4.25: Plantar Heel Pain

Plantar heel pain, also known as plantar fasciitis, is generally described as sharp or stabbing, and worse in the morning. The pain can decrease with activity but can return after long periods of standing or after getting up from a seated position.

Pathophysiology

Just because this condition is referred to as plantar fasciitis, does not mean that the plantar fascia is the primary contributor to symptoms. Entrapment of the tibial nerve and its branches in the tarsal tunnel (along the inner leg behind the ankle) may mimic symptoms of plantar fasciitis. Inside the tunnel, the nerve splits into three different segments – one nerve continues to the heel, the other two continue to the bottom of the foot.  Entrapment of any of these nerves may contribute to the complex clinical picture of plantar fasciitis (Plaza-Manzano et al., 2019).

Examination

A thorough health history intake can be done to gather information about patients’ limitations, course of pain, and prognostic factors for delayed recovery (e.g., low self-efficacy, fear of movement, ineffective coping strategies, fear-avoidance, pain catastrophizing) and answers to health-related questions. Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions. Then undertake a physical examination: neurological screening test, assess mobility and/or muscle strength.

Outcome Measurements

Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:

• Self-Rated Recovery Question
• Patient Specific Functional Scale
• Brief Pain Inventory (BPI)
• Visual Analog Scale (VAS)
• Lower Extremity Functional Scale (LEFS)
• Foot and Ankle Ability Measure
• Foot and Ankle Disability Index

Physical Examination

Incorporate one or more of the following physical examination tools and interpret examination results in the context of all clinical exam findings.

• Windlass Test
• Plantar Fascia Test
• Tinel’s Sign

Treatment

Education

Provide reassurance and patient education on condition and management options and encourage the use of active approaches (lifestyle, physical activity) to help manage symptoms.

Manual Therapy

A massage therapy treatment plan should be implemented based on patient-specific assessment findings and patient tolerance. Structures to keep in mind while assessing and treating patients suffering from plantar heel pain may include neurovascular structures and investing fascia of:

• Plantar Fascia
• Lumbricals
• Adductor Hallucis
• Flexor Hallucis Brevis
• Metatarsals & Interossei
• Peroneals (peroneus longus, peroneus brevis)
• Hamstring Muscles (semimembranosus, semitendinosus and biceps femoris)
• Anterior Compartment of the Leg (tibialis anterior, extensor hallucis longus, extensor digitorum longus, peroneus tertius)
• Superficial Posterior Compartment of the Leg (gastrocnemius, soleus, plantaris)
• Deep Posterior Compartment of the Leg (flexor hallucis longus, flexor digitorum longus, tibialis posterior, popliteus)
• Ankle Joint (the talocrural joint, subtalar joint and the inferior tibiofibular joint)

Self-Management Strategies

Massage therapists not only provide hands-on treatment they can also develop self-management programs to help patients manage symptoms. Stretching, foot taping and educational interventions are part of the core approach for people with plantar heel pain. Also intrinsic foot muscles play a crucial role in supporting the medial longitudinal arch, providing the foot stability and flexibility for shock absorption. Foot core exercises can help recondition foot muscles (McKeon et al., 2015).

• Toe Adduction & Abduction
• Doming & Arching
• Toe Splaying
• Big Toe Press
• Reverse Tandem Gait
• Vele’s Forward Lean

Prognosis

Current best practice recommendations are that plantar fascia stretching, foot taping and educational interventions should be the primary treatment for people with plantar heel pain (Morrissey et al., 2021). In addition evidence also suggests that massage therapy (joint mobilization and soft tissue massage) is helpful in improving function and reducing plantar heel pain (Fraser et al., 2018).

In cases that involve nerve entrapment, a massage therapist may use a specialized technique called neural mobilization. The goal of neural mobilization is to free the entrapped nerve by mobilization of the nerve itself or muscles that surround the nerve. There is research to support the use of neural mobilization. A 2017 meta-analysis published in the Journal of Orthopaedic & Sports Physical Therapy showed that nerve mobilizations are an effective treatment approach for patients with back, neck and foot pain (Basson et al., 2017).

Massage Sloth: Massage Tutorial – Myofascial Release for Plantar Fasciitis and Heel Pain

Key Takeaways

Contemporary multimodal massage therapists are uniquely suited to incorporate a number of rehabilitation strategies for plantar heel pain based on patient-specific assessment findings including, but not limited to:

• Manual Therapy (soft tissue massage, neural mobilization, joint mobilization)
• Education that is Person-Centered (e.g., biopsychosocial model of health and disease, self-efficacy beliefs, active coping strategies)
• Stretching & Loading Programs (e.g., concentric, eccentric, isometric exercises)
• Hydrotherapy (hot & cold)
• Self-Management Strategies (e.g., engaging in physical activity and exercise, social activities, and healthy sleep habits)

