Treating Plantar Fasciaitis

In this post we are going to talk about an orthopedic massage treatment for Plantars fascitis. Before we get down to the nitty gritty, however I want to discuss the pathology on the whole.

Plantar fasciitis has been previously classified as an inflammatory condition, hence the 'itis' at the end of the name. The literal translation of the medical language is foot part inflammation. Recent studies have concluded that its not really an inflammatory condition at all. Its is very important to understand however in treating this condition, that while it is not an inflammatory condition itself, there may be inflammation present especially post exercise or you may cause inflammation by working on it. Not being classified as an inflammatory condition does not exclude it from inflammation.

Clinically in my experience with sports massage, it has turned into a bit of a blanket term meaning pain in the bottom of the foot. The classic presentation is specifically pain in the AM after the tissue has contracted over night, however I have frequently had people come in with diagnosis from physicians where pain is during exercise or after only. If you are treating plantar fascia you also need to be aware of the risk of heel spurs and their contraindications.

People who have started training programs, had a recent weight gain, are pregnant, work standing all day, are logging a lot of miles, and who have inflammatory conditions are all at risk for Plantar fasciitis. Plantar fasciittis is one of the most common foot complaints.  Technically what is happening is the plantar fascia is being over stretched or over taxed for a number of reasons and is tearing at the most delicate part of the connective tissue in the leg, the plantar fascia. Tears can be small and irritating or in the worst case scenario, a full rupture. You can find out more about plantar fascia in my brief description here.

For the purposes of this treatment we will be treating as if we have performed a full body treatment with the focus on the lower leg. In progressive treatments I would then do a full body with the focus on the leg above the knee as well, and then a full body with the focus on treating plantar fascia at the hip...etc. Plantar fascia is rarely a foot problem, however it has been my experience that patients get the most initial relief from treating the lower leg, so that is where we will start.

Start your client in prone and with general Swedish massage. When ever possible I try to mix in as much general treatment as possible so that the client can benefit from the systemic benefits of massage as well as the focused ones. As you work towards the legs be aware of what you are touching, feel for anything that seems tighter or ropy-ier than it should be. Use this extended Swedish time as a palpitation exploration and add it to your full assessment. You are always going to start on the side with less pain so you can have a comparison of that persons 'normal' to dysfunction. Between each larger technique, I always return to Swedish massage to assess and sooth the tissue.

Once you have reached the lower leg warm the tissue with Swedish work.  After the tissue has been warmed, then move to deeper work such as trigger point and deep tissue on the whole of the lower leg structures. At this point, move to passive active release moving laterally to medially via anatomical structures. Starting at the peroneus muscles, anchor into the tissue with a thumb/finger/elbow at the origin and move the structure through its range of motion. Work down the whole length of the muscle doing this passive active release. (in some cases I would do this for gastrox and solus as well but usually I progress to straight active release)

Now that the client knows the motion of the peroneals, I as them to take the motion over on their own. As they evert/invert I again work my way down the length of the muscle, stopping of course for any thing that causes too much pain or discomfort. All motions and pressure are to remain within clients comfort level. After working the peroneals, then move onto the gastrox and solus active releases in the same manner. Start at the proximal attachment and move distally towards the Achilles. You can access deep into the muscle bellies from the sides and from the center of the tissue. Here is a video to help understand the process. Its important to note that at some points of the ROM in the active release there may be discomfort. That is fine, the client is in control of the motion and ask them to move slowly and carefully expressing that you will not increase the pressure.

 Using active release as the massage allows greater muscle pumping properties to the tissue, helps approximate muscle length and through conscious movement helps the client be more aware of movement patterns. It also puts the client in control of work that could be quite sensitive otherwise.

After the active release has been performed, and the client can move through the range of motion pain free, I move on to stretching. Using a number of different kinds of stretches is very helpful in when treating plantar fasciitis because each muscle presents its own challenges. For both gastrox and solus I use a pnf version of stretching. I stretch them separately, by putting them into their lengthened position and having the client resist the stretch for the count of 10, and then repeat that cycle until the desired length is achieved. For both tibialis posterior and the peroneal muscles I do the same, although much more delicately. You of course to do this must know exactly what the action of the muscle is.

S curve bowing of the achilles

After the active stretching I move on to stretching the tissue manually with fascia work and bowing. Sometimes because a client has a bone structure that prevents full ROM this is the most effective way across the board, however the calves on the whole are very strong muscles, my strength can never compare to theirs so using the clients own power is always safer and more effective generally as a means of tissue movement, which is why I perform both active release and fascia work. For this I manually pull the bulk of the muscles away from the bone, by anchoring the ankle and pulling the tissue towards or away from me in long steady movements. Sometimes it can be helpful to do this through a hot wet towel. In fascia work this would be a form of bowing. At the achilles I can bow laterally, medially or both in an s curve.

