Plantar fasciitis is one of the most common pain conditions of the foot; in fact, it is the most prevalent cause of foot pain encountered in clinical practice. Though athletes frequently experience plantar fasciitis, those not involved in active lifestyles also experience this condition.
While its name might lead one to think of it as an inflammatory condition (the "itis" suffix), new data suggests otherwise. There is mounting evidence that many common tendinitis complaints are actually not inflammatory problems at all, but instead are caused by a degeneration of the collagen matrix within the tissue. It has been suggested that plantar fasciitis is similar to these tendon pathologies, and that the problem is collagen degeneration in the fascial tissue. To help understand how this occurs, consider the mechanical function of the plantar fascia.
The plantar fascia has an attachment at the anterior calcaneus, and then separates into distal divisions that blend with other connective tissues near the metatarsophalangeal joints (see Figure 1). Its primary function is to help maintain the longitudinal arch of the foot. In addition, the plantar fascia acts as a powerful spring that has a fundamental role in shock absorption and forward propulsion.
Normal weight-bearing activities also create a natural degree of increased tension on the plantar fascia. As pressure is placed directly downward on the longitudinal arch, tension will naturally be increased along the plantar fascia. The increased tension will pull on each end of the plantar fascia. Due to the windlass arrangement in the foot, the tension will be greatest when the toes are in hyperextension.
The calcaneal attachment site for the plantar fascia is much smaller than the distal attachment spread across the metatarsal heads. Therefore, when tensile loads within the plantar fascia are spread to each end, the calcaneal attachment site bears a greater pulling force. Because the plantar fascia pulls on the periosteum at the attachment site, this site becomes the central problem in plantar fasciitis. Since the periosteum is one of the most pain-sensitive tissues in the body, this condition causes significant foot pain.
As mentioned earlier, plantar fasciitis has traditionally been characterized as a chronic inflammatory problem, although there is controversy about just how much inflammation is actually present. It is likely that a primary part of the problem involves collagen degeneration in the fibers of the plantar fascia more so than an inflammatory reaction in the tissue.
When a tendon or connective tissue like the plantar fascia inserts into a bone, it doesn't stop right at the bone. It has fibrous continuity with the bony matrix. Therefore, excessive tensile stress on that site may also affect the bone. This often occurs in plantar fasciitis. As a result of the tensile stress placed on the bony attachment site, an exostosis (bone spur) may develop.
Plantar fasciitis can occur from a number of causes. One of the most common causes is biomechanical dysfunction in the foot. While improper footwear may contribute, overpronation is frequently cited as the primary biomechanical dysfunction. Pronation is a diagonal movement of the foot that includes the combined motions of abduction, eversion, and dorsiflexion. Pronation happens during the normal gait, but if the person rolls over too far on the medial side of the foot this is considered overpronation. When the individual overpronates, the plantar fascia must take on a greater role in absorbing shock in the lower extremity. The increased tensile stress on the plantar fascia will often lead to fiber breakdown with resultant stress on the calcaneal attachment site.
Overpronation often accompanies a flat foot (pes planus), the presence of which is a strong indicator that plantar fasciitis may occur. However, a pes cavus (high arch) foot is also likely to contribute to the problem.
Assessment and evaluation
Maintaining tissues in a shortened position for long periods will often aggravate the symptoms. For example, a person with this condition will often sleep with his/her foot in plantar flexion. This position will keep the fascial tissues of the plantar flexor "sling" (including the plantar fascia) in more of a shortened position. When arising in the morning, weight is placed on the foot, providing a sudden tensile load to tissues that have been in an unloaded position all night long. Thus, clients will most commonly report the worst pain sensations as those felt first thing in the morning upon arising and just starting to walk after getting out of bed.
Plantar fasciitis is evaluated through an accurate history and physical examination. In the history, pay particular attention to descriptions of vigorous activity performed on an unyielding surface. Examples include running on pavement, aerobic dance classes on a hard floor, or walking on a hard surface all day. Also pay particular attention to the location of the key symptoms, as the client is most likely to report the primary pain on the bottom of the foot and exaggerated pain near the calcaneal attachment of the plantar fascia.
We also must consider that a bone spur may be present in the region, though we may not be able to palpate it. Although X-rays can identify the bone spur, they are not often used because they only provide information about the presence of the bone spur and not about the state of the plantar fascia. Presence of the spur may be indicative of excessive tensile loads on the calcaneus but does not necessarily mean the client has plantar fasciitis. Therefore, sound clinical judgment is considered the best tool for accurately evaluating this condition.
Traditional methods of treatment
Massage techniques are quite helpful for plantar fasciitis. Longitudinal stripping methods applied to the bottom surface of the foot will help reduce tension in the intrinsic flexor muscles. It will also maintain better tone in those tissues. Some practitioners advocate performing most of the longitudinal stripping methods toward the calcaneus in order not to create additional tensile stress on the plantar fascia.
Deep transverse friction may be used directly on the plantar fascia to stimulate fibroblast activity and tissue healing from chronic overuse. However, caution should be used in applying friction massage near the attachment on the calcaneus because of the possibility of a bone spur. Since the practitioner will not know whether a bone spur is present, it is best to assume that one might be there. The client's pain will generally be a good guide as to how much pressure may be used with various massage techniques. Pressure that is too painful for the client should not be used.
Working on the lower leg muscles, especially those involved in plantar flexion, is also important in addressing plantar fasciitis. Tightness in these muscles may contribute to excess tension in the fascial continuities running from the leg through the bottom surface of the foot. Massage of the gastrocnemius, soleus and tibialis posterior should be included.
Various broadening and lengthening techniques applied to the posterior calf muscles will be particularly helpful. Compressive effleurage, broad longitudinal stripping, and broadening techniques done with the palm are all beneficial for this purpose. Addressing these muscles will help the effectiveness of a tension night splint as well.
Practitioners should also massage muscles of the entire lower extremity when addressing plantar fasciitis. Biomechanical compensation may be occurring as a result of foot pain, the effects of which may not be limited to the lower extremity. The practitioner is encouraged to watch for soft-tissue effects throughout the rest of the body.
Stretching the gastrocnemius and soleus, as well as all of the other tissues of the plantar flexor "sling," will be important. Stretching is most beneficial when performed several times a day. The morning is especially effective as this is when the plantar fascia has been in a non-weight-bearing position all night. The classic "wall stretch" position (see Figure 2) is a good choice for these tissues. Pulling the toes into hyperextension as the foot is pulled in dorsiflexion works well in stretching these tissues.
Plantar fasciitis is a condition that affects a large percentage of the population; thus, massage therapists are frequently presented with this condition in their practices. Fundamental knowledge of foot biomechanics and the development of this pathological problem are essential for providing appropriate care. Some of the suggested treatment methods, such as orthotics or anti-inflammatory medications, necessitate treatment from other health professionals. Thus, it may require communication with these other professionals. As a massage therapist, you have a special and unique contribution to make in treating this problem. The better informed you are, the greater your session results will be.