Manual Therapy for Plantar Fasciitis

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Introduction

Plantar fasciitis is the most common form of heel pain and is caused by inflammation or noninflammatory degenerative changes of the plantar fascia. The plantar fascia is the ligament that connects your heel bone to your toes.

You may have plantar fasciitis if you are experiencing some of these symptoms:

• A sharp pain under the heel
• Pain along the medial border of plantar fascia
• Pain is worse in the morning
• Pain when putting weight on your feet after sitting
• Pain decreases with activity but increases towards the end of the day

Research:

Research shows that these common treatments for plantar fasciitis, such as corticosteroids, low intensity laser or therapeutic ultrasound, and stretching of the affect area, only show minimal to moderate improvement.

A study published in the Journal of Orthopaedic & Sports Physical Therapy found that myofascial trigger point manual therapy combined with self-stretching was very effective. Before we get to the details of the study, you may be wondering, what is a “myofascial trigger point”? Myofascial trigger points are sensitive areas of a tightly contracted muscle. Imagine it like a mini-muscle spasm, more commonly known as “muscle knots”. If you’ve heard someone say, “I’ve got a knot in my back”, then you know they have a trigger point in their back that requires attention to relieve the pain or ache. We’ll discuss more on trigger points in a future blog post, but in the meantime, back to the study. Two group of patients with plantar fasciitis were evaluated: one group receiving treatment by only stretching the plantar fascia and the calf muscle (as known as the gastrocnemius muscle), and the other group had the combination of stretching and myofascial trigger point manual therapy. The group who received the combination treatment of stretching and manual therapy showed greater improvement compared to those who only received the stretching treatment alone.

Treatment:
From the results of that study, adding myofascial trigger point manual therapy can be very beneficial for those who have plantar fasciitis. Dr. Cindy Zhang specializes in manual therapy and a typical treatment at Movement Wellness and Rehab may look like this for a patient with plantar fasciitis.

To alleviate the tight muscle and plantar fascia, you would start by performing calf stretches. As the diagram shows, extend your arms and place your hands on a sturdy wall. Extend one foot backwards with the heel is touching the floor. You should feel a stretch in your calf muscle in the extended leg. Hold for 10 seconds and repeat two to three times, or as needed.

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In addition to stretching your calf muscle, you will also need to stretch your plantar fascia. The diagram below shows how you can perform this stretch on your own. Sit in a comfortable position and bring your foot to rest on your knee. Stretch your plantar fascia by bending the toes downward and by pulling them back.

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Dr. Cindy Zhang recommends adding myofascial trigger point manual therapy to your stretches. Typical trigger point areas of the calf muscle is denoted in the picture by “TrP”. Of note, the trigger points of the calf muscle tend to be up to 50% tighter than the surrounding muscle. By relieving the trigger points (mini-muscle tissue spasms), this can help to ease the pain and discomfort in the heel and calf muscle.

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Finally, patients with plantar fasciitis should highly consider shoe inserts. Dr. Cindy Zhang can provide her recommendations for you upon evaluation, but if you are looking to purchase these on your own, here are some things to consider of the many different shoe insert options available to you. A clinical trial (Winemiller et al) showed that magnet-embedded insoles were no more effective than normal insoles in alleviating pain. Another study (Pfeffer et al) compared the use of custom orthotics versus prefabricated shoe inserts (e.g., silicone heel pad, felt pad, rubber heel cup). The study found that the use of prefabricated inserts combined with stretching exercises was significantly more effective than the use of custom orthotics and stretching exercises.

Prognosis:

Plantar fasciitis can be painful, but a combination of myofascial trigger point manual therapy and active stretching has shown the best results. Treatment usually takes about 4 to 6 weeks for most patients to feel better. Patients should also consider using shoe inserts to alleviate pain and active stretching helps to minimize the chance of it reoccurring.

References:

Renan-Ordine R, Alburquerque-Sendin F, De Souze DPR, Cleland JA, Fernandez-De-Las-Penas C. Effectiveness of Myofascial Trigger Point Manual Therapy Combined With a Self-Stretching Protocol for the Management of Plantar Heel Pain: A Randomized Controlled Trial. J Orthop Sports Phys Ther. 2011;41(2):43-51

Winemiller MH, Billow RG, Laskowski ER, Harmsen WS. Effect of magnetic vs shammagnetic insoles on plantar heel pain: a randomized controlled trial [published correction appears in JAMA 2004;291:46]. JAMA. 2003;290:1474–8.

Pfeffer G, Bacchetti P, Deland J, Lewis A, Anderson R, Davis W, et al. Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis. Foot Ankle Int. 1999;20:214–21.