to the floor: (A) Non-weight bearing position. (B) Weight bearing position. The sequential pattern of a pronated foot can be from various causes that may predispose a weak foot to develop into a hyperpronated foot: 6,7,8 Inactivity during childhood and adolescence may fail to develop the strength of muscles and ligaments needed to support the body weight. Constant walking on hard, flat surfaces such as cement sidewalks without proper foot support, can be too hard of an impact for each step. An imbalance between the posterior and anterior leg muscles. A shortened gastrocnemius/soleus group (triceps surae) tends to flatten the medial arch stretch and weaken the small muscles and ligaments of the foot. Weakening of the small plantar muscles, ligaments and plantar fascia allows the larger muscles to become imbalanced in an attempt to allay the strain upon the ligaments. Weakening of the tibialis posterior and shortening of the peroneus group. VI

7 The health of the spleen and kidney organs/meridians needs to be assessed due to their influences on the bony structure and soft tissue. The kidney meridian from K1 (Yaoquan) and K6 (Zhaohai) and spleen meridian from SP 2 (Dadu) to SP 5 (Shangqiu) traverse along supportive medial arch anatomy, thus an excessively pronated foot can most certainly create stagnation of qi in this area. Needling motor points, selective ah-shi points and acupuncture points to clear stagnation benefits these conditions. Although, once the arch has collapsed, going from a functional deformity into a structural one, inhibits what can be done with needle stimulation and exercises. Once the longitudinal arch has flattened, it cannot be elevated by exercising the muscles of the foot, as it is impossible for them to exert a tension great enough to raise a fallen arch. 2 Treatment - Acupuncture Rehabilitative Exercises Using orthotic shoe inserts can be very effective for supporting the medial arch, although an effort to strengthen the supporting soft tissue for arch stabilization needs to be considered first. Many times, adding integrity to the foot/ankle complex with acupuncture treatment and exercises, can eliminate the patient s complaints. If unsuccessful, then arch supports are indicated. The following treatment and exercises are suggested to use with or without the use of arch supports and can bring a rapid improvement of symptoms, in addition to helping the patient to adapt to arch supports. Acupuncture: Effective acupuncture points to choose from: Kidney and spleen meridian ah-shi points along the medial arch. These two tendinomuscular meridians cover and merge on the medial aspect of the foot. 9 K2 (Rangu): motor point for the abductor hallicus muscle. This muscle supports the medial arch. SP 3 (Taibai): motor point of the flexor hallicus brevis. This muscle arises from the tendon of the tibialis posterior located on the archís distal half. Deep insertion of.75-1 in. K3 (Taixi),UB 58 (Feiyang) - source/luo combination. The medial arch is influenced by the kidney meridian while the UB meridian traverses most the length of the gastrocnemius muscle. Tibialis posterior motor point: located halfway between UB 57 Chengshan) and UB 56 (Chengjin). Insert the needle slowly approximately 1 cun medial from this location with an oblique lateral angle 1.5 cun, toward the center of the calf. Note: this point is very close to the tibial nerve, posterior tibial and peroneal artery. The tibialis posterior muscle is the prime invertor of the foot, which opposes the overpronating eversion of the foot, thus its tendon may become tender and inflamed. Peroneus longus motor point: located cun directly below the fibular head, approximately level with ST 36 (Zusanli). Needle perpendicular to the skin.5-1 in. VII

8 into the muscle covering the bone. With a foot pronation problem, the peroneus group must shorten to take up the slack, become adaptively shortened and may become tender and painful. This tendon is important in maintaining the transverse arch. 10 Peroneus brevis motor point: located at GB 37 (Yangfu), 5 cun directly above the lateral malleolus, on the anterior border of the fibula. This muscle can become adaptively shortened and may become tender and painful. Needle perpendicular to the skin.5-1 in. Rehabilitative Exercises These exercises have three main objectives: to improve the local circulation, to stabilize the foot in the correct position in relation to the leg and to improve the range of motion of the individual joints. Towel Exercises: Exercise #1 Have the patient sit on a chair and place a towel on a smooth surface floor. Place the foot flat on the edge of the towel so that most of the towel is forward, away from the foot. The patient scrunches the towel under the foot, which moves the far end of the towel toward the foot. Make sure the foot stays on the floor as the movement is created by flexing the toes and forefoot. Add a weight to the end of the towel to provide resistance. Fig. 9 Exercise #1 VIII

