Point-Counterpoint: Stretching: Is It Beneficial For Plantar Fasciitis?

Lisa M. Schoene, DPM, ATC, FACFAS, and Stephen Pribut, DPM, FACFAS

A Closer Look At Compensations At The Midtarsal Joint, Subtalar Joint And The First Ray

Compensations can and will occur at these midtarsal joint, the subtalar joint and the first ray.

   Midtarsal joint. True full compensation of a decreased ankle joint range of motion (ROM) will cause potential collapse of the more obliquely oriented joint axis that moves the midtarsal joint. This would cause talar plantarflexion, forefoot abduction, the “too many toes sign” and possibly severe hallux abducto valgus, hammer digit syndrome, and even the rocker bottom type foot. Tendon pathology is also common. This is not a pretty foot and we have all seen it coming from a mile away. Compensation here produces prolonged abnormal pronation.

   Subtalar joint. When partial or full compensation occurs in the subtalar joint, it causes the rearfoot/calcaneus to evert past the norm, thus straining the alignment, length and motor function of the intrinsic and extrinsic foot musculature. When this occurs, hammertoes or other forefoot deformities can develop in the foot and tendinous strains may occur such as posterior tibial tendon dysfunction. Compensation here also produces prolonged abnormal pronation.

   First ray. Due to the obliquity of the axis of the first ray, partial or full compensation here will cause the first ray to dorsiflex and invert. If this occurs, first metatarsophalangeal joint (MPJ) function becomes limited, producing functional and/or potentially structural hallux limitus/rigidus. This chronically elevated first ray can be devastating as it impedes the normal lever needed for forward progression of gait. Couple this with the areas of compensation I mentioned above and there may be a poor outcome. Alone, this compensated joint can produce its own set of complications up the chain, even into the temporomandibular joint. Quite often, we may hear complaints of neck pain or headache after dispensing orthotics. This is not a coincidence but rather the work of changing the compensation patterns that the body is so used to. Changing them makes the fascia and musculature pull in a way they are not used to, resulting in strains.

Other Potential Compensation Issues With Equinus

Equinus and its path of destruction can also affect the knee joint because when the talus adducts and plantarflexes, internal rotation occurs at the tibia. This can contribute to patellofemoral syndrome, chondromalacia and iliotibial band friction syndrome. Over time, internal rotation at the tibia may even generate enough chronic rotational forces to damage the menisci. In general, longstanding gastroc equinus may directly cause genu recurvatum, which can show up in early adolescence.

   With continued internal rotation of the tibia comes internal femoral rotation. When this occurs, there is rotational pull through the hamstrings, which may produce chronic strain distally or proximally. Additionally, there may be strain at the sacroiliac joints and stress and strain to the external hip rotators, namely the piriformis. When overzealous traction occurs here, irritation to the sciatic nerve may occur, producing radicular pains into the buttocks and even the leg. Add a leg length discrepancy or other scenarios, and it turns out to be a real pain in the butt.

   If all of these compensations occur unilaterally, single foot abnormal pronation may induce unleveling of the limbs, possibly causing a leg length discrepancy and abnormal shear within numerous muscles of the lower extremity. Additionally, with abnormal pronation, the proper motor patterning of the gluteal muscles will be affected. This subsequently affects normal gait, limiting proper extension and may allow for weakness of hip abduction, which we call the Trendelenburg gait.

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