Plantar Fascia extension

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.

Plantar Fascia lever action

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.

Pathology
The spring and propulsion of the plantar fascia work like a nautical device called a Spanish Windlass (see Figure 1). The plantar fascia functions to maintain the longitudinal arch when the foot is in a normal weight-bearing position. In the windlass mechanism, tension on the "cable" (in this case, the plantar fascia) is increased as the second segment (the phalanges) is brought into extension. Therefore, during the end of the push-off phase of gait there is a greater degree of tension generated in the foot to help propel the body forward (see Figure 2).

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
The most common complaint of a client with plantar fasciitis is sharp pain felt on the bottom of the foot.

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
• Reducing tensile stress on the attachment site of the plantar fascia is one of the first treatments for plantar fasciitis. When tensile stress is reduced, the site of irritation and collagen degeneration in the fascial tissue will have a chance to heal. The best way to reduce tensile stress is to have the client rest from any offending activities.

  • Orthotics may also help change faulty biomechanical patterns in the foot and may take pressure off the plantar fascia and allow time for healing. Orthotics are most useful if the patient has either a flat foot or excessively high arch that is contributing to the irritation of the plantar fascia.
  • Corticosteroid injections into the plantar fascia are sometimes used to address inflammatory effects. However, there is evidence that steroid injections into the plantar fascia may have detrimental effects. Steroids have been shown to leak into the fat pad - that layer of fatty tissue directly underneath the calcaneus designed to help absorb shock - and cause the fat pad's degeneration, as well as rupture of the plantar fascia. There is also a question as to the reason for corticosteroid (anti-inflammatory) injections if the primary problem is not an inflammatory condition.
  • Ice applications are also commonly used as an anti-inflammatory treatment. Methods include placing a bag of frozen corn or peas on the foot because these mold well to the contour of the foot. Rolling the foot over a frozen plastic bottle of water also works as a type of ice application. One might question why these methods get beneficial results if the condition is not an inflammatory problem. Quite possibly, the beneficial result occurs from some of the other physiological effects of ice application, such as pain reduction.
  • A device that has been used extensively to treat plantar fasciitis with very good results is the tension night splint. This brace is worn on the foot to maintain a position of dorsiflexion during the night. Prolonged dorsiflexion will condition the plantar fascia to tensile stress and prevent the aggravation of tensile forces on the attachment site at the calcaneus.
  • Shock-wave therapy is another treatment method that is receiving frequent mention in the rehabilitation literature. This procedure is similar to that used to break up kidney stones. The reason for its use in plantar fasciitis is that it may help reduce the development of extra calcification, as with a bone spur, and therefore reduce pain in the region. However, there are differing opinions on the effectiveness of this approach.

Massage techniques

Plantar Fascia massage

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 Fascia exercise

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.

 


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