Summer time brings out many fun activities and with that, often pain and injuries occur, such as plantar fasciitis. Plantar fasciitis occurs in many people, not just athletes or weekend warriors. But certainly, those of us, particularly in the beautiful state of Colorado know that we must take care of our feet, especially while walking up rocky trails and scaling rocks, as well as everyday activities such as excessive standing.
What is plantar fasciitis? It is the most common foot pain in athletes. The condition occurs due to overuse and stress on the plantar fascia, which can result in tissue fatigue and micro tearing at the calcaneal attachments.
The plantar fascia attaches to the medial process of the calcaneal tuberosity and merges into the plantar surfaces of the metatarsophalangeal joints (toes) and flexor tendon sheaths. The plantar fascia functions as a passive bowstring during the mid-stance phase of the gait cycle (Fiona Rattray, 2002). This shortens and raises the medial longitudinal arch. Healthy plantar fascia acts like a windlass mechanism that provides tension and support through the arch of the foot. It functions as a tension bridge in the foot, providing both static support and dynamic shock absorption. The muscles of the lower leg compartment are greatly affected, especially the soleus and gastrocnemius which act as shock absorbers when walking and running (Craig C Young, MD).
Excessive supination can lead to plantar fasciitis. Supination is when the foot rolls out, usually due to excessive body weight which causes greater than normal compression at the heel. The plantar fascia and the heel fat pad are required to absorb more stress. The soleus muscle is than further stressed and compensates, which in turn places more stress on the plantar fascia and Achilles tendon.
A common myth is that bone spurs cause plantar fasciitis and vice versa. This is untrue. They can exist independently, or severe plantar fasciitis can be present without a bone spur (Hertling, Kessler 1996).
Causes of plantar fasciitis:
Overuse due to overtraining, poor technique, running on hard surfaces, or prolonged standing, activities that require ankle plantarflexion and simultaneous extension of the metatarsophalangeal joints (toes) such as running and dancing.
Predisposing factors are:
- Poor biomechanics such as excessive pronation or supination of the subtalar joint or excessive external rotation of the hip joint while walking (Hunt, McPoil, 1995; Brunker Khan, 1993).
- Short and tight gastrocnemius and soleus musculature (calf muscles) can contribute to over pronation.
- Improper foot wear with inadequate arch support.
- Weight gain either rapidly from pregnancy or over time due to lack of activity, over eating, health issues, etc.
Other musculature that affects plantar fasciitis: posterior tibialis, ankle plantar flexors, and peroneus longus muscles, as well as the proximal hip and knee musculature.
Treatment of plantar fasciitis:
- Non-steroidal anti-inflammatories
- Corticosteroid injections
- Rest and avoidance of specific activity causing the inflammation
- Crutches and immobilization in severe cases
- Massage and Physical Therapy
- Ice therapy
- Stretching of the foot, leg and hip musculature daily. This should be done bilaterally even if the plantar fascia is only on one foot. Generally, it is on sided but it can occur bilaterally.
- Mild or severe pain that is stabbing or a tearing feeling. It can often ache while just sitting.
- Pain occurs with the first steps of the day upon waking or after sitting for long periods of time. The pain is worse during the pre-swing phase of the gait cycle and while climbing stairs. Pain is also worse while standing in a static positon for long periods of time, whether on carpet or hard flooring.
- Pain lessens after 30 to 45 minutes of activity, then intensifies again two or three hours later with continued activity (Hunt, McPoil, 1995). It is generally relieved with rest and ice.
- The pain is usually located on the anterio-inferior surface of the calcaneus on weight bearing (Mooney, Maffey-Ward, 1995). It may also extend along the medial border of the plantar fascia towards the metatarsal heads (Brunker, Khan, 1993). Numbness can occur with compression on the medial longitudinal arch.
- Pes planus, pes cavus and Achilles tendinitis are often present. With repeated stress, a bone spur may develop on the medial aspect of the calcaneus (Fiona Rattray, 2000).