9 Exercise #2 Have the patient sit on a chair and place a towel on a smooth surfaced floor. Place the foot flat on the edge of the towel so that most of the towel is lateral from the foot. The patient scrunches the towel under the foot, which moves the far end of the towel toward the foot. Make sure the foot stays on floor, flexing the toes and inverting the foot to create the movement. Add a weight to the end of the towel to provide resistance. Be aware that the knee stays pointing forward. The patient may start to recruit the hip muscles when fatigue of the lower leg and foot muscles occur. Fig. 10 Exercise #2 Exercise #3 Have the patient sit on a chair and place a towel on a smooth surfaced floor. Place the foot flat on the edge of the towel so that most of the towel is medial from the foot. The patient scrunches the towel under the foot, which moves the far end of the towel toward the foot. Make sure the foot stays on floor, flexing the toes and everting the foot to create the movement. Add a weight to the end of the towel to provide resistance. Be aware that the knee stays pointing forward. The patient may start to recruit the hip muscles when fatigue of the lower leg and foot muscles occur. Tubing Exercises There are many types of exercise bands and tubing available from sporting good stores or medical rehabilitation supply sources. Tibial internal rotation exercise: Have the patient sit on a chair and place the tubing around the foot. Anchor the other end laterally away from the body so resistance is felt by moving the foot medially. Keep the foot flat on the ground and be aware that the knee stays pointing forward. The patient may start to recruit the hip muscles when fatigue of the lower leg and foot muscles occurs. Move the tibia from an external rotation starting position to internal rotation, moving the foot inward. The tubing should be taut in the starting position. Fig. 11 Exercise #3 Fig. 12 Tibial internal rotation IX

10 Tibial external rotation exercise: Have the patient sit on a chair and place the tubing around the foot. Anchor the other end medially away from the body so resistance is felt by moving the foot laterally. Keep the foot flat on the ground and be aware that the knee stays pointing forward. The patient may start to recruit the hip muscles when fatigue of the lower leg and foot muscles occurs. Move the tibia from an internal rotation starting position to external rotation, moving the foot outward. The tubing should be taut in the starting position. Fig. 13 Tibial external rotation exercise. Ankle/Calf Stretch: Have the patient place the anterior transverse arch, K 1 (Yongquan) area against the wall with the heel flat against the floor. Keeping the knee straight, move the entire body close to the wall, stretching the calf. From this stretching position, bend the knee, moving it close to the wall as the body sinks into the stretch. (Diagram not shown) When to Use Arch Supports Using arch supports can be very effective when foot over-pronation signs are evident and acupuncture treatment plus the prescribed exercises fail to eliminate the patient s pain completely. Arch supports can be purchased at many sporting good stores, foot accessory stores or custom made. A B Fig. 14 Arch supports help to correct foot over-pronation. (A) Medial bowing of the left foot, a positive Helbing s sign. (B) Notice the straightening of the achilles tendon with the arch support. X

11 The following are possible case scenarios to indicate arch support use: Recurrent ankle sprains may have permanent ligament damage, scar tissue adhesions and instability; arch supports may provide enough stability. History of lower extremity problems such as shin splints caused by inadequate mechanical pull of lower leg muscles, stress fractures and knee pain caused from an internally rotated tibia. Back problems are worse with walking, standing or running. Foot overpronation can create an unlevel pelvis thus putting the lumbar vertebrae and supporting musculature at risk for injury. Plantar Fasciitis and Heel Spurs The plantar fascia is a strong fibrous plantar aponeurosis tissue that supports the medial longitudinal arch. It connects the medial tuberosity of the calcaneus and flares outward as it extends distally to the five metatarsal heads. The plantar fascia can be irritated as a result of an extreme range-of-motion of the foot. During gait, the arch is flattened in dorsiflexion and increased in planta-flexion, placing a wide range of tensions on the plantar fascial attachments. With excessive foot pronation, stress is increased to the plantar aponeurosis with resultant microtearing at its attachment on the calcaneal tuberosity. Over time, the bone may grow creating a bony outcropping, or spur, usually from the anterior medial aspect of the calcaneus. The developing heel spur is the body s way of reinforcing a weakened area with a harder tissue that is strong enough to combat the long-term stress. Studies have shown that the heel pain of plantar fasciitis is not necessarily coming from irritation of the bone spur, but the inflammation of the tendinous attachment. 11,12 Over 50 % of the patients who had heel spurs surgically Spur removed continued to have pain afterward. 13 Assessment - Heel pain at the medial attachment on the calcaneus. Worse with walking and may refer between the spleen and kidney channels of the foot. Increased pain with the first steps out of bed in the morning. Pain upon palpation of the medial process of the calcaneus. Pain is increased with walking on the tiptoes. X-ray may show if heel spur is present. Fig. 15 Arrow indicates bony outcropping on the anterior medial aspect of the calcaneus. Fig. 16 (A) Heel pain at the medial attachment on the calcaneus. (B) Pain upon palpation of the medial process of the calcaneus. XI