References and Sources

Albin, S. R., Koppenhaver, S. L., Bailey, B., Blommel, H., Fenter, B., Lowrimore, C., … McPoil, T. G. (2019). The effect of manual therapy on gastrocnemius muscle stiffness in healthy individuals. Foot (Edinburgh, Scotland), 38, 70–75. doi:10.1016/j.foot.2019.01.006

AlKhadhrawi, N., & Alshami, A. (2019). Effects of myofascial trigger point dry cupping on pain and function in patients with plantar heel pain: A randomized controlled trial. Journal of bodywork and movement therapies, 23(3), 532–538. doi:10.1016/j.jbmt.2019.05.016

Basson, A., Olivier, B., Ellis, R., Coppieters, M., Stewart, A., & Mudzi, W. (2017). The Effectiveness of Neural Mobilization for Neuromusculoskeletal Conditions: A Systematic Review and Meta-analysis. The Journal of orthopaedic and sports physical therapy, 47(9), 593–615. doi:10.2519/jospt.2017.7117

Caratun, R., Rutkowski, N. A., & Finestone, H. M. (2018). Stubborn heel pain: Treatment of plantar fasciitis using high-load strength training. Canadian family physician, 64(1), 44–46.

Escaloni, J., Young, I., & Loss, J. (2019). Cupping with neural glides for the management of peripheral neuropathic plantar foot pain: a case study. The Journal of manual & manipulative therapy, 27(1), 54–61. doi:10.1080/10669817.2018.1514355

Fraser, J. J., Corbett, R., Donner, C., & Hertel, J. (2018). Does manual therapy improve pain and function in patients with plantar fasciitis? A systematic review. The Journal of manual & manipulative therapy, 26(2), 55–65. doi:10.1080/10669817.2017.1322736

Nahin, R. L. (2018). Prevalence and Pharmaceutical Treatment of Plantar Fasciitis in United States Adults. The journal of pain, 19(8), 885–896. doi:10.1016/j.jpain.2018.03.003

McKeon, P. O., Hertel, J., Bramble, D., & Davis, I. (2015). The foot core system: a new paradigm for understanding intrinsic foot muscle function. British journal of sports medicine, 49(5), 290. doi:10.1136/bjsports-2013-092690

Morrissey, D., Cotchett, M., Said J’Bari, A., Prior, T., Griffiths, I. B., Rathleff, M. S., Gulle, H., Vicenzino, B., & Barton, C. J. (2021). Management of plantar heel pain: a best practice guide informed by a systematic review, expert clinical reasoning and patient values. British journal of sports medicine, bjsports-2019-101970. Advance online publication. https://doi.org/10.1136/bjsports-2019-101970

Plaza-Manzano, G., Ríos-León, M., Martín-Casas, P., Arendt-Nielsen, L., Fernández-de-Las-Peñas, C., & Ortega-Santiago, R. (2019). Widespread Pressure Pain Hypersensitivity in Musculoskeletal and Nerve Trunk Areas as a Sign of Altered Nociceptive Processing in Unilateral Plantar Heel Pain. The journal of pain: official journal of the American Pain Society, 20(1), 60–67. doi:10.1016/j.jpain.2018.08.001

Rasenberg, N., Riel, H., Rathleff, M. S., Bierma-Zeinstra, S., & van Middelkoop, M. (2018). Efficacy of foot orthoses for the treatment of plantar heel pain: a systematic review and meta-analysis. British journal of sports medicine, 52(16), 1040–1046. doi:10.1136/bjsports-2017-097892

Rasenberg, N., Bierma-Zeinstra, S., Fuit, L., Rathleff, M. S., Dieker, A., van Veldhoven, P., Bindels, P., & van Middelkoop, M. (2021). Custom insoles versus sham and GP-led usual care in patients with plantar heel pain: results of the STAP-study – a randomised controlled trial. British journal of sports medicine, 55(5), 272–278. https://doi.org/10.1136/bjsports-2019-101409

Renan-Ordine, R., Alburquerque-Sendín, F., de Souza, D. P., Cleland, J. A., & Fernández-de-Las-Peñas, C. (2011). Effectiveness of myofascial trigger point manual therapy combined with a self-stretching protocol for the management of plantar heel pain: a randomized controlled trial. The Journal of orthopaedic and sports physical therapy, 41(2), 43–50. doi:10.2519/jospt.2011.3504

Ridge, S. T., Olsen, M. T., Bruening, D. A., Jurgensmeier, K., Griffin, D., Davis, I. S., & Johnson, A. W. (2019). Walking in Minimalist Shoes Is Effective for Strengthening Foot Muscles. Medicine and science in sports and exercise, 51(1), 104–113. https://doi.org/10.1249/MSS.0000000000001751

Saban, B., Deutscher, D., & Ziv, T. (2014). Deep massage to posterior calf muscles in combination with neural mobilization exercises as a treatment for heel pain: a pilot randomized clinical trial. Manual therapy, 19(2), 102–108. doi:10.1016/j.math.2013.08.001