release and relief. Light massage can also be combined with gentle, passive stretching if either deep tissue massage or trigger point therapy is too much for your client to tolerate in a session. In the case of treating plantar fasciitis with manual therapy, it may be useful to communicate to your 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 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 manual and exercise therapy as effective, ongoing tools 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, they 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 subsequently are the applications for modalities already discussed and additional As described in the section discussing acute plantar fasciitis, deep tissue massage to the calf muscles can be very effective for not only treating plantar fasciitis but also 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, and not necessarily used 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 previously 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, and the client’s comfort level will often allow for methods for treatment. Deep tissue massage
client that you are not likely to solve the inflammation problem in one session, and that lighter work applied over a few subsequent sessions may be a more effective course of treatment for long-term relief.
more intense work when their pain and inflammation are not as acute. You can 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 previously. Instrument-assisted soft tissue mobilization The Graston technique and Gua Sha, described previously as methods to treat acute plantar fasciitis, can also be useful tools in keeping chronic plantar fasciitis at bay. IASTM applied to the plantar fascia when it is not inflamed as well as the calf muscles can assist in preventing flare-ups by maintaining healthy tone. Exercises for lower leg strength For those who experience recurring episodes of plantar fasciitis, it may be necessary to continue maintenance exercises on a regular basis. A therapist can determine what exercises would be most effective as a routine for the client to do easily and safely at home. Massage and gliding of the plantar fascia When the plantar fascia is not acutely inflamed, it can usually tolerate more vigorous direct massage. Though we know from our study so far that the problem does not always originate in the plantar fascia itself, that 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 functional integrity. Passive stretching 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 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, and forcing a stretch can cause damage to the tissue. Let the fascia guide you to the appropriate amount of stretch.
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