12 Treatment - Acupuncture Rehabilitative Exercises Acupuncture: Fig. 17 Effective needling techniques to affect the plantar aponeurosis. Note: All plantar points are painful. Needling these points using a guide tube pressed firmly against the skin with a quick and direct insertion helps to lessen the painful response. Other effective acupuncture points to choose from: Shimian - proximal attachment of the plantar aponeurosis. Lineiting - distal medial attachment of the plantar aponeurosis. K3 (Taixi), UB 58 (Feiyang) - source/luo combination. Ren 4 (Guanyuan) - intersection point of the three yin foot muscle meridian. Ren 4 (Guanyuan), UB 23 (Shenshu), SP 6 (Sanyinjiao), LI 11(Quchi) - promotes qi circulation, removes blood stagnation in the channels, strengthens kidney qi. SP 5 (Shangqiu), SP 9 (Yinlingquan), Liv 3 (Taichong), LI 11 (Quchi), relieves spasms. ST 36 (Zusanli), Lanweixue - motor points of the tibialis anterior, the antagonist muscle to the tibialis posterior. GB 30 (Huantiao) - opens the channels of the GB and UB, clears channels and obstructions. SI 11(Tianzong) - removes stagnation systemically. UB 31(Shangliao), UB 32 (Ciliao) and L4, L5 Hautoujiaji points affects myotomal lower leg and foot muscles. Extra vessels: Chong mai/yin wei and Dai mai/yang wei, balances the yin and yang musculature of the lower leg. Consider a foot pronation problem. Treat with acupuncture and prescribe exercises for the foot and lower leg, in addition to arch supports if indicated. XII

13 Rehabilitative Exercises The aforementioned strengthening and strectching exercises noted above are good to include with the following plantar fascia stretches: Stretch #1 With one leg crossed over the opposite knee, grasp the ankle with one hand and the underside of the toes and the metatarsalphalangeal joint (ball of the foot) with the other hand. Pull the toes and ball of the foot toward the shin as the other hand pulls the calcaneus (heel bone) in the opposite direction. Stretch #2 Standing 2-3 steps away from a wall, bend the forward leg and keep the back leg straight with the back foot flat against the floor. Raise your rear heel off the floor and shift your weight onto the ball of your foot. Apply the appropriate amount of weight by pressing downward to feel a stretch of the underside of the foot. Fig. 18 Stretch #1 Stretch #3 Kneel on all fours with your toes underneath the body. Lower the pelvis backward and downward as pressure is kept on the balls of the feet. Fig. 19 Stretch #2 Fig. 20 Stretch #3 XIII

14 References 1 Hamill J. et al. Biomechanical Basis of Human Movement Media, PA: Williams and Wilkins, 1995: Rasch PJ. et al. Kinesiology and Applied Anatomy 6th ed. Philadelphia Lea & Febiger 1978: Huang CK et al. Biomechanical evaluation of longitudinal arch stability. Foot and Ankle 1993; 14: Callison M. Clinical trial of foot pronation and musculoskeletal complaints. San Diego, Friel, J.P., ed, Dorlandís Illustrated Medical Dictionary, 25th ed. Philadelphia: W.B. Saunders CO, Schafer RC Chiropractic Management of Extraspinal Articular Disorders. Arlington, VA : American Chiropractic Asssociation, 1989, 7 Viitasalo JT, Kvist M. Some biomechanical aspects of the foot and ankle of athletes with or without shin splints. Amer. J Sports Med 1983: 11: Calliett R. et al. Foot and Ankle Pain, 2nd ed. Philadelphia: F.A. Davis Company, 1983: Low R. et al. The Secondary Vessels of Acupuncture, New York: Thorsons Publishers, 1983: Clemente CD. et al. Anatomy: A Regional Atlas of the Human Body, 4th ed. Baltimore: Williams and Wilkins, 1997: Jahss MH et al. Functional biomechanical deficits in running athletes with plantar fasciitis. Am J Sports Med 1991: Booher JM et al. Athletic Injury Assessment. St. Louis: Mosby, 1994: Contompasis JP. Surgical Treatment of calcaneal spurs: a three year post surgical study. J Am Pod Med Assc 1991: 81: XIV