Once the calf work is completed I work around the heel, you can work around the heel with your fingertips encouraging the tissue towards the site of the pain. In school I learned then to do deep work on the plantar fascia at the site of pain, but have since abandoned that technique as too painful and too risky to the tissue. Clients would literally sweat on the table as you put the foot into flexion and dug away at the tissue. Instead I recommend this technique which is a variation of the work with the foot in flexion but far less painful.

Drop the foot off the table in prone so that the toes hang off . The heel will be just about level with the edge of the table. Stand so that you are facing the end of the table and the clients feet. Squat down or kneel so that you are  not using strength, but body mechanics and grasp the heel firmly with both hands and with medium pressure pull the foot into flexion and drag the tissue down. It is important to note I am not rubbing the surface of the skin but, letting the skin move me towards the toes.

After all of these steps are completed I would close with Swedish massage working my way back up the leg and moving onto the next side. Once that side is completed I would ask the client to turn over and work the anterior lower leg muscles in the same fashion, following the same protocol, of Swedish, active and stretching.  In my clinic we would also follow this up with a supportive taping for that plantar fascia.

For many people the initial treatment will bring considerable relief if the diagnosis is correct, however the condition is not 'fixed'. It is very important to continue maintenance, change behavior, and seek help in the form of strengthening. Any time the body lays down splinting or pulls tight in this manner its usually looking for extra support and you have to ask yourself 'why?'.  Giving your client a home care plan that works for them is also very important. Most people get stuck with plantar fascia issues because they are treating the plantar aspect rather than the problem, and only taking preventive measures, such as wearing a night sock. Full treatment constitutes a change in behavior, strengthening, manual therapy and a good home care program.

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It is running season, how about a little foot pain??

It's every runner's nightmare:  waking up one morning and feeling a stabbing pain on the bottom of the foot near the heel. Plantar fasciitis affects around 2 million Americans a year, and it's not just limited to runners. Anyone who is bearing extra weight on their feet, who has body-structure problems, is over-training, is pregnant, or has compounding injuries could be at risk. 

If you search the internet you will find loads of boots  and strange supportive gear that help you deal with plantar fasciitis after it appears. Doctors might prescribe pain killers, anti-inflammatories or cortisone injections to help you deal with the pain.  All these things are geared strictly to managing the problem. They are a mere band aid in for something that many people find literally debilitating.  

The plantar fascia is located on the bottom of the foot. It stretches from the heel to the ball of the foot, supporting the muscular arch above as well as interlocking bones. Technically, plantar fasciitis is billed as an inflammatory condition, however it's not that the body is randomly creating inflammation---rather, the inflammation is being created at the heel in order to try and repair the micro tearing that is occurring there, In truth, the problem is actually over-stress or tearing of the delicate foot fascia. and the inflammation is just a symptom. 

So here is the skinny. Understanding this problem for your body is key. The tissue on the bottom of the foot is very delicate when you compare it to the things it's being asked to do. The plantar fascia is not an isolated tissue, it is one small part of a long chain of tissue that runs from the top of the back of your body, down to the tip of your toes.  Picture this tissue as something like how, when you tie a rope around a box, it helps stabilize the box wrapping the whole way around If for some reason the rope were to get shorter, things would become uncomfortable for the box....there would be less and less space until finally the tension would be so great that most likely the rope would begin to fray at one of the corners (just like your heel) in order to create more length. That is exactly what is happening to your foot. The rope is tearing at its weakest point. When you have injuries that thicken the tissue and make it less contractile, or add extra stress to the "rope",  it is at risk for damage. 

By the same token, slackening the 'rope' can take pressure off the weaker tissues. Adding length to your

visual of the 'rope'

hamstrings and calves takes pressure off the bottom of the foot. Treating plantar fascia issues is a two-fold process. You must examine what caused the flair in the first place. Is it too much tension? A structural defect? Training?  Extra weight? Or is it another muscle pulling it tight?  The second step is to create less pressure on that plantar fascia by lengthening the tissue on the posterior chain, which will decrease the inflammatory reaction from the micro tearing. Professionals in sports medicine, physical therapy, massage and orthopedics can help you with the various parts of this painful problem to get you back on track, but I have also seen a good number of people help themselves once they truly understand the problem. A good foam roller and a trigger point ball are always a good investment for preventative care if you know you are prone to this malady. Once this is done and the cycle is broken, it is essential you give it time to heal...after all time heals all wounds.  If you are experiencing problems that are diagnosed or that do not resolve, it is very important to visit your primary care physician. 
For more info visit http://www.bodymechanicsnyc.com/
or see our sports massage program in NYC
By Beret Kirkeby