Chronic plantar fasciitis Clients who have experienced plantar fasciitis in the past can often recognize the symptoms when they begin to see the signs of a recurrence. These situations can be an opportunity for us as massage therapists to, essentially, nip those symptoms in the bud. Not everyone who suffers from plantar fasciitis has the ability to avoid the parts of their lifestyle that are causing the problem, particularly if the trigger is something related to their job, like standing for long periods of time. Athletes, especially runners, may experience frequent episodes of plantar fasciitis during intense training periods for an upcoming event and may not have the ability to halt activity without losing the progress gained in the training cycle. That’s where we come in: We can help manage the situation to keep it from getting to an acute stage of inflammation. When we introduce massage therapy as an effective, ongoing tool for treatment and prevention, we can further integrate ourselves as part of our clients’ comprehensive healthcare team. Our approach to aid in the prevention of a recurrence or to treat a low-grade chronic case of plantar fasciitis employs many of the same tools as we would in acute cases, but with a different level of intensity. While it is important to always work within your client’s comfort level, s/he can often tolerate deeper and more specific work when the inflammation is not as acute, and the pain associated with plantar fasciitis is not as intense. Listed below are the applications for modalities already discussed above and additional methods for treatment. Deep tissue massage As described above in the section discussing acute plantar fasciitis, deep tissue massage to the calf muscles can be very effective—not only when treating plantar fasciitis, but also in reducing or delaying recurrences of symptomatic inflammation. Deep tissue massage for the calf and lower leg muscles is often part of sports massage protocols, especially for endurance and competitive runners. For these purposes, it can work better during the training cycles between events. Deep tissue massage may not necessarily be helpful for immediate pre-event and post-event massage because of the risk of temporarily inciting low-grade inflammation and hindering performance. Deep tissue massage can also be effective in repetitive strain situations that are from triggers other than sports, like work-related contexts, obesity, and footwear choices. Knowing what those triggers might be will help you determine how to proceed and what areas of the foot and lower leg need attention. In addition to applying deep tissue massage to the calf muscles that inhibit dorsiflexion when they are hypertonic, you can also work the anterior tibialis at the front of the lower leg to improve its tone, because it is the primary mover in dorsiflexion of the ankle.
Trigger point therapy Trigger point therapy (as described above) can also be applied in chronic cases or preventative treatment of plantar fasciitis. It may be possible—or even necessary—to be a little more aggressive with trigger point therapy in these cases. Further, the client’s comfort level will often allow for more intense work when their pain and inflammation are not as acute. You may also be able to be more specific when targeting trigger points; however, the risk of causing foot cramping still exists and should be treated with the same protocol described above. Massage and gliding of the plantar fascia When the plantar fascia is not acutely inflamed, it can usually tolerate more vigorous direct massage. Although we know from our study so far that the problem does not always originate in the plantar fascia itself, this does not mean it should be ignored as part of a comprehensive treatment. Refer to the anatomical diagram in Section 1 of this course to refresh your memory of the structure of the plantar fascia. When the plantar fascia is not inflamed or only has low-grade inflammation, you can work the entire fascia from the heel to the base of the toes, letting the tightness of the tissue determine your degree of pressure and depth. Remember that it is the thickest in the center, closest to where it attaches to the calcaneus, at the common point of tenderness. Cross-fiber friction within the client’s comfort level can be applied to the thicker areas, with gliding applied to the less dense parts of the fascia. Our goal is to release and lengthen the tissue, which can help to maintain its structural and Just as in acute cases, stretching can be very beneficial in chronic cases of plantar fasciitis. Attending to all the key muscles of the calf, the Achilles, and the plantar fascia when performing passive stretching will get the most comprehensive results. Depending on the client’s comfort level, you may be able to stretch a little more deeply with more repetitions when there is no acute pain and inflammation present. Work gradually, starting with a light stretch and repeating until you get a deeper stretch without forcing, gradually increasing the length of time you are holding the stretch with each repetition. You may also be able to target the plantar fascia specifically by pinning the plantar fascia with one hand at the calcaneus and stretching the rest with the other functional integrity. Passive stretching hand, extending the toes (bending them back slightly from the base) as part of the stretch. Remember that fascia is not as flexible as muscle; forcing a stretch can cause damage to the tissue. Let the fascia guide you to the appropriate amount of stretch.
Exercise 5 This exercise is intended to give you a sense of the effects of massage therapy to the structures involved in plantar fasciitis. For this exercise, you will need a hand towel and a small amount of massage cream. Sit with your feet and lower legs bare. Choose one foot and leg to work on first. If you have any plantar fasciitis symptoms, work on that foot and leg first. Cross the foot you will be working on over the other leg, resting the outer ankle on the other leg’s knee. Apply massage cream to the sole of the foot, around the Achilles, and on the back of the lower leg. As best you can from this awkward angle, massage the sole of the foot, around the Achilles, and up the calf. Work on every muscle of the calf that you can effectively reach. Pay attention to the unique experience of being on both sides of the massage experience—as both the giver and the receiver. Follow your instincts. Pin and stretch the sole of the foot as outlined above in “passive stretching.” Then, uncross the leg you are working on, straighten it out in front of you, and use the hand towel around the ball of the foot, holding an end in each hand, to help you stretch the calf muscles. Repeat this process at least one time on the same foot and leg, giving it a thorough massage (as best you can on yourself). Before you work on the other foot and leg, get up and walk around the room. Do you notice a difference in how your two feet and calves feel, between the one that was massaged and the one that was not? How significant is the difference? Repeat the exercise again. This time, work on the other foot and leg, then get up and walk around the room again. Were you able to create the same sensation on both feet and legs? Does one need more work than the other?
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