My protocol for treating plantar fasciitis:
First, the client needs to know if they have plantar fasciitis. There needs to be a diagnosis by an MD, Psychical therapist, or foot specialist. I can ONLY assess. If I suspect plantar fasciitis, I will treat as so, and then recommend client see their PCP, PT with a PhD or a foot specialist. There needs to be a differentiation between a contusion of the fat pad covering the calcaneus, a stress fracture of the calcaneus, Tarsal tunnel syndrome, bursitis of the forefoot bursae—there are several, and of course, a bone spur. A client may also have more than one of these with plantar fasciitis.
Massage Treatment for plantar fasciitis:
- First I work client in prone position (face down). I start by working on the hip extensors, which include the gluteals. I often do PROM (passive range of motion) of the hips, with passive stretching of hips. I work the IT band also, and deep compression of the ischial tuberosity which is a huge attachment point for deep glute muscles, hamstrings, and adductor magnus, and the sacrotuberous ligament. I also work popliteus which is the back of the knee.
- If acute, all massage is moderate to lighter pressure to avoid further inflammation. I may do basic lymph drainage if there is significant edema (swelling).
- If chronic, I work deeper with muscle stripping and deep compression.
- Next I work the hamstrings, the soleus, gastrocnemius, the Achilles tendon and the complete foot. I use stripping, friction, and basic Swedish massage based on what stage of inflammation the client is in. I will also do trigger point therapy if needed and if tolerated.
- In supine position (face up), I work the anterior hip flexors which are the psoas major, illiacus, Tensor fascia latae, IT band again, adductor magnus again, adductor brevis, adductor longus, and gracillis. I do this with basic Swedish massage, and Myofascial Release (MFR). I continue to the lower anterior compartment of the leg. This includes Swedish massage, stripping and MFR to tibialis anterior, peroneus longus brevis, and extensor digitorum longus. I wrap my fingers underneath the lower leg and re-work the gastrocnemius. I once again work the bottom of the foot, the Achilles tendon and the heel (calcaneus).
- Stretch the gastrocnemius and foot.
- If a client is highly acute, I will do ice massage at the beginning for 10 minutes and then proceed with massage.
- I will use Sombra (a topical) on all clients after the massage as ice therapy, even if chronic and not acute.
- Home care instructions: hip extensor and flexor stretches, downward facing dog yoga pose to stretch gastrocnemius, stretching the anterior and lateral surface of the foot, stretching of the quadriceps as well, self-massage on the lower leg and foot. I may recommend a foam roller for hips, leg and foot affected, and the use of a lacrosse ball for the bottom of the affected foot.
- Ice therapy for acute pain and swelling. 20 minutes on, 20 minutes off. This can be done in a various of ways. The best way is an old water bottle filled with water andfrozen. Ice is always good, even if not acute. It is one of the best anti-inflammatories!
- Recommend to client to always wear good arch supportive foot wear, not to go barefoot for very long periods of time, and to avoid standing for long periods of time if possible. Rest and taking a break from heavy exercise is also a good idea. Client may also want to consider insoles made especially for their feet.
- Chiropractic/adjustment of the hips and ankles can also help greatly if a client is open to chiropractic.
Plantar fasciitis can last from 3 to 12 months if client is pro-active in taking care of the injury. Without any treatment, the condition will continue to get worse and may require surgery or cortisone injections, which is painful and does not heal the condition. Rather, it is used as a pain medication and can only be done up to 3x in a year. It is essential to be active in the recovery of plantar fasciitis, both at home and with a therapist. Multiple therapies are the best best for recovery so a client can continue to do the activities they love and enjoy everyday activity and work!
Madeline is a registered massage therapist from Boulder College of Massage Therapy. She has been in practice for 17 years, working mainly with chronic pain clients. Madeline also knows firsthand the pain of plantar fasciitis and hopes to educate and help those who also suffer from this unpleasant but curable foot pain.