Comprehensive Strategies For Addressing Plantar Fasciitis
In today’s clinical environment, plantar fasciitis is a common and debilitating condition. “Plantar fasciitis is the most frequent cause of heel pain in adults, accounting for 15% of visits to podiatrists and approximately 9% of running injuries”(1). The purpose of this article is to discuss comprehensive strategies that include instrument assisted soft tissue mobilization (IASTM) and functional evaluation techniques. Irritation to the plantar fascia is widely treated with immobilization and injections. Unfortunately these interventions are incomplete and short sighted. When faced with these types of complex injuries, each provider should ask; is the treatment we are rendering comprehensive? Many of the patients I have treated have most likely seen other types of providers before seeking our care as a last alternative. Chiropractic is touted as treating the root of the issue, but if we seek to only provide short term relief, how can we hold ourselves to that higher standard.
Form & Function;
Static analysis and Orthotic correction (shoe inserts) is a common treatment for plantar pain. Traditional approaches to heel pain have come up short fully addressing plantar pain. It’s been brought to my attention that much of the chiropractic (and physical therapy) profession is unaware of the rehab renaissance occurring. Functional movement analysis has allowed those who utilize it to find faulty movement patterns as well as muscle imbalances that are the underlying causes of dysfunction. The work of Janda, Liebenson, and Cook have provided us with screening tests that gauge the “quality” of movement and identify areas of overuse; thereby identifying underlying causes of injury(2).
A staple of the functional testing is the squat, in its performance we sometimes note the subject’s heels lifting off as the squat gets deeper. This would be indicative of calf/ankle hypo-mobility. Having the patient repeat the squat with the heels in the elevated position and having them perform it with greater competency would further validate calf and foot shortening. If you cannot deep squat, it may be because of your ankle mobility and that in turn is a major underlying reason your heel hurts!
Plantar fasciitis is surely a musculo-skeletal issue. Let’s investigate the work of Tom Myers “Anatomy Trains” to see what else may be associated with the chain of soft tissue(muscle/ ligament/ tendon) known as the plantar aponeurosis.
As we can see from the illustration above, there is a long track of fibrous tissue that runs contiguously from the plantar aspect of the foot to the top of the skull; therefore shortening the muscle along the superficial back line would shorten the continuous chain of connective tissue-in other words not only are bones connected to bones, but muscles are connected to muscles. Tightness in one muscle can and will affect other muscles along the same line. In my own clinical experience as well as medical literature, shortened calf/ heel chords are commonly noted in cases of plantar fasciitis (3). While almost everyone knows how to isolate the Gastrocs calf group, affecting the Soleus calf group seems to elude both patient and doctor. Most patients that present to my office with a plantar pain issue have NOT been shown this simple and ultimately effective move. Feel free to contact us for assistance in performing the Soleus mobility drill.
When treating movement related conditions it's best to use everything available. Massage, Release technique, avoidance strategies, mobility drills and strengthening rehab procedures. Restoring the amount the ankle can bend upwards (dorsiflexion) is a primary goal. Muscle energy techniques (contract/relax stretching) should also play an integral role in the muscles situated along the superficial back line as well as any tight/ overactive muscle groups. Restoring ankle Dorsiflexion through joint mobilization (Cook’s tall half kneel) of the ankle in addition to manipulation of the ankle joint will also aid in restoring proper biomechanics. Finally we need to address foot stability, as Boyle’s joint by joint approach(4) tells us, it’s an area designed for that role.
Self care and long range goals should include activities that would affect the superficial back line (Yoga). Finally, sparing strategies cannot be ignored, as self care will move the patient towards independence in their favorite activities. There is a wealth of tools and techniques available to us, and as my father the carpenter often told me “the right tool at the right time results in the best job”.
|Correct form for the tall half kneel.|
1. Ranawat, Chitranjan S., and Rock G. Positano. Disorders of the Heel, Rearfoot, and Ankle. New York: Churchill Livingstone, 1999. Print.
2. Page, Phillip. "3; Chain Reaction." Assessment and Treatment of Muscle Imbalance The Janda Approach. N.p.: n.p., n.d. N. pag. Print.
3. Garrett, T., and Pj Neibert. "The Effectiveness of a Gastrocnemius-soleus Stretching Program as a Therapeutic Treatment of Plantar Fasciitis." Journal of Sports Rehabilitation 12th ser. 22.308 (2013): n. pag. Web.
4. Boyle, Michael, Mark Verstegen, and Alwyn Cosgrove. Advanced in Functional Training: Training Techniques for Coaches, Personal Trainers and Athletes. Santa Cruz, CA: On Target Publications, 2010. Print.