Plantar Fasciosis can be a very difficult condition to treat because of the intricate anatomy of the foot and ankle complex. To complicate issues, we now know that many lower quarter problems root from lumbopelvic and hip dysfunction as well. In previous posts, TSPT has done a literature review of the condition as well as talked about new treatment methods regarding plantar fasciosis. In these posts, one aspect of management we did not discuss in depth is assessing for neuropathic pain. From my clinical experiences and the experiences of my colleagues at the Harris Health System, many patients with plantar fasciosis have positive neural provocation tests for the distal branches of the tibial nerve.
After the tibial nerve passes around the medial malleolus, it splits into three distal branches: the medial plantar nerve, lateral plantar nerve, and medial calcaneal branch. Specifically, the lateral plantar nerve innervates the fifth and lateral 1/2 of the fourth toes and provides motor input to many of the intrinsic foot muscles. The nerve passes laterally across the foot and splits between the flexor digitorum brevis and quadratus plantae.
To assess for tibial nerve adverse neural tension, have the patient lie supine. Passively extend the toes, dorsiflex and evert the ankle. This combined movement place a stress across the tibial nerve and its distal branches. Ask the patient if this position changes their primary symptoms (better, worse, or the same). Next, passively perform a straight leg raise maintaining the foot and ankle components. If this position recreates their primary symptoms, they have positive neural tension in the tibial nerve* (remember to test bilaterally as well). To further assess the tibial nerve, adduct and internally rotate the lower extremity. If the test is positive, appropriate treatment options include nerve sliders, tensioners, and manual therapy.
*When performing a straight leg raise, you are changing the hip component. No musculoskeletal structure courses from the hip to the ankle, so if symptoms change it must be the nervous system that is being assessed.
-Lateral plantar nerve pain can be a contributing factor to plantar fasciosis pain.
-By performing the proper assessment (discussed above), you can identify if neural tension is part of your patient's symptoms.
-Do not underestimate the impact of the peripheral nervous system in musculoskeletal dysfunction.
James Heafner PT, DPT, OCS:
Owner and lead physical therapist at Heafner Health, cash-based physical therapy in Boulder, CO. Areas of expertise include orthopedic and manual therapy, functional movement, pain science, and movement science.
In May 2013, I earned my Doctorate in Physical Therapy from Saint Louis University. After graduating from the Harris Health Systems Orthopedic Residency in October 2014, I moved to Boulder, CO. Since living in Boulder, I have started my own cash-based PT practice, earned my OCS certification, and teach for the OPTIM Fellowship and COMT program in Houston TX and Scottsdale, AZ.
Chris Fox PT, DPT, OCS: Physical therapist at Foothills Sports Medicine & Physical Therapy in Scottsdale, AZ and regularly lectures at the Phoenix Campus for NAU's DPT program and for Optim Manual Therapy's COMT program. Completed multiple advanced manual therapy courses implementing aspects of biomechanical analysis. He received his DPT from Saint Louis University in 2013. Completed Scottsdale Healthcare's Orthopaedic Residency (now Honor Health) in July 2014. He became a Board Certified Orthopaedic Specialist in 2015. Level I Expert in FMS and SFMA , Kinetacore FDN Level 1 certification, and IASTM Technique course completion. He would like to pursue further education in McKenzie Technique, Dry Needling, Strength & Conditioning, Orthopaedic and Manual Therapy.
Brian Schwabe PT, DPT, SCS, CSCS:
- Board Certified Sports Physical Therapist (SCS) at Elite OrthoSport in Santa Monica, CA which specializes in treating collegiate/professional athletes and clientele from the Beverly Hills, Hollywood, and Santa Monica areas.
- USC Sports Residency Trained Physical Therapist (<1% of all PT's residency trained)
- DPT from Saint Louis University
- Future plans/interest include:
1. USAW, SFMA & Catapult Systems technology for NBA teams
2. Pursuing a position as a sports physical therapist &/or Strength coach for a Division 1 athletic medicine department or professional sport team.
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